96 Forgiveness
J. Adam Rindfleisch, MD, MPhil
Abstract
Forgiveness is an essential part of healing, but it is often difficult for people to do. Research indicates forgiveness has many positive effects and can be effectively done as a step by step process, ideally guided by someone who can effectively offer support. There are resources on forgiveness that are widely available.
Keywords
forgiveness spirituality trauma-informed care mental health
Darkness cannot drive out darkness; only light can do that.
Hate cannot drive out hate; only love can do that.
Martin Luther King, Jr.
In October 2019, Brandt Jean, the youngest brother of Botham Jean, was in the courtroom giving the “victim’s impact statement” as Amber Guyger, the former Dallas police officer who shot and killed his brother, was being sentenced. He said, “If you truly are sorry, I know, I can speak for myself. I forgive you.” He then asked the judge, “I don’t know if this is possible, but can I give her a hug, please?” The judge gave him permission, and he embraced the woman who shot his brother. They hugged for over a minute, and she sobbed throughout.1
How does someone forgive like this? Forgiveness undoubtedly has great healing potential, but it requires much of the person doing the forgiving. Courage. Strength. Empathy. Altruism. And maybe more.
If you want to truly explore how forgiveness fits into your life and your practice, consider your own answers to these four fundamental questions as you read this chapter:
1. Whom do I need to forgive?
2. How can I forgive them?
3. What do I want to be forgiven for myself?
4. How does forgiving myself and others affect my health?
You will be more effective bringing forgiveness into your work with others if you practice it yourself. There are many possible ways for this to be done.
This chapter describes how forgiveness can influence health. It provides an overview of many of the key elements of the forgiveness process and describes ways clinicians and other healing professionals can make use of the power of forgiveness in their practices. Resources for further learning are provided at the end of the chapter.
If you work in a healing profession, you will meet people who have endured any number of traumatic experiences. In fact, it is estimated that more than 90% of people experience severe trauma at least once in their lives, and recent research confirms what clinicians instinctively know: Traumatic experiences can lead to lasting negative health effects.2 A 2010 review found that childhood trauma markedly increases the likelihood of several negative outcomes, including tobacco dependence, injection drug use, alcoholism, posttraumatic stress disorder, and a variety of other physical and psychiatric issues.3,4 Childhood traumatic events also are linked to a decrease in overall quality of life,5 increased incidence of chronic pain,6,7 higher risk of cardiovascular disease,8 and a multitude of other chronic physical problems.9 A 2020 review found that, in comparison to children who dealt with low adversity in early life, those who had multiple adverse experiences had 4.5 times the risk of all-cause mortality.10
Traumatic toxic stress can result in chronic activation in the stress response, which leads to chronically elevated cortisol (and eventual depletion of it), and this has a negative impact on immune system function; unfavorable neurological remodeling occurs.2,11,12 Unfortunately, the effects of trauma also have negative consequences that can have negative epigenetic effects, which can even affect the gene expression of a traumatized person’s descendants.13,14
Many traumas—such as violent crime, domestic violence, rape, child abuse, automobile accidents, and the effects of war—are perpetrated by one person or group of people. Pain inflicted by others, from minor slights and insults to the most horrifying experiences of brutality or betrayal, can have lasting negative health effects. Yet, we also know that despite horrible experiences, many people experience posttraumatic growth; they heal and even become stronger, despite being hurt.15 How can healing and growth occur in spite of, or in response to, traumatic events?
For many people, being able to forgive is vital to reclaiming wholeness after they have been injured by others. Integrative medicine is built on empathic, trusting relationships between caregivers and patients. If patients have the time, opportunity, and safety to do so, they may disclose traumatic experiences that they may not have ever shared before. Some people recognize the role of forgiveness in healing the damage caused by traumatic experiences, whereas many others do not. How and when to address issues of forgiveness can be one of the most challenging aspects of caring for those who have been traumatized; however, the potential benefits make it well worth the effort. Often, self-forgiveness, in addition to forgiving others, is also an essential part of the healing process.
The Health Benefits of Forgiveness
In the past several years, increasing numbers of studies have demonstrated that forgiveness favorably influences a number of physical and mental health outcomes. A 2018 review of 128 studies that included more than 58, 500 people concluded there is a significant positive relationship between forgiveness of others and physical health.16 Additional research has found that the effects of forgiveness may be even stronger for mental health outcomes.17 Examples of some more specific research findings include18:
• Longevity: A 2012 review of data from a nationally representative sample of 1232 U.S. adults concluded that “conditional forgiveness of others is associated with reduced risk for all-cause mortality, and … the mortality risk of conditional forgiveness may be conferred by its influences on physical health.”19
• Vital signs: Simply imagining oneself granting forgiveness alters physiology. Blood pressure is lowered, heart rate decreases, and skin conductance changes.20
• Immune function: Self-forgiveness is associated with decreased blood viscosity and improved ratios of helper T to cytotoxic T white blood cells.21
• Brain function: Forgiveness has been found to influence the function of neurons in the lateral and ventromedial prefrontal cortex and temporoparietal junction.12,22
• Mental and emotional health: People who are more inclined to forgive seem to experience less stress.23 They are less likely to experience depression and anxiety,24 not to mention posttraumatic stress.25 In women suffering from spousal emotional abuse, forgiveness therapy was found to lower depression, anxiety, and stress and to improve self-esteem, emotional mastery, and the ability to find meaning in suffering.26 Forgiveness improves mental health in part by decreasing the tendency to ruminate, and it probably improves social relationships as well.21 People with borderline personality27 and eating disorders28 are often less predisposed to forgive and may benefit from forgiveness training.
Pearls
A strong relationship exists between traumatic experiences and the emergence of physical and mental health problems. Strong evidence also indicates that forgiveness negates the harmful effects of trauma.
• Sleep: A 2019 review found that both forgiveness of others and self-forgiveness were associated with better sleep.29
• Chronic pain: A 2019 review of seven studies found an inverse association between forgiveness and participants’ overall levels of pain, as well as improvements in pain tolerance.30
• Cardiovascular effects: Forgiveness is associated with lower cardiovascular risk, possibly because of decreased anger and hostility.31 It has even been linked to improvements in lipid measures and found to have the opposite effects to anger when it comes to cardiac function measures.32 A recent study reported decreased anger-induced myocardial ischemic events in those practicing forgiveness.33 In a 2015 study, forgiveness was found to be cardioprotective, at least in part because it decreased aortic blood pressure.34
• Substance use disorder: Forgiveness has been shown to decrease anger, depression, anxiety, and vulnerability to drug use in people with a history of substance abuse.35
• Oncology and palliative care: A 4-week intervention helped terminally ill older patients with cancer to enhance levels of hope and quality of life.36 Use of a course entitled “Restore: The Journey Toward Self-Forgiveness” led to significant favorable changes not only in levels of self-forgiveness but also acceptance, self-improvement, and outlook.37 A large majority of people report wanting to address issues related to forgiveness at the end of a loved one’s life.38
• Other chronic health disorders: Investigators have suggested that forgiveness therapy may hold great potential in the treatment of fibromyalgia and chronic fatigue.39 A small 2014 pilot study found that a forgiveness intervention decreased fibromyalgia symptoms.40
• Miscellaneous benefits: Meta-analyses have pointed out the benefits of forgiveness for healing intergenerational pain, recovery from sexual abuse and incest, and abortion-related guilt.41,42 In two small studies, forgiveness of co-workers lowered levels of stress and conflict in the workplace; it also improved productivity.43 One study focused on racial disparities found that forgiveness was even more protective of older African Americans than whites; the benefit was less, however, if a person lived in a relatively unsafe neighborhood.44
Although forgiveness seems to have benefits for people with an array of health conditions, it also should be noted that, as is the case for many therapeutic approaches, one need not have a specific health problem to make good use of forgiveness for supporting overall well-being. Forgiveness likely has preventive benefits as well.
In recent years, a growing body of research has found that the benefits of forgiveness, as one might expect, are also present in people who practice self-forgiveness. Some important examples of self-forgiveness study findings include:
• A 2019 review found that self-compassion or self-forgiveness decreases the relationship between traumatic events and levels of self-harm or suicidal ideation.45 Self-forgiveness also reduces the effects of depression on suicidality.46
• Some conditions, such as fibromyalgia syndrome, are associated with decreased forgiveness of self and others. Higher levels of forgiveness are linked to better active coping and decreased catastrophizing in people suffering from these problems.47
• Moral injury, which can occur when people experience traumatic events associated with a violation of their moral values, can lead to significant functional impairment and distress.48 Self-forgiveness has great potential of benefit for those who have experienced moral injury, including military veterans.49
• Self-forgiveness can be an important aspect of recovery from eating disorders.28
• Forgiveness of self, but not forgiveness of others (according to one study), is linked to lower levels of high-risk alcohol use in college students.50
• Self-compassion, which may be closely linked to self-forgiveness, also has been found to have many health benefits.51 Self-compassion practices even improve adherence to treatment plans for people with an array of chronic health issues,52 such as chronic fatigue syndrome.
The Nature of Forgiveness
We have all heard stories about the mysterious power of compassion and forgiveness in the lives of others. Each time we are inspired by these accounts, we remember that we, too, can forgive.53
Jack Kornfield
Several different measurement instruments are used in forgiveness research studies, and many have proven quite useful. Ultimately, however, each individual must discern his/her own way of defining forgiveness and gaging when and how it has occurred. Even when people do not actually feel equipped to forgive, they typically can recognize that forgiving is important. When people are ready, integrative clinicians can guide them through the process. As is so often the case in integrative practice, trying these approaches oneself as a clinician before suggesting them for others can be helpful.
Ten Aspects of Forgiveness
The following perspectives are based in part on the writings of Enright and Luskin, which are featured in the resource list at the end of this chapter.
1. Forgiveness is a transformation. The key is to release suffering and thereby increase inner peace and understanding. Put another way, it has been said that holding onto vengeful anger is like drinking poison and waiting for the other person to die.18
2. Forgiveness is not forgetting. In fact, you have to remember and acknowledge negative emotions and events before forgiveness can occur.
3. Forgiveness is not pardoning, excusing, or saying that something will be treated as acceptable behavior in the future. It is not reconciling either. It might best be described as a gift we can give to ourselves.
4. Forgiveness is, first and foremost, done for the person doing the forgiving. It is paradoxical in that when you forgive others, you heal yourself.
5. Forgiveness is a path to freedom. It frees you from the control of the person or people who caused the harm. The offenders lose their power to cause you to feel negative emotions or additional suffering.
6. Forgiveness can break old patterns that may otherwise interfere with your being able to build new relationships.
7. Forgiveness can take a long time and require a lot of hard work.54
8. Forgiveness need not require “making up” with the person who caused the harm. It is an internal process. It is primarily for the person doing the forgiving, to help you heal and grow.
9. Just thinking about forgiveness may not be enough. For many, tapping into principles described in various spiritual traditions from around the world is necessary. Meditation, interpersonal dialogues, and intense emotional work may be essential parts of the forgiveness process for many people.
10. Forgiveness may not always be the best choice. In an ongoing relationship (especially with a significant other) it may create a pattern in which the offender behaves less skillfully if forgiven repeatedly.55 Self-forgiveness of a habitual behavior may help perpetuate the habit; for example, people may be less likely to stop smoking if they keep forgiving themselves for doing it.56
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용서의 10가지 측면
다음 관점은 부분적으로 Enright와 Luskin의 글을 기반으로 하며, 이 글은 이 장의 끝 부분에 있는 리소스 목록에 포함되어 있습니다.
1. 용서는 변화입니다. 열쇠는 고통을 풀어 내면의 평화와 이해를 높이는 것입니다. 달리 말하면 복수심에 찬 화를 참는 것은 독을 마시고 상대방이 죽기를 기다리는 것과 같다고 합니다.18
2. 용서는 잊는 것이 아닙니다. 사실, 용서가 일어나기 전에 부정적인 감정과 사건을 기억하고 인정해야 합니다.
3. 용서는 용서하거나 변명하거나 어떤 일이 미래에 받아들일 수 있는 행동으로 취급될 것이라고 말하는 것이 아닙니다. 조화롭지도 않습니다. 그것은 우리가 우리 자신에게 줄 수 있는 선물로 가장 잘 묘사될 수 있습니다.
4. 용서는 무엇보다도 용서하는 사람을 위해 이루어집니다. 다른 사람을 용서할 때 자신이 치유된다는 점에서 역설적입니다.
5. 용서는 자유로 가는 길입니다. 그것은 해를 입힌 사람 또는 사람들의 통제로부터 당신을 자유롭게 합니다. 가해자는 부정적인 감정이나 추가 고통을 느끼게 할 힘을 잃습니다.
6. 용서는 새로운 관계를 구축하는 데 방해가 될 수 있는 오래된 패턴을 깨뜨릴 수 있습니다.
7. 용서에는 오랜 시간이 걸리고 많은 노력이 필요합니다.54
8. 용서는 해를 입힌 사람과 “화해”할 필요가 없습니다. 내부 프로세스입니다. 당신이 치유하고 성장하도록 돕는 것은 주로 용서하는 사람을 위한 것입니다.
9. 용서에 대해 생각하는 것만으로는 충분하지 않을 수 있습니다. 많은 사람들에게 전 세계의 다양한 영적 전통에 설명된 원리를 활용하는 것이 필요합니다. 명상, 대인 관계 대화 및 강렬한 정서적 작업은 많은 사람들에게 용서 과정의 필수적인 부분일 수 있습니다.
10. 용서가 항상 최선의 선택은 아닙니다. 지속적인 관계(특히 중요한 다른 사람과의 관계)에서 반복적으로 용서를 받으면 범죄자가 덜 능숙하게 행동하는 패턴을 만들 수 있습니다.55 습관적인 행동에 대한 자기 용서는 습관을 지속시키는 데 도움이 될 수 있습니다. 예를 들어, 담배를 끊은 자신을 계속 용서한다면 담배를 끊을 가능성이 낮아질 수 있습니다.
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Guidelines for Helping People to Forgive
William Meninger defines the process of forgiveness as series of challenging steps that ultimately involve breaking out of unhelpful emotional and thought patterns:
When we finally do face them [our wounds] squarely and recognize the ones who inflicted them, we move on to the next step. This usually involves trying to excuse the perpetrator and blaming ourselves for causing or, at least, not stopping, the original wounds. When we are able to cease the self-blame, we begin to feel sorry for ourselves and to wallow in a mud hole of self-pity, bitterness, and recrimination. The next step is anger. We determine that we will do something about what happened to us and move forward with our lives. We stop rubbing salt in our wounds, and we actively seek healing. This leads us to the final stage, wholeness.57
Fig. 96.1 illustrates some of the key steps that occur as a person goes through the forgiveness process. These steps need not always occur in a particular order, and not every person experiences every step before forgiveness occurs.
FIG. 96.1 The Forgiveness Process
. General stages in the process are listed in the column on the left. Boxes overlying the arrow list major obstacles to forgiving. Specific actions are listed on the right. More detailed steps are outlined in the resource list in the patient handout at the end of this chapter. *Often the most difficult step.
Stepwise approaches guiding forgiveness have been developed by several authorities, and suggestions derived from several of these are summarized in the patient handout at the end of this chapter. For further information, clinicians are referred to the work of Robert Enright58,59 and Frederic Luskin,60,61 coordinator of the Stanford Forgiveness Project in Palo Alto, California. Additional recommended books and websites for both patients and providers are available in the list of references.62–69
In discussing forgiveness with patients and using the patient handout, keep the following in mind:
• As with counseling for weight loss, substance abuse, or other types of behavioral change, suggesting that people cultivate forgiveness is only likely to be useful if people are “in a place” in which they are willing and able to consider doing so. Some people may be offended if they are encouraged to forgive when they are not yet prepared to begin the process. As in motivational interviewing for substance use, the provider must assess readiness for change. Is the patient precontemplative, contemplative, or already taking steps toward forgiveness?
• The provider should emphasize, as noted in the patient handout, that forgiveness is not the same as tolerance, passivity, or forgetting what happened. No expectation exists that the patient must accept the perpetrator’s behavior as acceptable or allowable. Forgiveness is done for the person doing the forgiving; the goal is to free him/her as much as possible from the negative consequences of a traumatic experience.
• Moving through the steps described in this chapter may be associated with an intense release of emotions. The provider must carefully assess whether mental health professionals are needed to assist a patient with the forgiveness process.
• Asking a person to forgive may be asking him/her to move away from a pattern of thoughts and feelings that has been present for many years. It is not a simple process for many people. Follow-up is important. The process takes time.
• A person’s concept of forgiveness is based on his/her cultural and religious background. The provider should take a spiritual history and be aware of cultural beliefs, to suggest forgiveness as part of an individualized treatment plan that respects these beliefs and encourages appropriate social support.
• Forgiveness is not just a therapeutic intervention; it is an end point—a healthier state of being—unto itself.70
• Trauma informed care is receiving increased attention and continues to evolve.2 As noted by the Substance Abuse and Mental Health Services Administration, “A program organization or system that is trauma-informed realizes the widespread impact of trauma and understands the potential paths for recovery.”71 This care recognizes the signs and symptoms of trauma and responds in a way in which what is known about trauma is fully integrated into all practices, policies, and procedures. It is based on six broad principles, including72 (1) Safety; (2) Trustworthiness and transparency; (3) Peer support; (4) Collaboration and mutuality; (5) Empowerment, voice, and choice; and (6) Awareness of cultural, historical, gender, and other issues.
• Meditation has shown promise in bringing about forgiveness and should be considered.73
• Mindfulness training may have a role in negating some of the negative neurobiological and other changes associated with trauma.74
• One simple procedure that has been found to be beneficial and can be used by health care professionals is the REACH Forgiveness Model.36 REACH stands for:
• Recall the hurt. What happened? Who hurt you? How did they make you feel in the past, and how do you feel now?
• Empathize. Why might the offender(s) have done what they did? Can something from their past or present life explain their actions?
• Altruism. How is doing this forgiveness a gift to yourself and others?
• Commit to forgiving. Write a note to yourself about your decision or announce out loud to yourself that you have decided to forgive.
• Hold on. Decide how you know you are making progress and how you can encourage yourself.
Try using some of these questions, noting that forgiveness is not typically something that can happen during the space of one visit with someone. Provide more information (handouts) and help people connect with others who can also offer support—clergy, mental health professionals, etc.—as appropriate.
An integrative provider must carefully gauge whether a person is prepared to do forgiveness work. Readiness to change must be carefully assessed. A spiritual history can be useful in guiding a discussion of forgiveness as a tool for improving health.
Forgiving can be a difficult, emotion-laden, and time-consuming process. Be certain someone has the support he/she needs before beginning the process. Strongly consider requesting assistance from mental health professionals.
Unconditional forgiveness is a different model of forgiveness than the gift with strings. This is forgiveness as a grace, a free gift freely given. In this model, forgiveness frees the person who inflicted the harm from the weight of the victim’s whim—what the victim may demand in order to grant forgiveness—and the victim’s threat of vengeance. But it also frees the one who forgives. The one who offers forgiveness as a grace is immediately untethered from the yoke that bound him or her to the person who caused the harm. When you forgive, you are free to move on in life, to grow, to no longer be a victim. When you forgive, you slip the yoke, and your future is unshackled from your past.
Desmond and Mpho Tutu75
In October 2019, Father William Meninger describes the tale of Sister Catherine, a 55-year-old nun who was informed that a physician had mistakenly injected a lethal medication into her during the brain operation she had just undergone. Her response was to call in her fellow church officials and declare, “There will be no repercussions. No one is to be held at fault … I forgive without reservation anyone who may have been in any way responsible for what has happened.” She died 2 hours later.57
Conclusion
Viktor E. Frankl, a psychiatrist and Holocaust survivor, summarizes the importance of how we deal with traumatic experiences in his work, Man’s Search for Meaning:
We must never forget that we may also find meaning in life even when confronted with a hopeless situation, when facing a fate that cannot be changed. For what then matters is to bear witness to the uniquely human potential at its best, which is to transform a personal tragedy into a triumph, to turn one’s predicament into a human achievement.76
Patients continually seek the meaning underlying their illnesses, their suffering, and their terrible losses. As healers, we can help to guide this search. Forgiveness is one tool that may help us all move through tragedy and pain toward greater wholeness.
If you want to see the heroic, look at those who can love in return for hatred. If you want to see the brave, look for those who can forgive.
The Bhagavad-Gita
Key Web Resources
World Forgiveness Alliance: This alliance is “dedicated to evoking the healing power of forgiveness worldwide.” http://www.forgivenessday.org/
Forgive for Good: This website of Dr. Fred Luskin, who has done extensive forgiveness research, has links to his books, forgiveness tools, and other resources. http://learningtoforgive.com/
The Forgiveness Project: Offers an array of powerful stories that help to build hope, empathy, and understanding. https://www.theforgivenessproject.com
International Forgiveness Institute: Founded by Robert Enright, an excellent forgiveness resource. https://internationalforgiveness.com
References
References References are available online at expertconsult.com.
References
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Multiple Choice Questions
1. Which of the following about the nature of forgiveness is true?
a. It can be done by anyone at any time, if a person is willing to make up with the person/people who hurt him/her
b. It is a tool that only a relatively small number of people can truly derive benefit.
c. It requires one to reach a point at which he/she is at such peace that he/she can truly forgive and forget—that is, let go of the memories of a traumatic experience.
d. Forgiveness does not have to involve pardoning, excusing, or accepting something a perpetrator did; it is about freeing the person doing the forgiving.
e. Forgiveness is easy, once you know the steps to follow to do it.
2. Based on the research to date, as presented in this chapter, forgiveness has been found to be beneficial in terms of which of the following?
a. Longevity, mental health issues, lower cardiovascular risk
b. Mental health concerns, including depression and substance use disorder
c. Sleep problems
d. Healing from traumatic life experiences
e. All of the above
3. Which of the following is NOT a step in the forgiveness process?
a. Choosing to forgive
b. Understanding why it is necessary to forgive
c. Ceasing to identify with the pain
d. Making amends with the perpetrator
e. Self-forgiveness
4. Which of the following is NOT true of self-forgiveness?
a. It has even better research supporting its use than forgiveness of others.
b. It can help people who have experienced moral injury.
c. There is less research at this time relating to self-forgiveness versus forgiveness of others.
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