Therapeutic Groups to Help People Forgive Others: A Case Study.

Most people have been harmed by another at some point in their lives. Many of these hurts linger in the lives of those who were hurt, through anger, fear, and rumination. Forgiving others, when it is safe and prudent to do so, can be one route toward healing these past hurts. Group therapy has specific strengths that might help people to effectively forgive others. One of those strengths is the creation of therapeutic factors. In the current paper we discuss how group forgiveness interventions and the development of three specific therapeutic factors (universality, cohesion, and altruism) can help to promote forgiveness. We review prior work on forgiveness interventions in group therapy, focused on effectiveness generally. We then provide an applied case study of a specific group that used Worthington's REACH Forgiveness model. In this case study we highlight the themes of universality, cohesion, and altruism to illustrate the benefit of forgiveness interventions in group therapy.

Feasibility and preliminary efficacy of a theory-informed resistance exercise training single-arm intervention for major depression.

Many adults with major depressive disorder (MDD) do not receive effective treatment. The potential benefits of resistance exercise training (RET) are understudied and may be mechanistically related to cerebral blood flow changes. PURPOSE: To assess feasibility, acceptability, and preliminary efficacy of a 16-week, theory-informed RET trial for the treatment of MDD and explore changes in cerebral blood flow. METHODS: Ten adults with DSM-5-diagnosed MDD were enrolled in a single-arm, 16-week, twice-weekly, whole-body RET intervention, consistent with US and WHO Physical Activity resistance exercise guidelines. To build intrinsic motivation and develop exercise-preparatory habits, motivators and commitment were discussed weekly. Screening, enrollment, and intervention attendance and compliance rates documented feasibility. At baseline and weeks 8, 16, and 26, current MDD diagnosis, clinician-rated, and self-reported symptom severity were evaluated along with cerebral blood flow which was assessed as middle cerebral artery (MCA) mean blood velocity, conductance, and pulsatility. RESULTS: Nine participants completed the intervention. Strong feasibility and acceptability (98 % adherence, 93 % compliance, and 90 % retention) were found. MDD remission was reached by 8/9 participants at week 16 and persisted through week 26. There were large decreases in clinician-rated and self-reported symptoms at each assessment (Hedges' g = 0.84-2.13). There were small-to-moderate increases in MCA velocity (g = 0.32-0.57) and conductance (g = 0.20-0.76) across time, with minimal changes in pulsatility (all g < 0.21). CONCLUSIONS: Preliminary results suggest RET for MDD treatment is feasible and plausibly efficacious, finding large antidepressant effects. A sufficiently powered randomized controlled trial to assess RET's efficacy for treating MDD via potential cerebrovascular mechanisms is warranted.

Associations between forgiveness and physical and mental health in the context of long COVID.

OBJECTIVE: Forgiveness has been positively associated with health in those with functional disorders. This cross-sectional study examined the relationships among dimensions of forgiveness and physical and mental health in individuals with and without long COVID. METHODS: Adults (N = 4316) in the United States took part in an online survey study detailing long COVID presence, physical and mental health, and trait forgiveness. T-tests were performed to assess differences in types of trait forgiveness between individuals with and without long COVID. Linear regression models assessed the contribution of demographic covariates and forgiveness subscales to the physical and mental health of individuals with and without long COVID. RESULTS: Of 4316 participants, 379 (8.8%) reported current long COVID. Participants were an average age of 43.7, and most identified as female (51.9%), white (87.8%), and non-Hispanic/Latino (86.6%). Individuals with long COVID reported significantly less forgiveness of self (p < 0.001, d = 0.33), forgiveness of others (p = 0.004, d = 0.16), and forgiveness of situations (p < 0.001, d = 0.34) than those without long COVID. Among the long COVID sample, forgiveness of self and situations were positively associated with mental health (p < 0.05), but not physical health (p > 0.05). Forgiveness of others was negatively associated with both physical and mental health (p < 0.05). CONCLUSION: Forgiveness may be an important consideration in understanding health among individuals with long COVID, emphasizing the importance of developing a multifaceted understanding of the condition.

Feasibility of an Exercise and CBT Intervention for Treatment of Depression: A Pilot Randomized Controlled Trial.

Depression (DEP) is prevalent and current treatments are ineffective for many people. This pilot study's purpose was to assess the feasibility, acceptability, and plausible efficacy of an 8-week intervention employing 30 min of prescribed moderate intensity exercise ("ActiveCBT") compared to 30 min of usual activities ("CalmCBT") immediately prior to weekly online CBT sessions. Ten adults with DSM-5-diagnosed current DEP were randomized to groups and completed: an intake assessment, eight weekly CBT sessions, final assessment, and 3-month follow-up. ActiveCBT participants were prescribed 30-min of moderate exercise immediately prior to each standardized 50-min CBT session. CalmCBT participants continued with normal activities for 30 min before therapy. Questionnaires regarding DEP symptom severity (Patient Health Questionnaire-9 [PHQ-9]), between-session effectiveness (Behavioral Activation for Depression Survey [BADS], Automatic Thoughts Questionnaire [ATQ]), in-session effectiveness (Working Alliance Inventory-Short Revised [WAI]), and state anhedonia (Dimension Analog Rating Scale [DARS], Visual Analog Scale [VAS]; assessed 3 times: before Active/Calm condition, after, and after therapy) were completed each week. Therapy fidelity ratings were independently coded via a standardized codebook. The Structured Clinical Interview for DSM-5 (SCID) and Hamilton Rating Scale for Depression (HAMD) were used to assess DEP at intake, final, and 3-month follow-up. We found strong feasibility and acceptability (100% adherence, 100% retention at final visit, 74.6% therapy fidelity, and high patient satisfaction ratings). Differences between groups favoring ActiveCBT in anhedonia (DARS, Hedges' g = 0.92; VAS, g = 3.16), within- (WAI, g = 0.1.10), and between-session effectiveness (ATQ g = -0.65; BADS g = -1.40), suggest plausible efficacy of ActiveCBT for enhancing CBT. DEP rates were reduced in both groups from baseline to final (60% MDD SCID remission) and at follow up (Active: 40%; Calm: 25%). Larger and potentially quicker symptom improvement was found favoring the Active condition to the final visit (HAMD, between-group changes g = -1.33; PHQ-9, g = -0.62), with small differences remaining at follow-up (HAMD, g = -0.45; PHQ-9, g = -0.19). Exercise priming appears acceptable and plausibly efficacious for enhancing mechanisms of CBT and overall outcomes, though the present small sample precludes efficacy determinations. It appears feasible to conduct a randomized controlled trial comparing ActiveCBT to CalmCBT. Future trials evaluating this potentially promising treatment approach and mediating mechanisms are warranted.

The effects of group counseling and self-affirmation on stigma and group relationship development: A replication and extension.

The stigma of seeking counseling and negative attitudes about counseling are primary barriers to its use. In the only known study examining the utility of attending a group counseling session to ameliorate stigma (no control group), participation was associated with reductions in self-stigma (Wade et al., 2011). Self-affirmation interventions have shown promising results in reducing stigma and promoting positive expectations about counseling, but no research has examined its effects on a counseling session. In the present, two-part study, 172 college students who had previously completed an online screening survey, including measures of stigma, participated in a single session of group counseling at a mental health clinic. Upon arrival, participants completed a self-affirmation intervention before viewing psychoeducation (n = 66; 12 groups) or only viewed psychoeducation (n = 72; 14 groups); both groups then completed a session of group counseling. After, participants completed these same measures along with measures of group relationships. The remaining participants (n = 34; 7 groups) viewed psychoeducation and completed the same stigma measures before being informed of randomization to the wait-list control condition. Our results replicate and extend findings from Wade et al. (2011): Completing a single session of group counseling reduced self-stigma and promoted positive attitudes toward counseling. Further, completing self-affirmation reduced postsession perceptions of public stigma. Self-affirmation had no impact on group relationships. Overall, findings suggest the utility of offering a "try-out" session of group counseling as a stigma-reduction intervention; preceding with a brief self-affirmation intervention provides further benefits by reducing perceptions of public stigma. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Examining the Dimensionality, Reliability, and Invariance of the Depression, Anxiety, and Stress Scale-21 (DASS-21) Across Eight Countries.

This study evaluated the dimensionality, invariance, and reliability of the Depression, Anxiety, and Stress Scale-21 (DASS-21) within and across Brazil, Canada, Hong Kong, Romania, Taiwan, Turkey, United Arab Emirates, and the United States (N = 2,580) in college student samples. We used confirmatory factor analyses to compare the fit of four different factor structures of the DASS-21: a unidimensional model, a three-correlated-factors model, a higher order model, and a bifactor model. The bifactor model, with three specific factors (depression, anxiety, and stress) and one general factor (general distress), presented the best fit within each country. We also calculated ancillary bifactor indices of model-based dimensionality of the DASS-21 and model-based reliability to further examine the validity of the composite total and subscale scores and the use of unidimensional modeling. Results suggested the DASS-21 can be used as a unidimensional scale. Finally, measurement invariance of the best fitting model was tested across countries indicating configural invariance. The traditional three-correlated-factors model presented scalar invariance across Canada, Hong Kong, Romania, Taiwan, and the United States. Overall, these analyses indicate that the DASS-21 would best be used as a general score of distress rather than three separate factors of depression, anxiety, and stress, in the countries studied.

Modeling cohesion change in group counseling: The role of client characteristics, group variables, and leader behaviors.

Despite continued empirical support for a relationship between group cohesion and therapeutic gain, few studies have attempted to examine predictors of cohesion during the life of counseling groups. The present investigation explored the impact of client variables, group characteristics, and first-session leader behaviors on changes in cohesion across time. Participants were 128 volunteer clients and 14 group therapists participating in 23 separate 8-week-long counseling groups. Results of latent growth curve (LGC) analysis indicated that a piecewise, linear-quadratic model best fit the data at the individual level, while a simplified linear model best fit the data at the group level. Overall, individual differences accounted for 80-97% of the total variance in cohesion intercept and slope terms, with the included covariates explaining 9-39% of this variation. Significant individual-level covariates were gender and anxious and avoidant attachment. The only significant group-level predictor was an interaction effect between leadership behaviors in the first session. Specifically, when leaders performed a high number of structuring behaviors in the absence of facilitating emotional sharing, cohesion was lower at the end of the first session. Limitations, areas of future research, and implications for the theory and practice of brief group counseling are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Self-affirming values to increase student veterans' intentions to seek counseling.

Student veterans experiencing mental health concerns could benefit from seeking counseling (Rudd, Goulding, & Bryan, 2011), though they often avoid these services. Self-affirmation interventions have been developed to increase openness to health-related behaviors (Sherman & Cohen, 2006), and may also help promote psychological help-seeking intentions. This study explored whether a self-affirmation intervention increased intentions to seek counseling in a sample of 74 student veterans who had not previously sought counseling services. Participants completed pretest (Time 1) measures of distress and help seeking (i.e., self-stigma, attitudes, and intentions to seek counseling). A week later (Time 2), participants completed one of two conditions: (1) a self-affirmation intervention before viewing a psychoeducational video and brochure or (2) only the psychoeducational video and brochure before completing the same help-seeking measures as Time 1. A week after the intervention (Time 3), participants again completed the help-seeking measures. A focused longitudinal mediation model was conducted, examining the effect of the self-affirmation experimental condition on help-seeking intentions. Compared with those in the psychoeducation-only group, student veterans who completed the self-affirmation intervention reported increased intentions to seek counseling both immediately postintervention (Time 2) and a week later (Time 3). (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Promoting forgiveness: Characteristics of the treatment, the clients, and their interaction.

Forgiveness-based group treatments to address interpersonal hurts have been shown to be efficacious across a range of therapy models (Wade, Hoyt, Kidwell, & Worthington, 2014). However, little is known about how treatment and individual characteristics may interact in predicting outcomes. The present study examined a sample of 162 community adults randomly assigned to three treatment conditions; an 8-week REACH Forgiveness intervention (Worthington, 2006), an 8-week process group, and a waitlist control. Hierarchical linear modeling (HLM) indicated that the forgiveness-based treatment was more effective than the waitlist control across a range of forgiveness-related constructs but no more effective than the process condition. Furthermore, attachment avoidance and anxiety interacted with treatment type to predict certain outcomes, indicating that the REACH Forgiveness model may be more helpful for promoting forgiveness with insecurely attached individuals. (PsycINFO Database Record

Can use of positive religious coping predict greater distress? An examination of Army soldiers on deployment.

Although positive religious coping is generally viewed as an adaptive, functional coping pattern, some studies have actually found positive religious coping to be associated with more distress in military populations. In the current study, we examined the role of positive religious coping on distress across 2 time points. Participants in this study were 192 Army soldiers (men = 90.4%) who were stationed in Iraq for a 1-year deployment in 2005. Using structural equation modeling, we conducted a cross-lag analysis of positive religious coping and distress. Results indicated that greater use of positive religious coping significantly predicted greater distress 1 month later, whereas distress at T1 did not predict positive religious coping 1 month later. Combat exposure was also a significant predictor of distress 1 month later. Implications of these results include the need to inquire about clients' use of religious coping and whether such coping methods are having the desired effect for them. (PsycINFO Database Record

Working through past wrongdoing: Examination of a self-forgiveness counseling intervention.

This pilot study examined the effectiveness of a new emotion-focused individual counseling intervention designed to increase self-forgiveness for regretted actions committed against another person. Exactly 26 adult participants (21 completers) who indicated they had unresolved emotions about a past offense enrolled in the study and were randomly assigned to a delayed or immediate treatment condition. Controlling for screening scores, participants who received the treatment had significantly lower self-condemnation and significantly greater self-forgiveness regarding their offense at the end of treatment than did participants who spent time on a waiting list. Again controlling for screening scores, participants who received the treatment had significantly lower general psychological distress and significantly greater trait self-compassion at the end of treatment than did participants who spent time on a waiting list. All treatment gains were maintained at 2-month follow-up. In addition, increases in state self-forgiveness over the course of the intervention predicted lower levels of general psychological distress follow-up. Results of this study demonstrate the utility of this new intervention for helping clients resolve the negative residual effects of unforgiveness toward the self, both for offense-specific and general well-being outcomes.

Forgiveness in the Treatment of Borderline Personality Disorder: A Quasi-Experimental Study.

OBJECTIVE: This pilot study evaluated a manualized group forgiveness module within dialectical behavior therapy (DBT). METHOD: The study utilized a quasi-experimental double pretest design with adults (N = 40; 88.1% female, 11.9% male) diagnosed with borderline personality disorder in outpatient DBT. Measures of forgiveness, attachment, and psychiatric symptoms were completed at 4 time points. RESULTS: Participants showed increases in all measures of forgiveness and decreases in attachment insecurity and psychiatric symptoms during the forgiveness module and maintained to the 6-week follow-up. These effects were not observed during the prior distress tolerance module. Latent change score modeling showed reductions in anxious attachment mediated the effect of changes in benevolent motivations to forgive and trait forgiveness scores on reductions in psychiatric symptoms. CONCLUSIONS: Effect sizes were similar to meta-analytic findings on (a) forgiveness interventions and (b) reductions in psychiatric symptoms in DBT. Participant feedback suggested elements for further development. A randomized controlled trial is needed.

Modeling stigma, help-seeking attitudes, and intentions to seek behavioral healthcare in a clinical military sample.

OBJECTIVE: This study examined the relationship between public and self-stigma of seeking behavioral health services, and help-seeking attitudes and intent in a sample of active duty military personnel currently being assessed for traumatic brain injuries in a military health center. Although it has been suggested that many military personnel in need of care do not seek services due to concerns with stigma it is not fully clear what role different types of stigma play in the process. METHOD: Using previously collected data from a clinical sample of 97 military personnel, we conducted path analyses to test the mediation effects of self-stigma on the relationship between public stigma and attitudes toward and intentions to seek behavioral health care. RESULTS: In contrast to a model of military stigma but in line with research with civilian samples, results from this study indicate that self-stigma fully mediates the relationship between public stigma and help-seeking attitudes and intentions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: These results indicate that programming aimed at increasing mental health care use in the military might best focus on reducing self-stigma associated with seeking mental health services.

Forgiveness-reconciliation and communication-conflict-resolution interventions versus retested controls in early married couples.

The first 6 months of marriage are optimal for marriage enrichment interventions. The Hope-Focused Approach to couple enrichment was presented as two 9-hr interventions--(a) Handling Our Problems Effectively (HOPE), which emphasized communication and conflict resolution, and (b) Forgiveness and Reconciliation through Experiencing Empathy (FREE). HOPE and FREE were compared with repeated assessment controls. Couples were randomly assigned and were assessed at pretreatment (t1); 1 month posttreatment (t2) and at 3- (t3), 6- (t4), and 12-month (t5) follow-ups using self-reports. In addition to self-report measures, couples were assessed at t1, t2, and t5 using salivary cortisol, and behavioral coding of decision making. Of 179 couples who began the study, 145 cases were analyzed. Both FREE and HOPE produced lasting positive changes on self-reports. For cortisol reactivity, HOPE and FREE reduced reactivity at t2, but only HOPE at t5. For coded behaviors, control couples deteriorated; FREE and HOPE did not change. Enrichment training was effective regardless of the focus of the training.

Efficacy of psychotherapeutic interventions to promote forgiveness: a meta-analysis.

OBJECTIVE: This meta-analysis addressed the efficacy of psychotherapeutic interventions to help people forgive others and to examine moderators of treatment effects. METHOD: Eligible studies reported quantitative data on forgiveness of a specific hurt following treatment by a professional with an intervention designed explicitly to promote forgiveness. Random effects meta-analyses were conducted using k = 53 posttreatment effect sizes (N = 2,323) and k = 41 follow-up effect sizes (N = 1,716) from a total of 54 published and unpublished research reports. RESULTS: Participants receiving explicit forgiveness treatments reported significantly greater forgiveness than participants not receiving treatment (Δ+ = 0.56 [0.43, 0.68]) and participants, receiving alternative treatments (Δ+ = 0.45 [0.21, 0.69]). Also, forgiveness treatments resulted in greater changes in depression, anxiety, and hope than no-treatment conditions. Moderators of treatment efficacy included treatment dosage, offense severity, treatment model, and treatment modality. Multimoderator analyses indicated that treatment dosage (i.e., longer interventions) and modality (individual > group) uniquely predicted change in forgiveness compared with no-treatment controls. Compared with alternative treatment conditions, both modality (individual > group) and offense severity were marginally predictive (ps < .10) of treatment effects. CONCLUSIONS: It appears that using theoretically grounded forgiveness interventions is a sound choice for helping clients to deal with past offenses and helping them achieve resolution in the form of forgiveness. Differences between treatment approaches disappeared when controlling for other significant moderators; the advantage for individual interventions was most clearly demonstrated for Enright-model interventions, as there have been no studies of individual interventions using the Worthington model.

Understanding group therapists' use of spiritual and religious interventions in group therapy.

The current study examined therapist characteristics that are related to the use of spiritual and religious interventions in group therapy and to perceived barriers to attending to spirituality in group therapy among a sample of experienced group therapists. Results demonstrated that greater therapist spirituality was associated with more frequent use of both spiritual and religious interventions, as well as lower perceived barriers to attending to spirituality in group therapy. Religious commitment was only uniquely related to perceived barriers, such that therapists with higher religious commitment actually perceived greater barriers. Training in religion and spirituality and comfort with spiritual discussions was also related to therapists' use of religious and spiritual interventions and perceived barriers.

Disentangling self-stigma: are mental illness and help-seeking self-stigmas different?

Two established but disparate lines of research exist: studies examining the self-stigma associated with mental illness and studies examining the self-stigma associated with seeking psychological help. Whereas some researchers have implicitly treated these 2 constructs as synonymous, others have made the argument that they are theoretically and empirically distinct. To help clarify this debate, we examined in the present investigation the overlap and uniqueness of the self-stigmas associated with mental illness and with seeking psychological help. Data were collected from a sample of college undergraduates experiencing clinical levels of psychological distress (N = 217) and a second sample of community members with a self-reported history of mental illness (N = 324). Confirmatory factor analyses provide strong evidence for the factorial independence of the 2 types of self-stigma. Additionally, results of regression analyses in both samples suggest that the 2 self-stigmas uniquely predict variations in stigma-related constructs (i.e., shame, self-blame, and social inadequacy) and attitudes and intentions to seek help. Implications for researchers and clinicians interested in understanding stigma and enhancing mental health service utilization are discussed.

Cross-cultural validity of the Self-Stigma of Seeking Help (SSOSH) scale: examination across six nations.

Researchers have found that the stigma associated with seeking therapy--particularly self-stigma--can inhibit the use of psychological services. Yet, most of the research on self-stigma has been conducted in the United States. This is a considerable limitation, as the role of self-stigma in the help-seeking process may vary across cultural groups. However, to examine cross-cultural variations, researchers must first develop culturally valid scales. Therefore, this study examined scale validity and reliability of the widely used Self-Stigma of Seeking Help scale (SSOSH; Vogel, Wade, & Haake, 2006) across samples from 6 different countries (England, Greece, Israel, Taiwan, Turkey, and the United States). Specifically, we used a confirmatory factor analysis framework to conduct measurement invariance analysis and latent mean comparisons of the SSOSH across the 6 sampled countries. Overall, the results suggested that the SSOSH has a similar univariate structure across countries and is sufficiently invariant across countries to be used to explore cultural differences in the way that self-stigma relates to help-seeking behavior.

Is stigma internalized? The longitudinal impact of public stigma on self-stigma.

Stigma is considered an important barrier to seeking mental health services. Two types of stigma exist: public stigma and self-stigma. Theoretically, it has been argued that public stigma leads to the development of self-stigma. However, the empirical support for this assertion is limited to cross-sectional data. Therefore, the goal of this research was to examine the relationship between public stigma and self-stigma over time. Perceptions of public and self-stigma were measured at Time 1 (T1) and then again 3 months later at Time 2 (T2). Using structural equation modeling, we conducted a cross-lag analysis of public stigma and self-stigma among a sample of 448 college students. Consistent with assertions that public stigma leads to the development of self-stigma, we found that public stigma at T1 predicted self-stigma at T2, whereas the converse was not true. These findings suggest that if self-stigma develops from public stigma, interventions could be developed to interrupt this process at the individual level and reduce or eliminate self-stigma despite perceptions of public stigma.