A Novel Religious/Spiritual Group Psychotherapy Reduces Depressive Symptoms in a Randomized Clinical Trial

Two major features of Buddhism are first, that the nature of the soul is divine, and that if you perceive the law of “Causality” (i.e., cause and effect) and lead the best possible life in accordance with this law, then you can progress toward a being of higher spiritual level (Allen 2006; Okawa 2004). Second, in connection with any discussion of the meaning of cause and effect, the idea of “Reincarnation” is very important. Indeed, reincarnation has also been incorporated into some recent Western psychiatric practices such as Past-Life therapy (Weiss and Weiss 2012).

In addition to these Buddhist principles, the HSC group psychotherapy includes the Principles of Happiness of “Fourfold Paths” preached in Happy Science which is one of the largest Japanese religious institutions (Okawa 2009, 2013; Kurokawa et al. 2015). The first principle of Fourfold Paths is the principle of Love. When we give love, we discover that our thirst for love and happiness is eased. Love is also to believe in other people, recognizing that we are all children of God. As such, we have to suppress some of our less admirable desires, and instead, be kind to those around us and try to live a life that is of benefit to them and to society as a whole.

The second principle is the principle of Wisdom. Wisdom means deep, life-knowledge and includes knowing spiritual facts and the Universal Truth. Knowledge is power. It provides us with the answers to solve our problems and relieve us from our worries. Furthermore, by knowing the Truth, we can transform our lives by turning our former problems into rewarding experience. In turn, the experience will allow us to speak words of wisdom to guide others. The HSC group psychotherapy makes wisdom available to patients to encourage a shift from “Perfectionism” toward “Optimalism.” Optimalism is a philosophical form of optimism, which specifically refers to a belief that while the world may not be perfect it is better than the available alternatives (Ben-Shahar 2009). The Optimalist understands that failures in life are part of the learning process and appreciates the journey toward success. In contrast, the Perfectionist rejects the limits of human ability, and is driven by the fear of failure (Ben-Shahar 2009). This all-or-nothing approach leads to procrastination and, more generally, to inefficient use of time.

The third principle is the principle of Self-reflection. We think that once a mistake is made, it is fixed forever in reality and cannot be altered. In a material sense, this is true. But what happens in the mind encompasses past, present, and future. When we regret and truly repent on our actions, the mistake can not only be undone, but the blessings we receive for awakening the Truth will far outweigh what we had before. Genuine self-reflection can offer far more than simple forgiveness and provide support, encouragement, power, and energy.

The fourth principle is the principle of Progress. There are many methods to win or succeed whether in business or in life. The law of thought is that both good and bad thoughts will someday be manifested. By mastering love, wisdom, and self-reflection, we can find ourselves on the right path to progress: one in which the achievement of our goal will contribute to the happiness of all humankind. Optimism and hopefulness have critical effects on the ability to make progress as they protect against depression and promote better physical health (Chida and Steptoe 2008).

There is a need for more robust trials of HSC group psychotherapy. Our first randomized controlled trial (Chida and Kim 2011) had a very small sample size (26 outpatients), and although we found an effect of the HSC group psychotherapy on depressive symptoms, we assessed outcome effectiveness only immediately after the intervention. Moreover, we did not evaluate baseline religious demographic characteristics which may be powerful confounders especially in trials of religious/spiritual psychotherapy. The present trial aimed to enroll a larger sample size (140 outpatients), to evaluate outcome effectiveness not only at post-intervention but also at 3-month follow-up, and to explore the relationship of religious demographic characteristics with responses to the psychotherapy.

The study used a two-group (intervention vs. a usual care delayed-treatment control) by three-time (assessment at pre-intervention, post-intervention, and 3 months after intervention) trial design and was conducted at the Happy Smile Clinic in Kawasaki city, Kanagawa, Japan, between January 2012 and December 2013.

Criteria for enrollment were (1) 18 years or older; (2) Japanese literate; (3) diagnosed with a mood disorder (ICD-10 F30-39), neurotic stress-related and somatoform disorder (ICD-10 F40-48), or eating disorder (ICD-10 F50); (4) no psychotic symptoms; (5) no other medical condition that precluded completion of the self-report questionnaire without assistance. Participants gave full informed consent to participate in the study, and ethical approval was obtained from the Ethics Committee of the Department of Medical Science, Happy Smile Clinic. A total of 140 eligible patients were enrolled and randomly assigned to the intervention (n = 70) or delayed-treatment control condition (n = 70) (see Fig. 1 for details of patient recruitment). Twenty-two patients (10 in the treatment group and 12 in the control group) dropped out of the study because they were hospitalized or transferred to a different hospital due to mental deterioration, so the dropout rate for the current trial was 15.7 %. There were no significant differences in the demographic characteristics between patients who dropped out and remained in the trial.

Prior to the intervention, participants completed a set of questionnaires and a written consent form at the clinic. The questionnaires included questions on years of education, marital status, smoking history, alcohol consumption, religious belief, and illness duration. Their body height and weight were measured by nurses at the clinic. Their mental status was assessed at pre-intervention, post-intervention, and 3-month follow-up using the center for epidemiologic studies depression (CES-D) scale Japanese version, which has been validated previously (Shima et al. 1985). The CES-D scale consists of 20 items and assesses total depression symptoms together with four subscales: depressed affect, positive affect, somatic complaints, and interpersonal difficulties (Radloff 1977).

As described previously (Chida and Kim 2011), the 5-week (90 min/week) HSC group intervention (Table 1) consisted of orientation to symptoms from the view of Spiritual life lessons; especially Causality and Reincarnation (Session 1), and skills on how to shift from “a Love that takes” toward “a Love that gives” (Session 2), from “Perfectionism” toward “Optimalism” (Session 3), from “Anger, hatred, and grudge” toward “Forgiveness” (Session 4), and from “Hopelessness” toward “Hopefulness” (Session 5). Session 1 has patients who learn the view of Spiritual life by introducing some recent Western psychiatric practices such as Past-Life therapy (Weiss and Weiss 2012). Patients are encouraged to recognize that their current problems reveal what kind of challenges they have to overcome in this life, and that they are currently experiencing a crucial time for their spiritual growth. Session 2 encourages an appreciation of “love that gives” by asking patients to recall situations where they had been taken care of by others. Session 3 uses the Pareto principle (also known as the 80/20 rule) (Koch 2005) to encourage a shift from Perfectionism toward Optimalism. The patients are instructed to create a list of their real-life problems, order them in terms of priority, and adopt the 80/20 rule whereby they invest their efforts in the most important 20 %. Session 4 encourages patients to forgive using a self-reflection technique known as the “REACH” intervention, developed by Worthington (Seligman 2003). The patients are instructed to recall hurtful experiences and then to try to understand from the perpetrator’s point of view why this person hurt them. They are asked to recall a time they transgressed, felt guilty, and were forgiven. In return for forgiveness from another person, they might be more inclined to forgive their offender. Session 5 promotes optimism and hopefulness using a sentence-completion technique, devised by the psychotherapist Nathaniel Branden (Ben-Shahar 2007). In this simple technique, patients generate endings to incomplete sentences, helping them to come up with insights that bring about meaningful change in their lives. For instance, the phrase “If I had twice as much ability as I already have, I would become aware…………..” might be completed as follows: “If I had twice as much ability as I already have, I would become aware that I could make others happier by helping them.”

For comprehension purposes, participants in the treatment group were provided with a brief booklet and were shown some video films which introduced each session topic. In addition, they were encouraged to carry out homework between sessions. The participants in the delayed-treatment control group continued with their usual medical care including either weekly or monthly case manager and/or psychiatrist visits. They also continued any medication management if applicable. They did not, however, have any group meetings during the 5-week intervention period. After completing the final questionnaires, they received the 5-week intervention as courtesy for participating in the study.

Descriptive statistics were run on all variables to examine frequency distributions and to identify missing data and outliers. Group comparisons of descriptive data were carried out using t-tests for continuous variables (age, education years, BMI, mood status, and illness duration) and Chi-square tests for categorical variables (current smoking and alcohol intake (YES or NO); marital status (single, married, or divorced); religious belief (Buddhism, Shintoism, Christianity, Atheism or Materialism, or impossible to answer); diagnosis (depression [ICD-10 F32-33], panic disorder [ICD-10 F40.01, F41.0], social anxiety disorder (SAD) [ICD-10 F40.1], general anxiety disorder (GAD) [ICD-10 F41.1], obsessive–compulsive disorder (OCD) [ICD-10 F42], somatoform disorder [ICD-10 F45], and eating disorder [ICD-10 F50]); and medication (antidepressant, minor tranquilizer, and/or sleep inducer). Group comparisons of pre-intervention, post-intervention, and 3-month follow-up mean change scores (CES-D score at each time point—CES-D score at pre-intervention) were carried out using repeated analysis of covariance (ANCOVA), controlling for the descriptive characteristic shown in Table 2. The main analysis used total CES-D mean change scores as the outcome, and additional analyses were carried out with mean change scores on the separate CES-D subscales as outcome variables. In each analysis, only the descriptive characteristics which were significantly different between the control and trial groups were controlled in repeated ANCOVA. Sample size calculation was based on the absolute change in depressive symptoms as measured by the CES-D questionnaire from the pre-intervention to the post-intervention and at 3-month follow-up assessments. The trial is powered to detect an effect size of 4.5 or larger on the CES-D in a one-sided test (α = 0.05) at a power of 80 % (1-β), and assuming a common standard deviation of the CES-D scores of 8.4, a total of 106 participants (n = 53 in each group) are needed in the study. All analyses were performed using Statistical Package for the Social Sciences (SPSS, version 21.0), and all tests of statistical significance were based on two-sided probability.

As the control group in this trial received only usual care, the effects of the HSC intervention might have been at least partly due to social contact. Future trials should include a control group that involves some group social activity.