Pakistan Journal of Professional Psychology: Research and Practice Vol. 12, No. 2, 2021

Spiritually Integrated Cognitive Behavior Therapy for Treatment of Depression in a Male

Patient with Cardiac Illness and Diabetes

*Erum Kausar

Institute of Professional Psychology, Bahria University Karachi Campus

Zainab Hussain Bhutto

Institute of Professional Psychology, Bahria University Karachi Campus

This case study aimed to ascertain the effectiveness of spiritually integrated cognitive behavior

therapy (SICBT) in the treatment of depression in a male patient with cardiac illness and

diabetes. It was hypothesized that there would be a significant difference in the level of

depression reported by a male patient with cardiac illness and diabetes before and after being

treated with spiritually integrated cognitive behavior therapy (SICBT). This case study was

carried out at a private hospital in Karachi, Pakistan. The patient in this case study was a 49 year

old man. A semi-structured interview and Depression in Chronic llnesses Scale (DCIS; Yaseen,

2014) were used as pre and post measures. Techniques from spiritually integrated cognitive

behavior therapy (SICBT) (Good, 2010) were adapted to alter negative thoughts and modify

behavior. Post treatment assessment indicated an improvement in the patient’s overall

functioning and showed remarkable reduction in symptoms of depression. Patient reported

gaining insight and having control over negative thinking. Based on the post treatment

assessment, it can be concluded that SICBT can be an effective approach to treat depression in

patients with cardiac illness and diabetes. It is critical to note that the factor of subjective

inclination towards spirituality needs to be considered while drawing any conclusion.

Keywords: spirituality, cognitive behavior therapy, depression, cardiac illness, diabetes

Depression has become the key cause of worldwide disability and affects individuals of

all ages, and countries from all walks of life (Farahzadi, 2017). People experience depression in

different ways as it affects daily life, productivity, relationships, and some chronic health

conditions. There are many causes of depression ranging from brain related factors to

environmental factors (Marcus et al., 2012). Common etiology includes personal or family

history, early childhood trauma, and low self-esteem, being self-critical, stressful events, certain

medication or drug, and/or medical conditions such as cardiac illness or cardiovascular diseases,

which is a general term that refers to conditions affecting the heart or blood vessels (Huffman et

al., 2013).

Depression is a common occurrence among patients with cardiac diseases (Bekelman et

al., 2007). Prevalence of depression is 13.9 % to 36.5 % in patients with heart failure diseases

(Bekelman et al., 2007). In addition, depression in patients with cardiac diseases results in poor

quality of life, with a decline in health status and social functioning (Farahzadi, 2017). Many

patients with cardiac diseases feel worried and anxious as well. This is because cardiac illnesses

have become the leading causes of morbidity and mortality across the globe. Many researches

show a direct association of cardiac illnesses with psychological illnesses and have been

observed to be caused by one another. However, the exact nature of the link is still unknown (De

Hert et al., 2018).

_____________________________

*Correspondence concerning this article should be addressed to Ms. Erum Kausar, Institute of Professional

Psychology, Bahria University Karachi Campus, Pakistan. Email: erumkausars@yahoo.com

SPIRITUALLY INTEGRATED COGNITIVE BEHAVIOR THERAPY 71

Individuals with chronic medical conditions are more likely to be depressed as compared

to healthy people. Type 2 diabetes mellitus (T2DM) is one such medical condition. T2DM

patients are two times more likely to develop depression than the general population. The cause-

and-effect relationship between these two entities remains unclear as to whether diabetes

increases the risk of depression or depression increases the risk of diabetes. Despite the well-

known association, physicians often fail to recognize and appropriately address depression while

managing diabetics. This could be due to the limited time period available for consultations, a

perception that treating depression is not in the domain of physicians treating depression, or

doctors’ under-recognition of the potential impact of depression on diabetes (Arshad & Alvi,

2016). Depression associated with cardiac diseases and diabetes is distinct due to the medical

and social factors that accompany the diseases. World Health Organization (WHO) reports that

annually 57.02 million deaths occur from heart diseases. According to the College of Physicians

and Surgeons Pakistan (CPSP), across the globe, over 40 % of disease burden is because of the

group in cardiovascular diseases, whereas for all other diseases it measures less than 60 %

(WHO, 2017). It is however treatable through different methodologies.

Both psychological therapies and medications have proven to be useful in treating

depression. Psychotherapy, through different schools of thought, has been used for decades to

treat depression. Therapies such as solution-focused therapy, dialectical behavior therapy, and

cognitive behavior therapy are considered useful. Cognitive behavior therapy (CBT) is one of the

most used and effective methods for the treatment of depression, which targets the beliefs and

thoughts of the person (Pearce & Koenig, 2013). SICBT that is another method used for treating

depression. Through enhancing and modifying the beliefs and values of patients’ spiritual

narratives, this method is used for recovery, treatment adherence, low post-treatment relapse, and

reduced disparities (Bekelman et al., 2007).

Objective of the Study

To investigate the usefulness of the SICBT in reducing depression in a male patient with

cardiac illness and diabetes.

Hypothesis of the Study

There will be a significant difference in the level of depression experienced by a male

patient with cardiac illness and diabetes before and after the SICBT.

Method

Design of the Study

A pre-post quantitative research design was used in the current case study in which a pre-

treatment assessment was done, followed by a 12-week session plan, after which a post treatment

assessment was conducted.

Sample

The participant in this case study was a 49 year old man, of Pakistani origin, with Islamic

faith, who had cardiac illness and diabetes with a moderate level of depression as measured

through the Depression in Chronic Illness Scale (DCIS; Yaseen, 2014). The participant was able

to read, write, and comprehend the English language. The participant’s educational level was

graduation. He was offered treatment through a private hospital in Karachi, Pakistan. He was

diagnosed with cardiac illness and diabetes for one year and a few months.

72 KAUSAR AND BHUTTO

Assessment Protocols

Demographic Information Form

The form consisted of items related to demographic information, including name, age,

gender, qualification, marital status, address, religion, etc. This form also included questions

related to socio-economic background, employment status and duration of employment, and the

history of the cardiac condition and diabetes such as duration of the disease, course of medical

treatment, and doctors’ consultation.

Semi-Structured Interview Form

This form was administered to collect data about the participant’s developmental history

for the purpose of understanding his particular individual context. The form comprised questions

covering history of physical illness, early childhood, family and work, etc.

Depression in Chronic Illness Scale (DCIS; Yaseen, 2014)

The DCIS was administered. It is a culturally receptive scale to measure depression in

chronically ill patients. It is an 18 item Likert scale, and each item is scored from 0 to 3 (strongly

agree = 3, agree = 2, disagree = 1, strongly disagree = 0), and the total score ranges from 0 to

54. A score between 0-16, indicates no and/or minimal depression, 17-25, indicates mild

depression, 26-33 indicates moderate depression, and higher than 33 depicts severe level of

depression. The scale has demonstrated good psychometric properties, as the scale's internal

consistency is .83 and test-retest reliability is .85.

Procedure

Approval from the Ethical Review Committee was obtained. Permission was requested

from the authors for the use of DCIS and the use of a twelve-week manualized SICBT treatment

plan. After securing permission, and approval of relevant authorities at the hospital, the

participant was offered information about the treatment. The identified participant had a cardiac

condition and diabetes for one year, with moderate depression.

The participant was informed about the voluntary nature of his participation and his right

to withdraw at any time, the purpose of the research, and the maintenance of confidentiality. The

participant was presented with the pre-intervention measures, including the demographic

information form, semi-structured interview form, and the DCIS by Yaseen (2014), followed by

the twelve-week manualized SICBT treatment plan. This plan is based on a total of 12 sessions

over the course of 12 weeks, lasting for 60 minutes each, as adapted from Good (2010).

Table 1

Details of the Twelve-week Manualized SICBT Treatment Plan

Session

Aims and Objectives

Description and Homework

Explanation and

education about

depression

To go through the

working treatment

plan,

psycho-education

and learning,

setting goals,

An overview of the structure, the total number

of sessions with the expectation for each

session and answering participant’s queries.

The spiritual assessment and goal setting.

The depression symptoms questionnaire was

administered.

SPIRITUALLY INTEGRATED COGNITIVE BEHAVIOR THERAPY 73

Session

Aims and Objectives

Description and Homework

spiritual history for

designing an

individualized

treatment plan.

Identification of

participant’s

specific symptoms

of depression,

suicidality and self-

harm assessment.

The assessment of suicidality and self-harm.

In case of any suicidal thoughts, a safety plan

was developed to ensure the safety of the

participant.

Homework: The hand-out on depression and

CBT was shared.

To prepare questions from the handouts

regarding depression and symptomatology.

To read the given Quranic verses from Surah

Al-Qaf as a reminder of Allah’s blessings.

Education about

the SICBT

approach

Education about

approaches utilized

within the treatment

plan.

To answer the

queries of the

material and

content related to

the previous

session,

To introduce Surah

Rahman (audio

version).

Homework from the previous session was

reviewed.

Questions were answered from the hand-out on

depression, cognitive-behavior therapy, or

Quranic guidelines.

Briefing on SICBT and how it works.

Spiritual coping strategies were discussed, and

intervention regarding altering thought cycles

was discussed.

The participant also said prayer at the end of

the session.

Homework: The activity monitoring schedule

to keep a record of his daily activities to collect

objective information about functioning and

track the activities/events that lead to higher-

level enjoyment or higher level of depression.

Behavior

Strategies

The key focus of

the session was on

behavioral

strategies, which

were highlighted

briefly in session 2.

The aim was to

design a behavior

plan for the

participant.

Homework was reviewed, learning and

performing deep breathing exercises.

A behavior plan was devised.

This was done by completing a doing more

questionnaire, which helped in goal setting,

self-monitoring, and rewards for the participant

to keep motivated.

The audio version of Surah-Ar-Rahman (The

Beneficent) by Mishrary Rashid Alafasy was

played.

The participant was guided to say a prayer at

the end of the session.

Homework: To implement the behavioral

74 KAUSAR AND BHUTTO

Session

Aims and Objectives

Description and Homework

strategy developed in the present session for

increasing pleasurable activities, and reducing

the ones that contribute to increasing the level

of depression. This included increasing self-

monitoring towards achieving the goals and

following through with the rewards when

earned along with the weekly checklist.

Behavior

Strategies

To learn about the

concepts of being

more and doing less

with the learning of

new techniques.

Review homework and answering the basic

concept of doing more was explained in the

previous session, and the concept of being

more and doing less was explained in this

session.

The process of shaping, which involves

creating a series of steps to follow to carry out

a certain behavior and stimulus control, that is

related to dealing with the environment where

one carries out the behavior included in doing

more.

The idea of being more was explored.

Doing less was explored, and it was linked to

bitterness and problems with forgiveness and

overindulgence, which can contribute to

depression by impeding spiritual growth.

The participant was guided to do a deep

breathing exercise after which Surah-Ar-

Rahman was played.

The participant was guided to say a prayer at

the end of the session.

Homework: The participant was also asked to

focus on being more, spiritual identity

development, and doing less related to

behaviors that were inconsistent spiritually.

Cognitive

Strategies

To focus on

exploring cognitive

aspects and the

impact it has on

depression.

To explore the

ways in which

Review the homework and answer queries

regarding previous session and homework,

The researcher reminded the participant of the

cognitions previously discussed whilst looking

at the depression symptom questionnaire.

The participant was informed about the

cognitive-behavior model.

SPIRITUALLY INTEGRATED COGNITIVE BEHAVIOR THERAPY 75

Session

Aims and Objectives

Description and Homework

varying

interventions of the

spiritual domain

can be used

integrated with the

cognitive-behavior

model.

The participant was guided to do a deep

breathing exercise after which Surah-Ar-

Rahman was played.

The therapist incorporated the prayer.

Homework: To maintain a cognition log.

Cognitive

Strategies

To work on

identifying

cognitive strategies

of SICBT.

The therapist reviewed the cognition log.

The analysis and discussion of several

cognitive distortions.

The participant and the therapist worked

together to identify ways to combat cognitive

distortions, such as using Surah-Ar-Rahman

and Quranic passages from Surah al Inshirah

(as this Surah was revealed for easing the pain

of Prophet PBUH, surrendering to Allah and

prayer).

Therapist also reviewed the spiritually

integrated dysfunctional thought record step-

by-step with the participant and explained how

it would be filled as homework for monitoring

negative cognitions.

A deep breathing exercise and prayer was

done.

Homework: The participant was requested to

fill spiritually-integrated dysfunctional thought

records for monitoring negative cognitions.

Cognitive

Strategies

To focus on verbal

and visual beliefs

and how they play

out in their life.

To learn and

explore ways on

how Quranic

passages or stories

can be used to

challenge irrational

cognitions.

Review of homework of spiritually-integrated

dysfunctional thought record.

The participant was informed about the two

types of beliefs: Verbal and visual, and this

was linked with Quranic stories or passages of

Prophet Noah (A.S) and Prophet Ibrahim

(A.S). Allah helped them in difficult times,

challenging irrational cognitions and creating

healthy counterstatements reflective of Allah’s

love and supervision through different verses

from the Quran.

Surah-Ar-Rahman was played.

76 KAUSAR AND BHUTTO

Session

Aims and Objectives

Description and Homework

The session included a deep breathing exercise

and also incorporated a prayer.

Homework: To fill the index cards as

homework. These cards included a question on

the one hand “What am I particularly

struggling with right now?” And on the other

hand, the religious story or guideline that

challenged that statement. These cards were

used for converting negative thoughts into

positive ones.

Cognitive

Strategies

To address the

questions regarding

cognitive aspects,

which include self,

others, the future,

and Allah or

spirituality.

Identifying the

cause or root of

these belief

systems, which

contributed to

increase depression,

worked on

modifying these

beliefs in a

spiritually

consistent manner

with the

participant’s way of

living.

Review of the homework of index cards.

The participant was informed about the

cognitive quadrants, including beliefs about

self, others, future, Allah, and spirituality. The

participant had to fill different worksheets in

order to identify his cognitive quadrants.

Discussed ways in which these beliefs have an

influence on life and how they can be changed

towards healthier beliefs as per the spiritual

doctrine.

The participant was guided to do a deep

breathing exercise after which Surah-Ar-

Rahman was played.

The participant was guided to say a prayer at

the end of the session.

Homework: To continue evaluating the

cognitive triad and research on various Quranic

passages or truths which would negate

irrational beliefs and restructure his personal

beliefs to develop healthier working ones.

Cognitive quadrant form as homework in

which he had to write the Quranic verses that

challenged old beliefs and incorporate new

ones.

Surrender and

Control

To initiate the

surrendering

process in front of

Allah and allow

Him to control the

A review of the religious beliefs of the

participant.

The unconfessed sin/spiritual incongruence

was recognized, and Quranic references of a

loving Allah were discussed.

SPIRITUALLY INTEGRATED COGNITIVE BEHAVIOR THERAPY 77

Session

Aims and Objectives

Description and Homework

client's life.

To teach

surrendering

concerns, worries,

burdens, and

depression to Allah

as a coping skill for

ensuring that the

participant feels

relieved and stress-

free considering

that stress,

concerns, worries,

and burdens are

taken away and

placed into the hand

of Allah.

Surah-Ar-Rahman (The Beneficent) was

played.

The therapist took the participant through a

guided imagery exercise (followed by calming

breath exercise), which helped the participant

release concerns into the care of Allah’s loving

hands.

The therapist asked the participant to reflect on

the experience. The therapist allowed time to

process any experienced emotions.

The therapist incorporated a prayer at the end

of the session

Homework: To write a letter to Allah

including a description of the burdens of the

participant, present relationship with Allah and

the desired one, and the personal efforts to

bridge the gap.

Meditation

The session aimed

to teach the

meditation process

and review the

process of guided

imagery for gaining

perspective, quiet

reflection, and inner

peace.

Reviewing homework, the participant learned

the meditation process that incorporated

breathing, visual meditation, visualizations,

and counting breaths, and the importance of

gaining perspective, reflection, and inner

peace.

The surrender/control from the last session,

Serenity Prayer, and the ways of maintaining

the message in the Quranic passages from

Surah An-Nahl and serenity prayer for

acceptance in the life of the participant such as

reading a self-enhancement book, joining a

Quran research, and continuing to work on

developing ways to challenge those previous

negative beliefs.

Used other meditation methods by counting

breaths and a mantra, which included focusing

on a single word or phrase such as “Ar-

Rahman,” and repeating it silently to impact

the thoughts positively.

Listening to Surah-Ar-Rahman during the

session.

78 KAUSAR AND BHUTTO

Session

Aims and Objectives

Description and Homework

The session ended after saying the prayer.

Homework: The therapist asked the

participant to listen to Surah-Ar-Rahman daily,

for a week, till the next session

Relaxation

Introductory

Discussion,

Explanation of

Relaxation

Review of meditational exercises that were

previously taught.

The therapist explained the rationale for

relaxation technique. Progressive muscle

relaxation was practiced.

The participant was given time to reflect on the

new exercises and encouraged to implement

relaxation over the next week.

Surah-Ar-Rahman was played.

The session ended with a prayer.

Homework: The progressive muscle

relaxation (PMR) exercise to be practiced daily

throughout the week.

Review and

Overview of

Treatment/

Closure

This session aimed to

review whatever has

been discussed and

practiced as the

treatment, and analyze

the change for possible

relapse prevention

The session started by answering any of the

participant’s queries related to the reading

material given in the previous sessions,

followed by the discussion of different things

to give closure for the developed therapeutic

relationship and treatment.

The participant and the therapist reviewed the

ways the participant has changed through the

treatment and examined the goals established

initially and how the participant has achieved

them during this treatment.

The closure activities entailed a discussion of

the depressive symptoms that the participant

had from the start of the treatment, areas of

change, the learned tools, and identifying the

ones that are effective and helped in the

reduction of the individual symptoms.

The participant communicated personal views

on spirituality and noted any changes in this

respect.

The therapist and the participant also reviewed

the learned skills and strategies and how,

SPIRITUALLY INTEGRATED COGNITIVE BEHAVIOR THERAPY 79

Session

Aims and Objectives

Description and Homework

when, and why they could be used.

Finally, the participant set the goals for future

and discussed relapse prevention with the

therapist.

In the end, all queries of the participant were

addressed.

Results

The result was compiled and analyzed using pre-post analysis. After completion of the

twelve-week manualized SICBT treatment plan, post-treatment assessment was conducted using

the measure of DCIS. Participant’s post treatment score of 18, as compared to the pretreatment

scores of 31, indicated a significant decrease.

Discussion

Results showed significant difference in the level of depression from the pretreatment

score of 31 (pre-test) to the post treatment score of 18 (post-test). This decreased value (18) is

just above the range of no depression (score falling in the range of 0-16). This indicated that the

treatment procedure is effective in decreasing the level of depression of the participant. Thus, the

hypothesis that SICBT would be effective in reducing the level of depression, was supported.

One of the reasons behind the effectiveness of the treatment was the participant’s faith as

a Muslim and belief in Quranic verses. These verses were used in the treatment plan according to

the faith of the research participant.

All the strategies utilized in the current research, including religious coping strategies, are

very much a part of the coping strategies among the Muslims in Pakistan. Similarly, the

researcher used Quranic and spiritual elements during meditation as well. Common phrases such

as “Allah,” “Al-Rahman,” “Raheem,” “Alhamdulillah,” “Allah is with me” were used during

meditation to reinforce not being alone and having divine support.

The inclusion of Surah Rahman and prayer in the treatment helped the researcher model

the spiritual part of the intervention effectively and assisted in regulating positive emotions and

strengthening faith in times of difficulty. Surah Rahman has been associated with possible

mechanisms of activating and releasing emotions that affect the symptoms of depression, such as

negative thinking patterns. This is similar to Mahjoob et al. (2016), which showed the positive

effect of listening to recitation from the Holy Quran, without its rhythmic tone, on participants’

mental health in Iran. Behavior and cognitive strategies were utilized including activity

monitoring schedule, deep breathing exercises, goal setting, and self-monitoring which would

have been helpful in self-regulation and in creating awareness about the connection between

thoughts, feelings and behavior. The present positive gains through treatment utilizing SICBT,

highlight that psychological intervention of this type helped the participant to alter his cognitive

distortions and use faith based practices in decreasing depression whilst allowing greater positive

emotions. These findings are in line with Azhar and Varma (2000). The spiritual component of

the treatment provided assistance in building the capacity to allow emotions (as opposed to

suppressing them), leading to a sense of wellbeing. The present outcome is in line with the

research by Pearce et al. (2015) which highlighted the integration of spiritual and religious

beliefs in intervention as a means of reducing depression rather than the use of secular therapies

80 KAUSAR AND BHUTTO

for religious patients. Some of the major tools of the present therapeutic approaches, (which were

also part of the current treatment plan), included scripture memorization to renew one’s mind,

contemplative prayer, challenging thoughts using religious teachings, engaging in religious

practices (e.g., gratitude, altruism, forgiveness), and involvement in a religious community. The

basis and foundation of this therapy is the integrative therapeutic plan in which an individual’s

own beliefs, behaviors, and resources are analyzed and utilized to facilitate recovery.

Conclusion

The present research aimed to investigate the efficacy of SICBT in reducing depression

in a male patient with cardiac illness and diabetes. Results of the current case are in favor of

utilizing SICBT to reduce the level of depression.

Implications

The present research provides a therapeutic direction for the treatment of depression in

patients suffering from cardiac illnesses and diabetes with the help of SICBT. It also reinforces

the need to pay close attention to a person’s faith and utilization of spirituality in treatment

planning and implementation.

Limitations and Recommendations

 The research included a participant with the Muslim faith. Future research could include

participants from other faith traditions.

 The research participant was a man in his 40s. Future work can focus on different age

ranges including different genders.

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Contribution of Authors

Sr. No.

Author

Contribution

Erum Kausar

Conceptualization, methodology, research conduction, analyses

and interpretation, write-up

Zainab Hussain

Bhutto

Critical review of manuscript and supervision