May 2010 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Lawler-Row, K. A. "Forgiveness as a Mediator of the Religiosity-Health Relationship." Psychology of Religion and Spirituality 2, no. 1 (February 2010): 1-16.
SUMMARY and COMMENT: Our article this month revisits the topic of forgiveness, which was last explored in our October 2007 selection. That earlier AoM looked broadly at relationships between forgiveness and health and -- in the Related Items of Interest section -- addressed of some spiritual factors. The current article reports three studies that attempt to discern specifically how forgiveness may mediate religion-health associations. This is a highly technical piece, employing a variety of instruments that bring a number of variables into play. It implicitly testifies to the difficulty of working with such a complex concept as forgiveness, atop the complexity already present in spirituality/religion and health research. However, for this reader, it is remarkable for 1) establishing some bases to see forgiveness as a mediator, 2) noting the potential importance of the little-researched dynamic of feeling forgiven by God, 3) highlighting the significance of differences between state and trait forgiveness, and 4) suggesting that the context of a person's religious belief-system could be a key to understanding the power of forgiveness to affect religion-health associations. This latter point may raise for clinical chaplains a useful area for spiritual assessment.
Lawler-Row describes in detail three studies of 605, 253, and 80 middle-aged or older adults. Two of these are new and one examines archival data. Excerpts from her general discussion [--see pp. 12-14] best characterize the studies:
The author sums up:
In Experiment 1, we assessed religion with a multidimensional instrument that included three forgiveness items. Forgiveness of self and others, along with feeling forgiven by God were all associated with religious variables, such as attendance, prayer, religious coping, and religious beliefs, and with health measures such as successful aging and depression. Religious commitment…and a belief that one is responsible for reducing pain and suffering in the world were not strongly related to health variables. However, for the many religious-health associations that met criteria, all were either partially or fully mediated by forgiveness. Feeling forgiven by God fully mediated the associations between frequency of attendance, frequency of prayer, and belief in a watchful God with successful aging. …Within Study 1, there were also differences in religious commitment that were not associated with forgiveness. …Thus, religion does not necessarily have an impact on forgiveness. However, when religion is associated with both forgiveness and better health, forgiveness may be a primary pathway explaining that relationship.
Study 2 used a more extensive measure of trait forgiveness…, as well as traditional measures of religious involvement…. With the exception of autonomy, all dimensions of successful aging, as well as illness symptoms, were significantly related to both trait forgiveness and to frequency of prayer and intrinsic religious orientation. In every case, trait forgiveness fully mediated these associations.
Study 3 expanded the mediating effects of forgiveness to include state forgiveness, or perceived forgiveness in regard to a particular offense. We included two measures of state forgiveness…. Only the Existential subscale [of the Spiritual Well-Being Scale] predicted physical symptoms[,] and state forgiveness…fully mediated that relationship. Similarly, state forgiveness…fully mediated the relationship between existential well-being and number of medications and partially mediated the relationships with quality of sleep and depression. Trait forgiveness fully mediated the relationship between religious well-being and quality of sleep. [pp. 13-14]
On the basis of these three studies, one would have to conclude that religious involvement is predictive of psychological and physical health in adults. Furthermore, religious involvement is consistently related to trait forgiveness and, in some cases, to state forgiveness. The latter appears to reflect an association with spirituality or existential well-being more strongly than traditional religious commitment. Finally, in all three studies, forgiveness consistently mediated the religion-health associations. Feeling forgiven by God is a dimension of forgiveness that has rarely been assessed, yet it fully mediated associations with successful aging in Study 1. In addition, full mediation was found in Study 2 for trait forgiveness in all religion-health (i.e., prayer and intrinsic religiosity) relationships, and in Study 3 for trait forgiveness between religious well-being and quality of sleep. Finally, state forgiveness fully mediated the relationships between existential well-being and physical symptoms and number of medications. State forgiveness partially mediated the remaining associations between spirituality (existential well-being, spirituality as measured by the Stanford [Spiritual Experiences] scale) and health (sleep and depression).
Thus, forgiveness mediated the majority of the religion-health relationships obtained. Trait forgiveness appears to mediate the associations between more traditional religious variables, such as attendance, prayer and intrinsic religiosity, and psychological or subjective health, whereas state forgiveness, …appears to mediate the relationships between spirituality and physical health outcomes. In both cases, religious involvement appears to operate through a concordance between religious values and an embodied state of forgiveness, whether as a general personality trait or as a response to a specific interpersonal offense. Although the relationship between forgiveness and religious factors may be modest, it appears to play an important role in the health benefits associated with religion. [p. 14]
Clinical chaplains should find intriguing the proposal that "people who are committed to a religious belief system that has forgiveness at its core will benefit from religion most when they perceive themselves as behaving consistently with those tenets" [p. 12, and see also pp. 3-4]. Discord between oneself and one's religious belief system, specifically regarding forgiveness, could be a productive area for spiritual assessment by chaplains. Also, while most research on forgiveness has focused on a person's capacity/act of forgiving others, the present research brings into the fore the value -- so apparent to many chaplains in conversations with patients -- of feeling forgiven by God. These are two avenues by which chaplains engaged in research may find a practical foothold in the further investigation of forgiveness. Of course, beyond this, Lawler-Row offers a range of insights about instruments and associations between data for additional study. Of special note is the fact that these three studies involved mature adults, as much of the forgiveness research in the psychological literature has been conducted with younger people, often college students, since "both forgiveness and religious commitment are presumed to develop with maturity" [p. 2]. However, these studies did not involve patients per se, in the context of clinical treatment, and that could be an attractive next step for health care chaplains.
One final note about measures: the author employs the Fetzer Multidimensional Measure of Religiousness and Spirituality, which is available from the Fetzer Institute freely online (though minus the original printed booklet's covers, title page, preface, table of contents, and statement that the publication "may be used and reprinted without special permission"). This measure -- actually a collections of measures -- continues to be widely used now over a decade after its publication, and it remains a good resource for chaplain researchers. See especially Ellen Idler's section, "Forgiveness," on pp. 35-37 of the booklet, in addition to the three items incorporated in the general measure on p. 86. Lawler-Row also employs three forgiveness measures that deserve attention in further research: 1) the Forgiving Personality Scale, 2) the Transgression-Related Interpersonal Motivations Inventory, and 3) the Acts of Forgiveness Scale. The Forgiving Personality Scale can be found on pp. 329-330 of Kamat, B. I., Jones, W. H., and Row, K. L., "Assessing forgiveness as a dimension of personality," Individual Differences Research 4, no. 5 (December 2006): 322-330. The TRIM can be found on p. 1603 of McCullough, M. E., Rachal, K. C., Sandage, S. J., Worthington, E. L. Jr., Brown, S. W. and Hight, T. L., "Interpersonal forgiving in close relationships: II. theoretical elaboration and measurement," Journal of Personality and Social Psychology 75, no. 6 (December 1998): 1586-1603. The Acts of Forgiveness Scale, a 45-item instrument focusing on a single event of betrayal, is currently unpublished, but the author, Joy R. Drinnon, Assistant Professor of Psychology at Milligan College, may be contacted at JRDrinnon@milligan.edu for information [and a copy of the measure may also be obtained from the Research Network convener at email@example.com]. None of these three instruments explicitly addresses religious/spiritual aspects of forgiveness.
Suggestions for the Use of the Article for Discussion in CPE:
This month's article is not given to casual reading, and the many technical aspects may be a challenge for all but the most research-savvy CPE students. That being said, the article could still be useful for discussion in the CPE setting late in a residency year, after students have had some exposure to spirituality & health research. The introductory section (pp. 1-4) is quite clear, and the general discussion (pp. 12-14) offers a good summary account of the three studies. Students will need to understand the concept of a mediating variable, but the author gives a nice practical explanation at the beginning of her general discussion [pp. 12-13]. CPE discussion could focus on the nature of forgiveness and the distinction between "trait" and "state" forgiveness. Also, what may be the differences between the effects of forgiving others, being forgiven by others, forgiving oneself, and feeling forgiven by God? Students may especially be drawn into the idea that the power of forgiveness in the connection of religion to health may be affected by the degree of harmony or discord between a person's perception of him/herself as "forgiving," in relation to a religious tradition's teaching about forgiveness. How might chaplains listen for (and assess for) this dynamic in pastoral conversations?
Related Items of Interest:
I. For a review of earlier forgiveness research, see the October 2007 Article of the Month.
II. For other recent articles in the healt care literature on forgiveness that consider religion/spirituality, see:
Bauman, J. "The role of forgiveness in rehabilitation." Journal of Health Care Chaplaincy 14, no. 2 (2008): 75-82. [(Abstract:) This article proposes that unresolved forgiveness issues may affect rehabilitation patients' motivation to participate in their physical therapy, and that their therapeutic outcomes may benefit from working through a forgiveness process. I also suggest that chaplains have a role in helping patients address their unresolved forgiveness issues and lowered motivation by helping the patients work through a forgiveness process. For patients with conditions caused at least in part by their own behavior, or even by someone else, this article offers a case study of pastoral care provided in light of unresolved forgiveness issues and a working through of a forgiveness process. Also presented is a revised model of a forgiveness process that informs the pastoral care provided in the case study.]
Elliott, B. A. "Forgiveness Therapy: a clinical intervention for chronic disease." Journal of Religion and Health [published online-ahead-of-print: accessed 5/16/10]. [This review notes religion at a few points, but most significantly in the statement: "The observed and documented power of forgiveness interventions have been carefully designed to remain largely independent of religious insights and variables; future research will need to address questions at the intersection of forgiveness and religion…" (--no page number in online-ahead-of-print version).]
Lambert, N. M., Fincham, F. D., Stillman, T. F., Graham, S. M. and Beach, S. R. [Florida State University, Tallahassee, FL]. "Motivating change in relationships: can prayer increase forgiveness?" Psychological Science 21, no. 1 (January 1, 2010): 126-132. [(Abstract:) The objective of the current studies was to test whether praying for a relationship partner would increase willingness to forgive that partner. In Study 1 (N = 52), participants assigned to pray for their romantic partner reported greater willingness to forgive that partner than those who described their partner to an imagined parent. In Study 2 (N = 67), participants were assigned to pray for a friend, pray about any topic, or think positive thoughts about a friend every day for 4 weeks. Those who prayed for their friend reported greater forgiveness for their friend than did those in the other two conditions, even when we controlled for baseline forgiveness scores. Participants who prayed for their friend also increased in selfless concern during the 4 weeks, and this variable mediated the relationship between experimental condition and increased forgiveness. Together, these studies provide an enhanced understanding of the relationship benefits of praying for a partner and begin to identify potential mediators of the effect.]
Recine, A. C., Stehle Werner, J. and Recine, L.
"Health promotion through forgiveness intervention." Journal of Holistic Nursing 27, no. 2 (June 2009): 115-123. [(Abstract:) The author notes religious aspects of forgiveness interventions at various points. (Abstract:) The purpose of this article is to offer evidence-based forgiveness interventions clinically useful to nurses in holistic health promotion for individuals, families, and communities. Forgiveness interventions are developed and described within four approaches inspired by midrange nursing theorists who have adapted their theories from Bandura's Social Learning Theory and Frankl's Theory of Meaning. Interventions are also assimilated from a comprehensive review of theoretical and research literature. The four interventional approaches include persuasive information, vicarious experience, awareness of physiological reactions, and enactive attainment. Barriers to implementation are discussed as well as ways to individualize the interventions.]
III. For recent articles in the health care literature on forgiveness (that do not explicitly consider spirituality/religion), see:
Exline, J. J., Baumeister, R. F., Zell, A. L., Kraft, A. J. and Witvliet, C. V. [Department of Psychology, Case Western Reserve University, Cleveland, OH]. "Not so innocent: does seeing one's own capacity for wrongdoing predict forgiveness?" Journal of Personality & Social Psychology 94, no. 3 (March 2008): 495-515. [(Abstract:) People are more forgiving toward transgressors if they see themselves as capable of committing similar offenses, as demonstrated in 7 studies. Methods included hypothetical scenarios, actual recalled offenses, individual and group processes, and correlational and experimental designs. Three factors mediated the link between personal capability and forgiveness: seeing the other's offense as less severe, greater empathic understanding, and perceiving oneself as similar to the transgressor. In terms of predicting forgiveness, it was important that people's own offenses were similar to the target offense in terms of both severity and type. The personal capability effect was independent of other established predictors of forgiveness and was more pronounced among men than women.]
Friedberg, J. P., Suchday, S. and Srinivas, V. S. [VA NY Harbor Healthcare System, New York, NY]. "Relationship between forgiveness and psychological and physiological indices in cardiac patients." International Journal of Behavioral Medicine 16, no. 3 (2009): 205-211. [(Abstract:) BACKGROUND: Research suggests that forgiveness is associated with better psychological and physical health and in particular cardiovascular functioning. Despite these findings, most forgiveness studies involve healthy participants. PURPOSE: The current study assessed the psychological and physiological correlates of forgiveness in individuals with coronary artery disease (CAD). METHOD: Self-reported forgiveness, perceived stress, anxiety, and depression, and physiological data, including triglycerides, total cholesterol, high- (HDL) and low-density lipoprotein (LDL) cholesterol, were obtained from 85 hospitalized CAD patients. RESULTS: Higher levels of forgiveness were associated with lower levels of anxiety (p < 0.05), depression (p < 0.01), and perceived stress (p < 0.005) as well as lower total cholesterol to HDL and LDL to HDL ratios (both at p < 0.05) after controlling for age and gender. The psychological indices did not mediate the relationship between forgiveness and cholesterol ratios. CONCLUSIONS: Results suggest that the psychological correlates of forgiveness are similar in cardiac patients and healthy individuals. Further, among cardiac patients, forgiveness may be associated with reduced risk for future cardiovascular events.]
Hansen, M. J., Enright, R. D., Baskin, T. W. and Klatt, J. [Meriter Health Services Incorporated, Madison, WI]. "A palliative care intervention in forgiveness therapy for elderly terminally ill cancer patients." Journal of Palliative Care 25, no. 1 (2009): 51-60. [(Abstract:) Palliative care is now considered an essential part of end-of-life care, yet little research examines the efficacy of interventions addressing the psychological treatment of dying patients. Forgiveness therapy has been shown to be effective in improving psychological well-being and may provide a valuable addition to a terminal cancer patient's overall treatment plan. This study experimentally tested the effectiveness of a four-week forgiveness therapy in improving the quality of life of elderly terminally ill cancer patients. Participants (n = 20) were randomly assigned to a forgiveness therapy group or to a wait-list control group, which received forgiveness therapy in the second four-week period. All participants completed instruments measuring forgiveness, hope, quality of life, and anger at pre-test, post-test 1, and post-test 2. The forgiveness therapy group showed greater improvement than the control group, with one-tailed t-tests, on all measures. After receiving forgiveness therapy, participants in both forgiveness treatment conditions demonstrated significant improvements on all measures. The aggregated effect size was large. The four-week forgiveness therapy demonstrated psychological benefits for elderly terminally ill cancer patients and thus may be an appropriate addition to the treatment plan for terminal cancer patients.]
Lawler-Row, K. A., Karremans, J. C., Scott, C., Edlis-Matityahou, M. and Edwards, L. [Department of Psychology, East Carolina University, Greenville, NC].
"Forgiveness, physiological reactivity and health: the role of anger." International Journal of Psychophysiology 68, no. 1 (April 2008): 51-58. [(Abstract:) Research has revealed that forgiveness may have beneficial effects for the forgiver's health. The present research explored whether reductions in anger underlie such effects, or whether forgiveness has beneficial health effects above and beyond the effects of decreasing anger. State and trait forgiveness were examined, along with styles of anger expression, for their relationship to physiological responses during recalled betrayal, and to self-reported health indices. State and trait forgiveness were negatively associated with anger-out; however, with one exception, no other styles of anger expression were linked with forgiveness. Both forgiveness and anger-out were associated with systolic blood pressure, heart rate and rate-pressure product. Partial correlations revealed that trait forgiveness accounted for significant variance in mean systolic blood pressure and rate-pressure product, and state forgiveness predicted mean heart rate, even after gender and anger-out had been controlled. On the other hand, anger-out fully mediated the trait forgiveness-heart rate and state forgiveness-rate pressure product effects. Trait forgiveness was significantly associated with fewer medications and less alcohol use, lower blood pressure and rate pressure product; state forgiveness was significantly associated with lower heart rate and fewer physical symptoms. Neither of these sets of findings were the result of decreased levels of anger-out being associated with forgiveness. These findings have important theoretical implications regarding the forgiveness-health link, suggesting that the benefits of forgiveness extend beyond the dissipation of anger.]
Luchies, L. B., Finkel, E. J., McNulty, J. K. and Kumashiro, M.
"The doormat effect: when forgiving erodes self-respect and self-concept clarity." Journal of Personality & Social Psychology 98, no. 5 (May 2010): 734-749. [(Abstract:) We build on principles from interdependence theory and evolutionary psychology to propose that forgiving bolsters one's self-respect and self-concept clarity if the perpetrator has acted in a manner that signals that the victim will be safe and valued in a continued relationship with the perpetrator but that forgiving diminishes one's self-respect and self-concept clarity if the perpetrator has not. Study 1 employed a longitudinal design to demonstrate that the association of marital forgiveness with trajectories of self-respect over the first 5 years of marriage depends on the spouse's dispositional tendency to indicate that the partner will be safe and valued (i.e., agreeableness). Studies 2 and 3 employed experimental procedures to demonstrate that the effects of forgiveness on self-respect and self-concept clarity depend on the perpetrator's event-specific indication that the victim will be safe and valued (i.e., amends). Study 4 employed a longitudinal design to demonstrate that the association of forgiveness with subsequent self-respect and self-concept clarity similarly depends on the extent to which the perpetrator has made amends. These studies reveal that, under some circumstances, forgiveness negatively impacts the self.]
Pronk, T. M., Karremans, J. C., Overbeek, G., Vermulst, A. A. and Wigboldus, D. H. [Behavioural Science Institute, Radboud University Nijmegen, The Netherlands].
"What it takes to forgive: when and why executive functioning facilitates forgiveness." Journal of Personality & Social Psychology 98, no. 1 (Janauary 2010): 119-131. [(Abstract:) To establish what it takes to forgive, the present research focused on the cognitive underpinnings of the forgiveness process. We conducted four studies that examined and supported the prediction that executive functioning (a set of cognitive control processes) facilitates forgiveness. First, a correlational study revealed a positive relation between executive functioning and dispositional forgiveness (Study 1). Second, a longitudinal study demonstrated that executive functioning predicts the development of forgiveness over a period of 5 weeks after the offense (Study 2). Finally, two experiments examined when and why executive functioning facilitates forgiveness. Specifically, and in line with predictions, Studies 3 and 4 showed that executive functioning facilitates forgiveness only in the case of relatively severe (as compared with mild) offenses. Furthermore, Study 4 provided evidence for a psychological mechanism underlying the relation between executive functioning and forgiveness by demonstrating the mediating role of rumination about the offense. Implications of these findings for the literature on forgiveness and the role of executive functioning in interpersonal relationships more generally are discussed.]
Waltman, M. A., Russell, D. C., Coyle, C. T., Enright, R. D., Holter, A. C. M and Swoboda, C. [Department of Education Psychology, University of Wisconsin-Madison]. "The effects of a forgiveness intervention on patients with coronary artery disease." Psychology & Health 24, no. 1 (January 2009): 11-27. [(Abstract:) This research assesses the effects of a psychology of forgiveness pilot study on anger-recall stress induced changes in myocardial perfusion, forgiveness and related variables. Thirty-two patients were administered baseline rest and anger-recall stress imaging studies, and 17 of these participants who demonstrated anger-recall stress induced myocardial perfusion defects (forgiveness group, n = 9; control group, n = 8) were randomly assigned to a series of 10 weekly interpersonal forgiveness or control therapy sessions with a trained psychologist, and underwent additional anger-recall stress myocardial perfusion nuclear imaging studies post-test and at 10-week follow-up. Patients assigned to the forgiveness group showed significantly fewer anger-recall induced myocardial perfusion defects from pre-test to the 10-week follow-up as well as significantly greater gains in forgiveness from pre-test to post-test and from pre-test to follow-up compared to the control group. Forgiveness intervention may be an effective means of reducing anger-induced myocardial ischemia in patients with coronary artery disease.
Webb, J. R., Toussaint, L., Kalpakjian, C. Z. and Tate, D. G. [Department of Psychology, East Tennessee State University, Johnson City, TX]. "Forgiveness and health-related outcomes among people with spinal cord injury." Disability & Rehabilitation 32, no. 5 (2010): 360-366. [(Abstract:) Purpose. As motor vehicle accidents and violence cause the majority of spinal cord injuries (SCI) sustained in the USA and people with SCI will likely struggle with emotional issues related to the offender, the purpose of this exploratory study was to examine potential salutary effects of forgiveness among people with SCI incurred traumatically. Specifically, we hypothesized that forgiveness would have positive associations with health-related outcomes. Method. A community-based sample of 140 adults (19-82 years of age) with SCI completed a self-report survey regarding dispositional forgiveness of self and others, health behavior, health status, and life satisfaction. Hierarchical multiple regression analyses were employed to examine the relationships in question. Results. After controlling for demographic variables, forgiveness of self was significantly associated with health behavior and life satisfaction (uniquely accounting for 7% and 13% of the variance, respectively) and forgiveness of others was significantly associated with health status (uniquely accounting for 9% of the variance). Conclusion. Results suggest that forgiveness may play a role in the health and life satisfaction of people with traumatic SCI, with the benefit depending on the type of forgiveness offered.]
Young, L. and Saxe, R. [Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA]. "Innocent intentions: a correlation between forgiveness for accidental harm and neural activity." Neuropsychologia 47, no. 10 (August 2009): 2065-2072. [(Abstract:) Contemporary moral psychology often emphasizes the universality of moral judgments. Across age, gender, religion and ethnicity, people's judgments on classic dilemmas are sensitive to the same moral principles. In many cases, moral judgments depend not only on the outcome of the action, but on the agent's beliefs and intentions at the time of action. For example, we blame agents who attempt but fail to harm others, while generally forgiving agents who harm others accidentally and unknowingly. Nevertheless, as we report here, there are individual differences in the extent to which observers exculpate agents for accidental harms. Furthermore, we find that the extent to which innocent intentions are taken to mitigate blame for accidental harms is correlated with activation in a specific brain region during moral judgment. This brain region, the right temporo-parietal junction, has been previously implicated in reasoning about other people's thoughts, beliefs, and intentions in moral and non-moral contexts.]
IV. [Added September 8, 2014:] Chaplain Gerald M. Gundersen, at the Psychiatric Institute of Washington, has offered to our Network a brief article about "Helping Mental Health Patients Heal Through Forgiveness," which he describes as "an effort to link pastoral care with applied research through an individual case study methodology." Chaplain Gunderson has long been a supporter of spiritual care research, and he brings a research-mindedness generally to his work.