Development and evaluation of mindfulness-based cognitive therapy integrated with islamic psychology of self for psychological distress among Singaporean Malay muslims

Abstract

Background: The indigenous Malay Muslim minority in Singapore is disproportionately affected by psychosocial stressors linked to structural inequalities in employment and economic stability. Epidemiological data show that 1 in 6 Malays and Indians, compared to 1 in 8 Chinese, experience poorer mental health. Among Malays, culturally rooted spiritual attributions of mental illness may contribute to delayed help-seeking and lower engagement with conventional psychological interventions. Addressing the need for culturally sensitive interventions, this study has three primary aims: (1) to develop the Islamic Psychology of Self (IPS) module, enabling Asatizah (Islamic religious teachers) to collaborate with mental health practitioners using Mindfulness-Based Cognitive Therapy (MBCT), a therapy that combines aspects of cognitive behavioural therapy with mindfulness that instils compassion, acceptance and non-judgement; (2a) to investigate the effectiveness of MBCT integrated with the Islamic Psychology of Self (MBCT-IPS) in alleviating psychological distress, improving mental wellbeing, and enhancing self-compassion among Singaporean Malay Muslims; (2b) to assess the appropriateness, acceptability, and feasibility of the intervention; and (3) to explore participants' qualitative experiences with the intervention. Methods: The study was conducted in three phases. Phase 1 involved the development of the IPS module based on the Dharuriyyatil-Khams (Five Basic Essentials) of human needs and Ilmun-Nafs (Knowledge of the Self). Phases 2 and 3 utilised a sequential mixed-method explanatory design. In Phase 2, 80 Malay Muslim participants were randomly assigned to one of three arms: the experimental MBCT-IPS, conventional MBCT, or counselling. Primary outcomes were measured using the Depression, Anxiety, and Stress Scale (DASS-21). Secondary outcomes included the Positive Mental Health Instrument (PMHI-19), the Self-Compassion Scale–Short Form (SCS-SF12), and post-intervention measures of Acceptability, Appropriateness, and Feasibility (AIM, IAM, FIM). Assessments were conducted at baseline, mid-intervention, post-intervention, and one-month and three-month follow-ups. Analyses used a General Linear Model with intention-to-treat (ITT) and per-protocol (PP) approaches. Phase 3 involved thematic analysis of semi-structured interviews with participants who completed therapy. Results: In Phase 1, the IPS module demonstrated strong expert-rated content validity (I-CVI=0.924) and was successfully pilot-tested with 12 participants. In Phase 2, all three interventions—MBCT, MBCT-IPS, and counselling—led to significant improvements across all outcome measures over time. Comparing mean scores, MBCT-IPS was found to be more effective in reducing DASS-21 depressive symptoms compared to counselling and MBCT based on both ITT and PP analyses. Counselling showed consistent reduction in DASS-21 anxiety symptoms in ITT analysis, outperforming both MBCT and MBCT-IPS, whereas MBCT-IPS demonstrated greater reductions in the PP analysis. MBCT more effective in reducing DASS-21 stress symptoms than both MBCT-IPS and counselling, in both ITT and PP analyses. Counselling showed greater improvements in PMHI-19 compared to MBCT-IPS and MBCT across ITT and PP analyses. For SCS-SF12, ITT analysis revealed that MBCT-IPS was more effective than counselling and MBCT, while PP analysis indicated counselling was more effective than both MBCT-IPS and MBCT. Notably, therapy attrition was highest (61.25%) where therapists were non-Muslims. In Phase 3, participants who completed therapy reported positive experiences, particularly favouring Islamic psychotherapy as culturally relevant, emotionally meaningful, and spiritually aligned with their values. Conclusion: This study underscores the importance of culturally adapted interventions in addressing mental health disparities among minority populations. Findings highlight the potential of integrating Islamic concepts into therapy and fostering collaboration between mental health professionals and Asatizah to enhance treatment acceptability, cultural relevance, and psychological outcomes for Malay Muslims in Singapore.