In Nigeria, religious leaders act as the de facto frontline for mental health support, yet meaningful collaboration with formal services remains elusive despite high stated willingness on both sides. This study, part of the CLERIC programme, investigates this "collaboration paradox" to identify its root causes and co-design a viable implementation strategy. Using a multi-phase qualitative design in Lagos, Phase 1 explored the explanatory models of 79 Christian and Islamic religious leaders through 25 key informant interviews and 8 focus group discussions, informed by Kleinman's explanatory models framework. Phase 2 engaged 30 stakeholders (religious leaders, mental health professionals, and policymakers) to map implementation determinants using the Consolidated Framework for Implementation Research (CFIR) and the COM-B model. Religious leaders employ pluralistic explanatory models (a Hierarchical Causation Model and a Dual Track Model) that permit biomedical integration under specific conditions. The collaboration paradox operates through two sequential mechanisms: leaders who are "willing but unable" due to prohibitive costs, inaccessible services, and absent referral infrastructure; and "conditional collaborators" who withhold referrals where they perceive epistemic disrespect and threats to their pastoral role and livelihood. Knowledge gaps are genuinely bidirectional: clergy lack mental health literacy and risk-assessment skills, while clinicians lack religious literacy. The collaboration gap is not primarily theological but systemic and relational. Sustainable integration requires co-designed bidirectional training; formal primary-care-anchored referral pathways with feedback loops; explicit role boundaries with safeguards against harmful practices; and recognition of religious leaders within Nigeria's mental health policy framework. • Religious leaders hold pluralistic, not anti-medical, explanatory models • Non-referral reflects systemic and relational failure, not theological resistance • Livelihood threats and epistemic disrespect sustain the collaboration paradox • Knowledge deficits are bidirectional: clinicians also lack religious literacy • A co-designed bidirectional model anchored in primary care is feasible and acceptable
Oladipo et al. (Fri,) studied this question.