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October 2007 Article of the Month
This month’s article is highlighted by Margot Hover, D.Min., ACPE/NACC Supervisor
(with Related Items of Interest by Chaplain John Ehman, Newsletter editor)


Worthington, E. L., Jr., Witvliet, C. V., Pietrini, P. and Miller, A. J. "Forgiveness, health, and well-being: a review of evidence for emotional versus decisional forgiveness, dispositional forgiveness, and reduced unforgiveness." Journal of Behavioral Medicine 30, no. 4 (August 2007): 291-302.

[NOTE: This article appears in a special theme issue of the Journal of Behavioral Medicine on Religiosity/Spirituality and Behavioral Medicine.]


SUMMARY: This review article begins with an overview of the concept of forgiveness in the literature, noting that there is general consensus that forgiveness is not simply excusing, exonerating, condoning, pardoning or reconciling; rather, "Forgiveness is broadly understood as a process of decreasing inter-related negative resentment-based emotions, motivations, and cognition" [p. 292]. Duration relationships also comes under consideration. Forgiveness in non-continuing relationships is seen as reducing unforgiveness; in longer relationships, it includes moving from negative feelings to positive ones that eventually flavor the entire relationship itself.

A related distinction in the literature is between decisional forgiveness and emotional forgiveness:

Decisional forgiveness is a behavioral intention to resist an unforgiving stance and to respond differently toward a transgressor. Emotional forgiveness is the replacement of negative unforgiving emotions with positive other-oriented emotions. Emotional forgiveness involves psychophysiological changes, and it has more direct health and well-being consequences. [p. 291]
Some acts are confused with forgiveness when they merely reduce unforgiveness: for example, successful vengeance, seeing justice done, letting go and moving on, excusing, justifying or condoning an offense, and "turning the issue over to God because one does not believe oneself capable of judging, or turning the issue over to God in hopes of divine retribution" [p. 292]. (Chaplains should be particularly familiar with these last examples.) The authors emphasize that while "[a]ll of those reduce unforgiveness, thus usually contributing to positive health outcomes," none of them are true forgiveness.

Worthington and his colleagues find the following eight common denominators in discussions of forgiveness in the literature:

First, unforgiveness involves ruminations that may be begrudging, vengeful, hostile, bitter, resentful, angry, fearful of future harm, and depressed. Second, unforgiveness is hypothesized to be directly related to the amount of remaining justice being experienced.... Third, forgiveness involves reducing unforgiveness. Fourth, forgiveness is a process rather than an event.... Fifth, the internal experience of forgiveness can be distinguished from its interpersonal context.... Sixth, forgiveness of fundamentally different from forgiving a loved one. Seventh, making a decision to change one’s behavior could be a sincere and permanent form of forgiving, and yet that decision must be differentiated from emotionally forgiving.... Eighth, most would agree that (a) decisional forgiveness has the potential to lead to changes in emotion and eventually behavior whereas (b) emotional forgiveness, by definition, involves changes in emotion, motivation, cognition, and eventually behavior. [p. 292]
Several more recent distinctions are proving to open up deeper exploration. Forgivingness is a disposition, in contrast to forgiveness, seen as a response to a specific situation. Forgivingness seems more directly related to health, although like stress-related disorders, it normally takes years for forgivingness to impact the body. Also, forgivingness of the self is related to the physical health of the young and middle aged, but not the elderly. [See pp. 292-293.]

The authors are intrigued by the physiological mechanisms of these operations. For example, decisional forgiveness may reduce hostility without necessarily reducing stress. Its effect may be more directly related to improved relationships, a complex subject in itself. Similarly, unforgivingness of the self may negatively impact self-care and coping ability, thus effecting health in a roundabout way:

High and low forgivingness conditions differed on four potential mediators--healthy behaviors, social support, religious well-being, and existential well-being. Furthermore, high and low forgivingness conditions also differed on several indices of successful aging--autonomy, environmental mastery, positive relations with others, purpose in life, personal growth, and self-acceptance. [p. 293]
The second half of the article moves to relationships between forgiveness and health. In a section on Forgiveness in Relation to Brain Physiology and Functioning and Health, the authors cite a study [Greene, J. D., et al., "An fMRI investigation of emotional engagement in moral judgment," Science 293, no. 5537 (September 14, 2001): 2105–2108] using functional magnetic resonance imaging units to track subjects’ responses to a moral dilemma involving a speeding trolley, where either throwing a switch involving the death of one passenger or throwing the passenger to his/her death would save the train and the rest of the passengers. While this study deals with the physiological aspects of moral decision making, Worthington and his co-authors wonder: "just as there is a distinction between decisional and emotional decision making, there may be a similar distinction between decisional and emotional forgiveness and processes" [p. 294].

Another study [Farrow, T. F. D. and Woodruff, P. W. R., "Neuroimaging of forgivability," in Worthington, E. L., Jr., ed., Handbook of Forgiveness (New York: Brunner-Routledge, 2005): 259–272], this one with an intervention, utilized a functional MRI to map brain regions where forgiveness occurred for 13 patients diagnosed with post-traumatic stress disorder. Post-tests following 10 weekly 1-hour sessions of forgiveness-oriented cognitive-behavior therapy showed evidence of increased forgivability judgments and empathy. A further study [Pietrini, P., et al., "Neural correlates of imaginal aggressive behavior assessed by positron emission tomography in healthy subjects," American Journal of Psychiatry 157, no. 11 (November 2000): 1772–1781] used that technology to map imaginal aggression and inhibitory control of violence, then instructed 10 randomized subjects to forgive or not. In addition to locating forgiveness in the brain, so to speak, it appeared that females had a stronger affective response to morally hurtful events than males. And because the targeted neural activity in the brain is modulated by pain-killing drugs, hypnosis and placebo, researchers have speculated whether "forgiveness may represent a natural ‘self-aid medication mechanism’ that was selected through evolution for people to overcome distressful situations much before pharmacological agents or therapeutic interventions became available" [p. 295]. In the same way, they wonder if emotional forgiveness may serve "as an agonist for the health-promoting processes of positive other-oriented emotion" [p. 296].

A number of small studies looked at blood pressure, heart rate, and other physiological reactions both within and between subjects’ empathy, emotional forgiveness, and nursing a grudge; noting significant joy, relaxation and perceived control when forgiving, and higher sadness, anger and fear when unforgiving. One study of 100 Midwestern community residents [Toussaint, L. L. and Williams, D. R., "Physiological correlates of forgiveness: findings from a racially and socio-economically diverse sample of community residents," unpublished presentation from A Campaign for Forgiveness Research Conference, Atlanta, GA (October, 2003)] found an interesting differentiation by race:

Among white participants of high socioeconomic status, total forgiveness and forgiveness of self were associated with lower resting diastolic blood pressure. Among black participants with low socioeconomic status, forgiveness of others was associated with lower resting diastolic blood pressure, and forgiveness of others, total forgiveness, and perceived divine forgiveness were associated with lower resting cortisol levels. [p. 297]
Imaging research by Witvliet, C. V. O., et al., ["Please forgive me: transgressors’ emotions and physiology during imagery of seeking forgiveness and victim responses," Journal of Psychology and Christianity 21, no. 3 (Fall 2002): 219–233], indicated: "Apparently, while reconciliation is often valued, contemplating making a reconciliative gesture can provoke stress reactions" [p. 297].

The literature in this field is growing, but it appears to suffer from growing pains as does any new field of exploration. Sample sizes in most of the studies are very small, and many rely on self-report instruments that are brief and unproven for reliability or validity. One of the conclusions of this article is that the psychophysiology laboratory has its limits for the study of forgiveness. The authors link generalizability to the use of real-life activities, aggregate repeated measures across tasks, and pre/during/post physiology measures; but such studies are difficult to do, to say the least.

Because "forgiveness interventions" are still implemented infrequently in medical settings despite the early evidence of a link with health, the authors highlight seven areas where they might be employed: medical family therapy, cardiovascular health, chronic pain, substance use, traumatic brain injuries, cancer, and medical errors. For instance, therapy for a family struggling with a member’s illness and the resulting guilt might go in the direction of asking each person to share what they think they did to deserve or cause the illness. One five-year clinical trial of a group therapy intervention aimed at reducing hostility linked that with participants’ learning "how to cultivate the forgiving heart" [p. 298; the quote is from Kaplan, B. H., "Social health and the forgiving heart: the Type B story," Journal of Behavioral Medicine 15, no. 1 (February1992): 3–14].

The article concludes with a list of suggestions for further study: forgiveness across the life span, forgiveness training vs. interventions such as those designed to lower stress or enhance problem-solving skills. There is an extensive bibliography which includes journal articles developing definitions in this field, applications to specific medical diagnostic groups, and several touching on theology and faith in this context [--see Related Items of Interest (below)].


Suggestions for the Use of the Article for Discussion in CPE: 

This article might be discussed from several angles, depending on the educational task at the moment (e.g., exploring ones pastoral authority and identity, theological reflection in a "high tech" medical environment, developing a ministry specialty, or learning to critique or set up a research project):

1) Research Methodology: Are there any ethical implications for studies in this area? How does your institution’s Human Subjects Committee/Institutional Research Board deal with studies of traits like forgiveness?

2) Pastoral Implications: How would a chaplain design an intervention with a particular patient or staff member around the trait of forgiveness? What tools would a chaplain or congregational clergy person have available?

3) The 1999 Broadway hit, W;t [sic], dealt with the terminal illness and death of an embittered, lonely professor of English literature and expert on John Donne’s Holy Sonnets. The play is widely used in medical education as a satire on medical treatment of the dying (and was featured at the ACPE's 2006 national conference in Tampa, FL). It may be good companion piece to this article, with discussion exploring who in the play is in need of forgiveness, who can give forgiveness. How would you as a chaplain promote/bestow/inculcate/facilitate forgiveness to each of the major players? Daniel Sulmasy, OFM, MD, PhD, has written a probing and insightful analysis of the play from the standpoint of forgiveness that could be a further useful guide to a group discussion --see "At wit’s end: forgiveness, dignity, and the care of the dying," Journal of General Internal Medicine 16, no. 5 (May 2001): 335-338.


Related Items of Interest:

I. The article's bibliography cites the following regarding theology and faith in relation to forgiveness:

Romero, C., Friedman, L. C., Kalidas, M., Elledge, R., Chang, J., and Liscum, K. R. "Self-forgiveness, spirituality, and psychological adjustment in women with breast cancer." Journal of Behavioral Medicine 29, no. 1 (February 2006): 29–36. [(Abstract:) We evaluated whether a self-forgiving attitude and spirituality were related to psychological adjustment among 81 women being treated for breast cancer at a medical oncology clinic in a county general hospital. Both a self-forgiving attitude and spirituality were unique predictors of less mood disturbance and better quality of life (p's < 0.001). These results are consistent with previous research that has demonstrated a positive relationship between spirituality and well-being. The findings also suggest that self-forgiveness should be explored experimentally to determine whether it can protect against the psychological effects of breast cancer-related stress. Interventions targeting these characteristics could improve the quality of life and alleviate stress, especially in women with breast cancer in public sector settings.]

Rippentrop, A. E., Altmaier, E. M., Chen, J. J., Found, E. M., and Keffala, V. J. "The relationship between religion/spirituality and physical health, mental health, and pain in a chronic pain population." Pain 116, no. 3 (August 2005): 311–321. [Among the findings of this study of 157 patients at the Department of Surgery of a large Midwest University Medical Center were: "the longer a person had been in pain, the less forgiving they were and the less support they experienced from a religious congregation" (p. 315), "better mental health status was related to more daily spiritual experiences, forgiveness, and support from a religious congregation" (p. 315), "the intensity of participants’ pain was negatively correlated with forgiveness and positively correlated with negative religious coping" (p. 315), "the older the patient was, the more likely they were to have daily spiritual experiences, religious values/beliefs, engage in private religious practices and organizational religious practices, experience forgiveness, and see themselves as religious and spiritual" (319), and in general a "lack of forgiveness and engaging in negative religious coping seem to contribute to poor mental health and higher pain intensity" (p. 319).]

Witvliet, C. V. O. "Forgiveness and health: review and reflections on a matter of faith, feelings, and physiology." Journal of Psychology and Theology 29 (2001): 212–224. [(From the abstract:) ...This article reviews current research, with reflections on how Christians might engage this literature. It considers Christian and psychological conceptualizations of forgiveness, reviews the published literature on forgiveness and mental and physical health, addresses theoretical and interpretive issues, and reflects on ways that Christians may thoughtfully consider the contributions and limitations of empirical research on forgiveness and health.]

Worthington, E. L., Jr., ed. "Dimensions of Forgiveness: Psychological Research and Theological Perspectives." Philadelphia: Templeton Foundation Press, 1998. [Chapters: "The ethos of Christian forgiveness," by Martin E. Marty; "The elements of forgiveness: a Jewish approach, " by Elliot N. Dorff; "Forgiveness as a method of religious coping," by Kenneth I. Pargament and Mark S. Rye; "The victim role, grudge theory, and two dimensions of forgiveness," by Roy F. Baumeister, Julie Juola Exline, and Kristin L. Sommer; "The pyramid model of forgiveness: some interdisciplinary speculations about unforgiveness and the promotion of forgiveness," by Everett L. Worthington, Jr.; "Researching the process model of forgiveness within psychological interventions," by Robert D. Enright and Catherine T. Coyle; "Science and forgiveness interventions: reflections and recommendations," by Carl E. Thoresen, Frederic Luskin, and Alex H. S. Harris; "An annotated bibliography of research on forgiveness and related concepts," by Michael E. McCullough, Julie Juola Exline, and Roy F. Baumeister; "Empirical research in forgiveness: looking backward, looking forward," by Everett L. Worthington, Jr.; and "Stations on the journey from forgiveness to hope," by Lewis B. Smedes.]

II. Other recent articles addressing forgiveness, with an eye toward religion/spirituality and health:

Cohen, A. B., Malka, A., Rozin, P., and Cherfas, L. "Religion and unforgivable offenses." Journal of Personality 74, no. 1 (February 2006): 85-118. [(From the abstract:) The value of forgiveness is emphasized in many religions, but little is known about how members of distinct religious cultures differ in their views of forgiveness. We hypothesized and found that Jews would agree more than Protestants that certain offenses are unforgivable and that religious commitment would be more negatively correlated with belief in unforgivable offenses among Protestants than among Jews (Studies 1 and 2). Dispositional forgiveness tendencies did not explain these effects (Studies 1 and 2). In Study 3, Jews were more inclined than Protestants to endorse theologically derived reasons for unforgivable offenses (i.e., some offenses are too severe to forgive, only victims have the right to forgive, and forgiveness requires repentance by the perpetrator)….]

Knight, J. R. and Hugenberger, G. P. "On forgiveness." Southern Medical Journal 100, no. 4 (April 2007): 420-421. [This brief commentary introduces a special section on Spirituality and Alcoholism, part of the Southern Medical Journal's ongoing series on Spirituality and Medicine. One of the authors' own studies appearing in the issue is noted: Knight, J. R., et al. "Alcohol use and religiousness/spirituality among adolescents," (pp. 349-355), indicating that forgiveness may be a protective factor for underage drinking. The authors poses questions about the potential role of forgiveness in matters of health, religion, the contemporary socio-political world.]

Levenson, M. R., Aldwin, C. M. and Yancura, L. "Positive emotional change: mediating effects of forgiveness and spirituality." Explore--The Journal of Science and Healing 2, no. 6 (November-December 2006): 498-508. [(Abstract:) We evaluated the efficacy of an emotional education program that seeks to reduce the intergenerational transmission of negative interaction patterns by increasing forgiveness and spirituality. We examined both reduction of psychological symptoms and increase in positive psychological outcomes over the course of a year, as well as the mediators of this change. At baseline, the sample consisted of 99 participants and 47 waiting list controls. Comparisons of scores from baseline (Time 1) to one week after the Hoffman Quadrinity Process (Time 2) showed large declines in negative affect (depressive symptoms) and increases in both positive outcomes (mastery, empathy, emotional intelligence, life satisfaction, forgiveness, and spiritual experience) and health and well-being. Over the course of a year, most of these gains were sustained, in comparison with the control group. Further, increases in forgiveness and spirituality mediated the effect of program participation on depressive symptoms.]

Romero, C., Friedman, L. C., Kalidas, M., Elledge, R., Chang, J. and Liscum, K. R. "Self-forgiveness, spirituality, and psychological adjustment in women with breast cancer." Journal of Behavioral Medicine 29, no. 1 (February 2006): 29-36. [(Abstract:) We evaluated whether a self-forgiving attitude and spirituality were related to psychological adjustment among 81 women being treated for breast cancer at a medical oncology clinic in a county general hospital. Both a self-forgiving attitude and spirituality were unique predictors of less mood disturbance and better quality of life (p's < 0.001). These results are consistent with previous research that has demonstrated a positive relationship between spirituality and well-being. The findings also suggest that self-forgiveness should be explored experimentally to determine whether it can protect against the psychological effects of breast cancer-related stress. Interventions targeting these characteristics could improve the quality of life and alleviate stress, especially in women with breast cancer in public sector settings.]

Witvliet, C. V., Phipps, K. A., Feldman, M. E. and Beckham, J. C. "Posttraumatic mental and physical health correlates of forgiveness and religious coping in military veterans." Journal of Traumatic Stress 17, no. 3 (June 2004): 269-273. [(Abstract:) This study assessed mental and physical health correlates of dispositional forgiveness and religious coping responses in 213 help-seeking veterans diagnosed with PTSD. Controlling for age, socioeconomic status, ethnicity, combat exposure, and hostility, the results indicated that difficulty forgiving oneself and negative religious coping were related to depression, anxiety, and PTSD symptom severity. Difficulty forgiving others was associated with depression and PTSD symptom severity, but not anxiety. Positive religious coping was associated with PTSD symptom severity in this sample. Further investigations that delineate the relevance of forgiveness and religious coping in PTSD may enhance current clinical assessment and treatment approaches.]


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