International REACH Forgiveness Intervention: A Multi-Site Randomized Controlled Trial

Importance: Forgiveness interventions have been shown in prior randomized trials to reduce depression and anxiety symptoms. Most such interventions require trained therapists, limiting scalability. Objective: To determine whether a brief self-directed forgiveness workbook intervention could alter forgiveness, depression symptoms, and anxiety symptoms. Design: A multi-site randomized waitlist-controlled trial was conducted among 4,598 participants. Recruitment occurred from February 11, 2020 to September 30, 2021. Final follow-up occured October 25, 2021. Setting: Participants were recruited from community-based samples in sites in Colombia, Hong Kong, Indonesia, South Africa, and Ukraine. Participants: Individuals (N = 7,837) were screened for eligibility. For inclusion, participants needed to be ≥18 years and have experienced an interpersonal transgression. Based on these criteria, 4,786 individuals were randomized, but 55 individuals were excluded for suspicious/fraudulent online participation, and 133 were excluded for not providing age or indicating age below 18. The analytic sample consisted of N = 4,598. Interventions: At each site, participants were randomly assigned to either immediate receipt of a self-directed forgiveness workbook intervention, or to receipt after a two-week delay. Main Outcomes and Measures: The primary outcomes were unforgiveness (Transgression-Related Interpersonal Motivations Inventory-18), depression symptoms, and anxiety symptoms (Brief Symptom Inventory-18) measured at two weeks following intervention assignment. Results: The study sample was median age 26 and 73% female. At two weeks follow-up, unforgiveness was lower among the immediate-treatment group compared to the delayed-treatment group (standardized mean difference=-0.52 [95% CI=-0.58, -0.46]); similar patterns were found for depression (standardized mean difference=-0.22 [95% CI=-0.28, -0.16]) and anxiety symptoms (standardized mean difference=-0.21 [95% CI=-0.27, -0.15]). Conclusions and Relevance: A brief workbook intervention promoted forgiveness and reduced depression and anxiety symptoms. The promotion of forgiveness with such workbooks has the potential for widespread dissemination to improve global mental health. Trial Registration: ClinicalTrials.gov Identifier: NCT04257773.