There has been growing awareness of the importance of death anxiety (DA) in pathological anxiety. DA is defined as a persistent and unreasonable fear of death and thoughts, fears, and emotions associated with the end of life. DA has been suggested as a core fear that underpins the emergence and perseverance of numerous anxiety disorders. However, previous DA-based treatment studies focus on the elderly, the patients, or health professionals who care for the terminally ill. Therefore, there is a need to examine the effect of psychological interventions on DA and current disorder symptoms in a clinical sample through randomized controlled trials. The current study aims to develop a novel Religiously Integrated Cognitive Behavioral Therapy (RCBT)-based intervention on DA in individuals diagnosed with an anxiety disorder and to compare the effectiveness of RCBT-based intervention with classical CBT-based intervention.
Aged 18-65
A score of > 26 on the Turkish Death Anxiety Scale
Diagnosed with one of the anxiety disorders
Believing in life after death
Diagnosed with schizophrenia, schizophreniform disorder, schizoaffective disorder, and delusional disorder
Being in an active manic episode
Possessing a mental disorder that interferes with completing measures or understanding the exercises conducted during sessions
Extreme symptoms of depression (score of > 20 on the Patient Health Questionnaire (PHQ-9), and >1 on the item assessing suicidality)
Parallel
Religiously-integrated Cognitive Behavioral Therapy
Other interventionThis study aims to assess the efficacy and feasibility of a newly developed online intervention for death anxiety based on Religiously Integrated Cognitive Behavioral Therapy (RCBT). Building upon the framework of Furer and Walker's 2008 intervention protocol, this adaptation incorporates beliefs in an afterlife, aligning with Turkish society's cultural and religious values. The RCBT intervention consists of seven structured group therapy sessions, each lasting 90 minutes. The program is designed to help participants identify and challenge unhelpful thoughts related to death anxiety while integrating religious resources to promote cognitive restructuring. Key components of the intervention include psychoeducation, cognitive restructuring, exposure exercises, the concept of repentance in the context of trust and belief in the afterlife, gratitude, and value-oriented behaviors.
Classical Cognitive Behavioral Therapy
Other interventionThe standard CBT intervention follows the structured protocol developed by Furer and Walker (2008), which targets cognitive distortions, avoidance behaviors, and excessive safety-seeking behaviors contributing to death anxiety. The researcher has adapted the session content to fit the protocol's core components while maintaining fidelity to the original intervention model. Sessions last 90 minutes and are conducted in an online group format. Session Structure: Session 1: Treatment Rationale, Session 2: Reducing Excessive Checking, Reassurance Seeking, and Safety Behaviors, Session 3: Exposure, Session 4: Cognitive Reappraisal, Session 5: Enhancing Enjoyment of Life, Session 6: Healthy Lifestyle, and Session 7: Relapse Prevention.
Turkish Death Anxiety Scale (TDAS)
The Turkish Death Anxiety Scale consists of 20 items that are divided into three subscales: (a) ambiguity of death, (b) exposure to death, and (c) agony of death. These subscales exhibit strong internal consistency, with Cronbach's alpha values of .91, .94, .76 respectively, adding up to a total of .95). It consists of a five-point Likert (0 = Never to 4 = Always). Subscale scores are determined by summing the individual item scores, and the total scale score is determined by summing the subscale scores. Total scale scores can be between 0 and 80, and the higher the score, the greater the level of DA. A score range of 0-7 indicates very low-level DA, 8-25 indicates low-level DA, 26-44 indicates medium-level DA, 45-63 indicates high-level DA, and 64-80 indicates very high-level DA.
Abdel-Khalek's Death Anxiety Scale (ASDA)
Abdel-Khalek's Death Anxiety Scale is a 20-item questionnaire that measures DA. The scale is one-dimensional. Higher scores indicate a greater degree of DA. It consists of a five-point Likert (1 = No to 5 = Very much). The Turkish reliability and validity of the scale were conducted by Sarıçiçek-Aydoğan et al. in 2015 (Cronbach's alpha = .86).
Generalized Anxiety Disorder-7 (GAD-7)
Generalized Anxiety Disorder-7 consists of a four-point Likert (0 = never to3 = almost every day) and 7 items that assess anxiety symptoms. The highest score that can be attained ranges up to 21. A score range of 0-4 indicates mild anxiety, 5-9 indicates moderate anxiety, 10-14 indicates high anxiety, and 15-21 indicates severe anxiety. A cut-off point of 10 points was determined for the total score. The Turkish reliability and validity of the scale were conducted by Konkan et al. in 2013 (Cronbach's alpha = .85).
Patient Health Questionnaire (PHQ-9)
Patient Health Questionnaire consists of a four-point Likert and nine items that screen depressive symptoms. Each of these items is rated on a scale of 0 (never) to 3 (almost every day). The highest score that can be attained ranges up to 27. A score range of 1-4 indicates low depressive symptoms, 5-9 indicates mild depressive symptoms, 10-14 indicates moderate depressive symptoms, 15-19 indicates partially severe depressive symptoms, and 20-27 indicates severe depressive symptoms. The Turkish reliability and validity of the scale were conducted by Sarı et al. (2016) (Cronbach's alpha = .84).
Belief in a Day of Judgment Scale
The Belief in a Day of Judgment Scale comprises 20 items with two subscales: (1) belief in a day of judgment, and (2) bad behavior/actions toward others. It consists of a five-point Likert (1 = Strongly disagree to 5 = Strongly agree). Examples of the items include, "God is the savior and judge of mankind.", and "If I am pure of heart and hands, I shall live in the fear of a just God". A high score on the Belief in a Day of Judgment subscale indicates a strong belief in a Day of Judgment, the conviction that God will judge the living and the dead, and the belief in life after death. A high score on the Bad Behavior/Actions Toward Others subscale reflects the belief that human relationships and actions towards others will be scrutinized on the Day of Judgment. The Turkish reliability and validity of the scale were conducted by Turan et al. in 2020 (Cronbach's alpha = .92).
Muslim Practice and Belief Scale
The Muslim Practice and Belief Scale- Short Form comprises nine items with two subscales: (1) social beliefs and prayers, and (2) individual beliefs and prayers subscale (PF). It consists of a five-point Likert (1 = Strongly Disagree to 5 = Strongly Agree). The Turkish reliability and validity of the scale were conducted by Akın and Yalnız in 2015 (Cronbach's alpha = .90). The subscales demonstrate good internal consistency, with Cronbach's alphas of. 86 and .91 respectively. Higher scores indicate a greater level of Muslim practice and belief.
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