Received Date: April 28, 2017; Accepted Date: May 08, 2017; Published Date: May 25, 2017
Citation: Freedman S, Enright RD (2017) The Use of Forgiveness Therapy with Female Survivors of Abuse. J Women's Health Care 6:369. doi: 10.4172/2167-0420.1000369
Copyright: © 2017 Freedman S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Three intervention studies focusing on the psychology of forgiveness for women who have been abused are reviewed. All three incorporated the process model of forgiveness, used randomized assignment to experimental and control groups, and examined effectiveness through pre-test, post-test, and follow-up assessments. All three were conducted by different interveners. Results show that forgiveness is an effective way of restoring psychological health following abuse as well as increasing forgiveness toward the offender. For example, in Freedman and Enright’s study with incest survivors, the experimental group showed a significantly greater reduction in anxiety, state anxiety, trait anxiety, and depression, and a greater increase in forgiving the perpetrator, and in hope. Similar results were found in Reed and Enright’s study with women who experienced spousal emotional abuse. Participants who received Forgiveness Therapy, compared to an alternative therapy, demonstrated a statistically significantly greater increase in forgiving the former abusive partner, in self-esteem, in environmental mastery (everyday decisions), and in finding meaning in suffering (moral decisions), and a statistically significantly greater reduction in trait anxiety, in depression, and in post-traumatic stress symptoms. Lee and Enright’s study with women with fibromyalgia, who experienced parental abuse in childhood, additionally shows that forgiveness, can help alleviate physical symptoms as well as psychological symptoms. Specifically, the forgiveness intervention participants had greater improvements in forgiveness and overall fibromyalgia health from pretest to the post-test, and in forgiveness and state anger from the pretest to the follow-up test than the fibromyalgia health intervention participants.
Forgiveness therapy; Sexual abuse; Emotional abuse; Fibromyalgia; Depression; Anxiety
The idea of forgiveness for women who have experienced emotional, physical and/or sexual abuse is often met with surprise, skepticism, and even horror. In our view, the opposition to forgiveness in this context is based more on a misunderstanding of what forgiveness is rather than on what forgiveness actually is. For example, some people are concerned that if a woman forgives a perpetrator, then she will go back into the abusive relationship .
Others think that if she forgives, this will suppress her anger or show that she is weak and not worthy of respect . In contrast to such criticisms, research on forgiveness therapy illustrates that a self-chosen decision to forgive a perpetrator can be effective in restoring positive psychological health for women who have experienced past abuse [3-6].
The purpose of this article is to review the research conducted on the effects of forgiving for women who have experienced emotional, physical, and/or sexual abuse as well as discuss the implications of forgiveness therapy or education for women who have experienced abuse of any kind. Specifically, three studies that focus on forgiveness therapy with female survivors of abuse will be reviewed. Prior to reviewing this research, the definition of forgiveness as discussed in the literature will be given as well as briefly describing the model of forgiveness used in the research studies reviewed.
When discussing the topic of forgiveness for female survivors of abuse, it is important to be clear about what exactly is meant by forgiveness, specifically what forgiveness is and is not. Forgiveness is a complicated term that is often misunderstood by individuals in the general population as well as academics, helping professionals, and religious leaders . According to Enright  and North , forgiving others encompasses two parts. First there is a willingness to abandon one’s right to resentment, negative judgment, and negative behavior toward one who acted unjustly. Second, forgiving involves the voluntary fostering of the undeserved qualities of compassion, generosity, and sometimes even love toward the one who offended [8,9]. Forgiveness also can be more simply defined as a decrease in negative thoughts, feelings and behaviors toward an offender and perhaps, over time, a gradual increase in more positive thoughts, feelings and sometimes even behaviors toward an offender can occur [1,10]. It is important to highlight, especially to female survivors of abuse, that forgiveness does not mean that you deny or excuse the offender of the wrongdoing or deny and ignore one’s feelings of pain.
As Smedes  states, we forgive in contexts of deep, personal, and unfair hurt. The injury might be psychological, emotional, physical or moral. When one forgives, she admits that the injury occurred and that she was hurt. One also recognizes that what was done to her was wrong as she works through her feelings of pain, anger, and resentment. Admitting that the past abuse occurred and working through one’s negative feelings is not easy. It is often easier to deny, ignore, or displace the pain resulting from one’s past physical, emotional, and/or abuse.
Although as stated by Arnold-Ratliff  in a discussion on both the difficulty and the importance of admitting to and dealing with hurt feelings, “You realize that when you refuse to feel pain, you wind up feeling it forever; you finance it, setting up an installment plan to buy decades of chronic anguish”. Admitting that the abuse happened and dealing with one’s negative feelings is one of the first steps in the forgiveness journey [8,13].
Forgiveness often is confused with reconciling, forgetting, pardoning, and/or accepting [14,15] even though it is different than all of those terms. Some people criticize forgiveness because they think that advocating forgiveness leads to further abuse or hurt. Safety is the first and most important consideration. Thus, a survivor of any type of abuse would not be encouraged to forgive her abuser until she was safe and removed from the abusive environment . When one forgives, she does not give up her right to a just solution; forgiveness and justice occurs together . Forgiveness is one person’s response; reconciliation is a coming together in trust by two or more people .
For example, a woman can be abused by her partner, leave him, forgive him, but not reconcile with him. Forgiveness can include a willingness to reconcile or waiting in the hope that the abuser changes his behavior and/or apologizes. Forgiveness is something the injured can do on her own without any response from the abuser. Reconciliation is dependent on a change in the offender’s behavior and oftentimes includes an admittance of wrongdoing and/or an apology. The following quote by a survivor of domestic abuse clarifies well the difference between forgiving and other concepts including reconciliation, “Upon forgiving, I have not forgotten what happened. In remembering I make different choices in my intimate relationships. I do not condone what was done to me. It was morally wrong and undeserved. This forgiveness is not pardon, for I do not excuse his behavior or pretend it never occurred. My process of forgiveness was not reconciliation. In fact, mine was the opposite. It is a fracture that will never be mended .
Several models of forgiveness are described in the literature [18,19]. Enright and the Human Development Study Group  developed one of the most comprehensive models of interpersonal forgiveness and to date it is the only forgiveness model that has been tested successfully with one-on-one interventions between the intervener and the participant  and the one that focuses on abused women. It consists of four phases and 20-units (initially included 17-units) and is the basis for the Forgiveness Therapy and research studies discussed in this paper.
In brief, the first phase is the Uncovering phase (units 1-8) and deals with the awareness of one’s deep hurt and feelings associated with the abuse, such as anger, shame and guilt, and cognitive rehearsal or replaying the event in one’s mind over a long period of time. The decision phase (units 9 to 11) is next in which the injured person recognizes the way she has been coping is no longer effective and begins to explore forgiveness as an option for healing before making the commitment to forgive. This includes exploring what forgiveness is and is not. Although one makes the commitment to forgive, this does not mean she feels forgiving at that time. The Work phase (units 12-15) is where the injured actively engages in processes such as reframing who the offender is, which includes broadening one’s view of the offender as well as recognizing the inherent worth of all individuals, including the abuser, developing empathy and compassion for one’s abuser (which takes time and patience), and accepting and absorbing the pain of her injury rather than passing it onto others. As stated by one of the incest survivor’s in Freedman and Enright’s  study 17 years following the forgiveness intervention,
“There is not a day that goes by where I don’t think about how much my participation in your group changed my life and my attitude. Forgiveness is not just an act-it’s a way of life. My strongest beliefs are not necessarily religious ones, but ones rooted in Mother Theresa’s idea that ‘we cannot hate someone whose story we know.’ Part of what I learned from you was that opening myself to more about what may have happened to my father in his own childhood made it possible for me to understand that he, too, may have been a victim of abuse” .
This phase includes some of the most difficult units in the process model and leads to the outcome or discovery phase (units 16 to 20) in which the injured finds meaning in her suffering and the forgiveness process, realizes that she has needed others’ forgiveness in the past, that she is not alone in her pain and that she may have a new purpose in life because of her experience. The forgiver also realizes that as she gives the gift of forgiveness to the offender, she is healed as experienced by decreased negative feelings and thoughts towards the offender and perhaps, increased positive feelings and thoughts toward the offender.
It is important to note that forgiving takes time. This is especially true in situations of deep hurt, such as physical, sexual and/or emotional abuse . Previous research conducted on Forgiveness Therapy illustrates that the longer the duration of the counseling or education, the stronger the results [18,19].
According to Worthington, et al. , “Anything done to promote forgiveness has little impact unless substantial time is spent at helping participants think through and emotionally experience their forgiveness” .
Three studies of women suffering abuse of different kinds are reviewed here. All incorporated the process model of forgiveness, were randomized trials, and employed one-on-one interventions between interventionists and the participants.
Freedman and Enright  conducted an individual educational intervention using forgiveness as the goal with 12 incest survivors from a Midwestern community. This research was the first study to empirically examine the role of forgiveness as a treatment for incest survivors and the first to identify a relationship between forgiving and improved psychological health . The average age of the 12 participants was 36 years with a range of 24 to 54 years. All participants were Caucasian and the average education was 15 years with a range of 12-19 years. For six of the participants (50%) their perpetrator was their natural father; for 8% their stepfather; for 16% their brother; for 16% their grandfather, and for 8% an uncle .
The design of the study was a yoked, randomized experimental and control group design in which pairs of participants were matched as closely as possible on nature of abuse, abuser, age abuse began, duration of abuse, current age of the survivor, SES status, and education level. One participant from each yoked pair was randomly selected to be in the experimental group (receive the forgiveness intervention first) and the other participant to be in the control group (receive the forgiveness education after one’s yoked partner completed her forgiveness education). Freedman and Enright’s  study was unique in that there was no specific ending point for participants and the intervention lasted as long as it took for the participants to forgive. Because the intervention was individual, experimental subjects met weekly with the first author for 60 minutes until they had progressed through all 17 units in the process model .
At the time of this study, the model included 17 units rather than 20. Each experimental participant was given a manual that described each unit in the process model and offered examples applicable to incest survivors. When a participant had experienced all 17 units and reported that she had forgiven she was given the Self-Report Forgiveness Measure , which included three definitions of forgiveness taken from the literature and five questions the survivor responded to regarding her feelings and thoughts toward the abuser in relation to the definitions of forgiveness. If the participant stated she had forgiven and her responses were logical and rational, her forgiveness was considered genuine.
Although Freedman and Enright  acknowledge the benefits of group therapy for incest survivors, they explain that the,
“…advantages of individual sessions for this specific intervention outweighed the advantages of group therapy. Because each participant continued with the intervention to criterion, each participant had differing amount of time within the intervention”, and were able to spend as much time as necessary on a specific unit. As stated by Freedman and Enright , one survivor who felt particularly guilty and ashamed about the abuse was able to spend four weeks discussing her feelings related to this unit.
Once the experimental participant had completed her individual intervention, she and her matched control participant were given the dependent measures and then the yoked control participant began the intervention and followed the same procedure as the original experimental participant. The average length of the intervention was 14.3 months (range of 10 to 16 months), illustrating that forgiveness is not a quick fix for deep hurts. Both the therapist or educator and client must be willing to invest the necessary time it takes to work through all the units in the forgiveness model.
Results illustrated that post intervention participants were more forgiving toward their abusers, had decreased anxiety and depression and increased hope for the future as well as greater self-esteem compared to those who had not experienced the forgiveness education and themselves pre-intervention . In addition, experimental participants were assessed again when their matched control participant completed the intervention and they had maintained their change patterns on all dependent scales illustrating that there was no washout effect 14-months post-intervention. To show the effectiveness of this approach, the participants not only improved in psychological depression but also that depression was reduced to normal levels which were maintained 14 months after treatment ended.
In a similar study Reed and Enright  examined the use of forgiveness therapy on depression, anxiety, and post-traumatic stress with women who experienced spousal emotional abuse and compared it to an active control group who received a different treatment. They hypothesized that Forgiveness Therapy may be more effective than other treatments because it focuses on decreasing resentment and feelings of revenge towards one’s abusive ex-partner as well as the development of goodwill toward the abuser. Reed and Enright , emphasize that Forgiveness Therapy does not encourage nor require reconciliation, a frequent criticism of forgiveness in the literature [22,23].
Forgiveness Therapy allows women who have been abused to choose a moral response to injustice and deep hurt which is both empowering and effective in decreasing the negative psychological outcomes of emotional abuse as one is validated for their anger and other negative feelings and then helped to move beyond them .
Participants in Reed and Enright’s study included 20 psychologically abused women, ranging in age from 32 to 54 years (with a mean age of 45) in a Midwestern city who had been divorced or permanently separated for at least two years from their abusive spouse or romantic partner. Five (25%) of the participants had remarried and 15 (75%) had not remarried or started a new relationship with a live-in partner. The psychological abuse reported included criticizing; ridiculing; jealous control; purposeful ignoring; threats of abandonment; threats of personal harm; and threats of harm to property or pets. Six participants (30%) also disclosed experiences of sexual abuse.
As in Freedman and Enright’s  study, a matched, yoked and randomized experimental and control group design was used. Ten pairs were formed from the 20 participants and matched as closely as possible on age, duration of abusive relationship, and time since permanent separation or divorce. Participants were randomly assigned to either the Forgiveness Therapy (FT) group in which they received one hour weekly individual sessions based on Enright’s 20-unit forgiveness model or the control group in which they received one hour individual sessions of an alternative treatment (AT) focused on current life concerns, validating survivors’ anger, strategies for making healthy choices, and interpersonal relationship skills. Participants in both groups received a treatment manual that included a protocol on FT or the AT. The Forgiveness Therapy was criterion based, as in Freedman and Enright’s  study, and was completed when each participant reported that she had forgiven her abuser. The matched control participant ended the therapy at that time as well and the mean treatment time for all pairs was 7.95 months with a range of five to 12 months.
Gain scores from pretest to post-test on all dependent variables for the two treatment groups were analyzed using matched-pair t-tests. Results illustrated that Forgiveness Therapy participants demonstrated a statistically significantly greater increase in forgiving the former abusive partner, in self-esteem, in environmental mastery, and in finding meaning in suffering and illustrated a statistically significantly greater reduction in trait anxiety, in depression, and in post-traumatic stress symptoms compared to the participants in the control group who experienced the alternative treatment. Follow-up assessment for the Forgiveness Therapy participants also indicates that there was maintenance of gains from post-test to follow-up. This research is significant as it is the first study to demonstrate that Forgiveness Therapy is effective as a treatment for women who have experienced spousal psychological abuse and were experiencing long-term negative consequences. This study also illustrated that Forgiveness Therapy is significantly more effective in improving psychological health than an alternative treatment recommended in the literature for emotionally- abused women . This study also attempted to control confounds that were present in previous research such as equal treatment duration for the two conditions, presentation of only psychological abuse, and complete separation from the abusing spouse for at least two years before the start of treatment.
Reed and Enright  hypothesized specific benefits of the Forgiveness Therapy to survivors of spousal psychological abuse that may not be present in other forms of therapy. These include a specific focus on decreasing resentment towards the abuser as well as the validation of one’s anger, the acknowledgement that the survivor is a person of worth and the abuse does not change that worth, and that the survivor is also a person of courage because of her willingness to relinquish her resentment and recognize that her abuser is also a person of worth .
The Forgiveness Therapy also was found to be instrumental in helping survivors of spousal psychological abuse engage in relevant social justice issues and causes with positive energy as well as find new purpose in helping others who are in pain or are experiencing injustice. This is important to point out because Forgiveness Therapy and education has been criticized in the past because of the assumption that it prevents female survivors of abuse from assuming an activist role against such abuse and injustices .
The third study illustrating forgiveness as an effective form of treatment with female abuse survivors was conducted by Lee and Enright . This research compared the efficacy of a forgiveness intervention based on Enright’s  process model with a fibromyalgia health intervention, focusing on healthy lifestyles and diets, and sleep and stress management, on women with fibromyalgia (FM) who had experienced physical, or sexual abuse, and emotional or physical neglect in childhood by one of their parents. Previous research on forgiveness illustrates that forgiveness is effective in improving physical as well as mental health [24,25]. The participants in Lee and Enright’s study were 11 women diagnosed with FM for 1 to 20 years (M=8.91) and ranging in age from 21 to 68 years old (M=43.55). Participants were all volunteers recruited from newspaper advertisements as well as flyers and mass e-mails.
Screening measures were used to identify 16 participants (dropped to 11 by the end of the study) who completed the pretests and then were randomly assigned to either the forgiveness or a FM health intervention. As in the Freedman and Enright  and the Reed and Enright  studies, participants engaged in individual sessions, although the limit was set at 24 sessions for both groups. Sessions occurred once weekly for one hour with the same intervener. The treatment manual for the participants who received the forgiveness intervention was Enright’s  book, Forgiveness Is a Choice. Participants (N=5) in the FM health intervention received a 290-page manual consisting of 32 book chapters selected from 15 books, three journal articles, and one outline resource as well as a 10-page syllabus including learning objectives and summaries of all sessions developed by the first author. The intervener had extensive knowledge in both the forgiveness process and the FM .
What is unique about this study is that the FM intervention participants completed weekly quizzes to assess their understanding of the readings and both the FM and forgiveness intervention participants completed final tests in FM and forgiveness. According to Lee and Enright  the weekly quizzes and final tests were important motivators for participants to read their materials before each session and know that the intervener was intent on helping them learn as much as possible about FM healthy practices and forgiveness. Results illustrate that the forgiveness group participants showed greater improvements in forgiveness, overall FM health, and state anger compared to participants in the FM health group. A follow-up assessment occurred 12 weeks following the intervention and results showed greater reduction of state anger in the forgiveness group. Lee and Enright  hypothesize that forgiving parents also may have gradually reduced the forgiveness participants’ situational anger .
Subjective comments from the forgiveness intervention participants lend additional evidence to the effectiveness of the forgiveness intervention for these women who had FM and experienced some type of parental abuse. Forgiveness intervention participants found the intervention therapeutic, they benefited from learning to view their parents with respect, the forgiveness process appeared to positively impact their FM health, and they appreciated learning about forgiveness as a way to cope with both their past abuse and FM. Learning to forgive for the participants, who experienced both some form of parental abuse as well as FM, not only changed participants’ views of their abuser but also impacted their physical and mental health.
From a clinical perspective, the women in the Forgiveness Therapy condition across all three studies went from clinically depressed (mild to moderate depression) to non-depressed at the follow-up testing time. The well-established Beck Depression Inventory served as the dependent variable in each study. The results, seen in Figure 1, are important because depression can be difficult to ameliorate and the reported findings occurred not just directly after the intervention but at follow-up when the participants were without the forgiveness treatment for 14 months in Freedman and Enright , 3 months in Lee and Enright , 8.3 months in Reed and Enright (Figure 1) .
Research illustrates the potential effectiveness of Forgiveness Therapy and intervention for women who have experienced sexual abuse and incest, spousal emotional abuse, and some type of childhood abuse from a parent. These three studies were similar in that the intervention was individual for all participants, each study used some type of written manual or guide and for two of the three studies, and individuals were able to spend as much time as necessary in working through the forgiveness model. These factors may be an important part of Forgiveness Therapy and intervention in addition to the specific forgiveness content.
The power of forgiveness to impact the survivors’ psychological and physical health was illustrated in all research reviewed. As a moral response to injustice and deep hurt, forgiveness focuses on more than just decreasing anger and increasing self-esteem. Forgiveness includes a focus on the paradoxes of extending mercy and good will toward those who were not merciful to the participants. This approach enables female survivors of abuse to see their offenders as human beings who deserve respect despite their hurtful actions. According to Enright and Fitzgibbons [1,10], Forgiveness Therapy helps clients better understand their offenders as well as make a morally good response toward those offenders. As
Freedman and Zarifkar  emphasize, “The role of the therapist is critical in educating clients about the forgiveness process as well as supporting clients in their decision to forgive and during their forgiveness journey”.
In an article discussing patient empowerment and the use of care managers in the treatment of 1160 patients living with cardiovascular disease, diabetes, heart failure, and/or at risk of cardiovascular disease in Italy, it was shown that partnerships and collaboration of all health professionals as well as having a care manager for each patient not only improved patients’ disease-related health but also empowered and motivated patients to be more proactive regarding their health behavior . This model could be applied to Forgiveness Therapy in a way that could help women who have experienced some type of abuse recognize that forgiveness can be an important component of their healing and provide them with support during their forgiveness journey.
If more medical professionals are aware of Forgiveness Therapy as an option for healing, women who might potentially benefit from forgiving could be targeted early in their treatment by their primary care physician or a care manager. The primary care physician can refer women with a past history of abuse to a professional serving as a “forgiveness” care manager. This “forgiveness” care manager could help women, who have been abused, become educated about forgiveness and support them on their journey as necessary. Women with more complicated issues and past abuse experiences could be referred to a mental health professional with expertise in Forgiveness Therapy. This mental health professional as well as the care manager and primary physician can all support the client during her journey toward forgiveness. The processes in the forgiveness model would be applied to forgiving the specific offender as well as being discussed and highlighted as a way to live a more forgiving life . As in Ciccone et al.  research, clients can be empowered to recognize their anger and do something about it before it becomes unhealthy as well as motivated, for example, to use the idea of reframing (seeing the worth in others, including those who abuse) to develop more compassion and empathy when interacting with others or to accept and absorb their pain rather than pass it on to someone else.
Not only does Forgiveness Therapy change one’s psychology for the better but also the results reviewed here are strong enough for mental health professionals to begin thinking about incorporating this form of therapy into their practices as stated above. We say this because, for example, depression not only can be reduced but also actually can fall to normal levels in women experiencing the serious injustice of incest and other forms of abuse. It is rare for any kind of treatment to show such effects. By our providing more information about Forgiveness Therapy and the forgiveness process in this article, it is our hope that professionals in the mental health field both recognize and use forgiveness as an effective form of therapy for female survivors of abuse. It further is our hope that more primary care physicians will recognize women who have been abused and who could benefit from Forgiveness Therapy and refer them to appropriate mental health professionals. We encourage more researchers to enter this new and potentially healing area of work so that more replications occur in the published literature. Such efforts could go a long way in alleviating the suffering of too many women who experience injustice.