The Role of Forgiveness in Helping People Achieve Wellness And Optimal Mental Health

Question:

"Can you say more about the role of forgiveness in helping people achieve wellness or optimal mental health? Has the ability and process of forgiving a perpetrator of harm ever been evaluated or studied? As with exercise, I have anecdotally noted improved remission in depression plus PTSD when a patient is able to feel that forgiveness has taken place. Is anyone looking at this with inflammatory markers or PET scan?"

Charles Raison, MD:

"Peter came to Jesus and asked, 'Lord, how many times shall I forgive my brother when he sins against me? Up to seven times?' Jesus answered, 'I tell you, not seven times, but seventy-seven times [or seventy times seven].'"
Matthew 18:21-22

"All major religious traditions carry basically the same message, that is love, compassion and forgiveness … the important thing is they should be part of our daily lives.”
Dalai Lama

"I forgo all the vengeance in the case of my son [Sonny]…but I'm a superstitious man, and if some unlucky accident should befall him [his other son, Michael], if he should get shot in the head by a police officer, or if he should hang himself in his jail cell, or if he's struck by a bolt of lightning, then I'm going to blame some of the people in this room. And that, I do not forgive."
Don Corleone in The Godfather Part I

Let me start answering this series of important questions by dealing with the easiest one first. Yes, the association between forgiveness and both mental and physical health has been studied repeatedly, and a number of studies have examined whether interventions based on enhancing forgiveness have therapeutic efficacy. To give you a sense of just how much research has been done, go to the computer with me; go to PubMed.gov and type in the word “forgiveness.” If you do this, you’ll see that 400 peer-reviewed studies have been published since 1990. By way of comparison, only 31 papers on forgiveness were published between 1960 and 1990. So the challenge in answering your other questions lies not in finding information about the relationship between forgiveness and mental or physical health, but rather trying to come to coherent conclusions about what this voluminous literature has to say about this relationship. After having reviewed this literature, it is clear that forgiveness can be good or bad depending on a person’s motives and context. Thus, it is too simple to say that learning to always be forgiving is a straightforward pathway to wellness and improved physical health. Rather, as clinicians the challenge before us is to help our patients see when forgiveness can benefit their well-being and when it can actually cause them harm. Forgiveness can be powerful, but it is no panacea, and should not be proffered by us as being one.

Let’s take a closer look.

What is Forgiveness?

Forgiveness is not one thing. Sometimes it can be a freely given gift offered from a position of power. Other times it can be used as a dodge to avoid taking personal responsibility or to face the fact that one is being bullied by someone else. Researchers have defined it as a “prosocial change toward a perceived transgressor,” ¹ “a freely made choice to give up revenge, resentment, or harsh judgments toward a person who caused a hurt…and a striving to respond with generosity, compassion, and kindness toward that person.” ^2,3

The Good Side of Forgiveness

It is indisputable that forgiveness can be a healing force of good in the world, based both on studies that compare one’s ability to forgive with a variety of health outcomes and on studies showing that teaching people to forgive others can improve health and well-being. (See below for a discussion of studies examining forgiveness as a therapeutic intervention). In response to your question about posttraumatic stress disorder (PTSD) and depression in particular, studies suggest that being able to forgive others is protective against both conditions. A study of 213 veterans with PTSD found that difficulty forgiving oneself and/or others was associated with increased depression, anxiety, and PTSD symptom severity. ⁴ In a large study of twins, forgiveness and related emotional/behavioral states (eg, non-vengefulness) were associated with a reduced risk of having either an internalizing or externalizing psychiatric condition. ⁵ Both a self-forgiving attitude and spirituality were unique predictors of less mood disturbance and better quality of life in women being treated for breast cancer, ⁶ and forgiveness has been shown to be similarly protective against anxiety and depression in patients with cardiovascular disease. ⁷ Other studies have shown that an inability to forgive self or others predicts depression, especially in those who hold positive views of forgiveness. ⁸ One tangible benefit of the positive effect of forgiveness on mood comes in the form of improved sleep in those more able to forgive others. ⁹

In addition to protecting against negative emotionality in general and psychiatric disturbance in particular, the ability to forgive has also been associated in a number of studies with improved well-being. One particularly touching example of this comes from a qualitative study done in aged survivors of the atomic bombing of Hiroshima. Those who had responded to the bombing and its aftermath with a life-long tendency toward anxiety and a focus on themselves were found to be “surviving” whereas those who had transcended the catastrophe to thrive (as opposed to merely surviving) were found to demonstrate higher levels of several positive traits, forgiveness among them. ¹⁰ People high in emotional intelligence—which is associated with various measures of health and well-being—are less likely than others to hold lasting resentments. ¹¹

I discuss positive physical effects of forgiveness a little later in this Q&A, but this is an appropriate point to mention an interesting study that found that older adults who were unable to forgive themselves or forgive others, or feel forgiven by God, were more likely to have had an infection in the previous month, although no immune mechanism for this association was tested. ¹²

This listing of studies showing health benefits for forgiveness barely scratches the surface of this huge literature and should in no way be seen as presenting all important or interesting findings in this area. But the list is incomplete not just due to brevity, but also to the fact that not all findings regarding forgiveness and health are so rosy, a subject to which we turn now.

The Bad Side of Forgiveness

An essential—and unanswered—question in forgiveness research is whether there can be “too much of a good thing” when it comes to cutting other people a break. If one followed Jesus’ advice quoted above and forgave people endlessly, one might achieve the kingdom of heaven, but might not have a viable strategy for living life on this earth. Evidence for this comes from a study that employed a fascinating game called the Prisoner’s Dilemma (PD). In PD two individuals interact with each other repeatedly. In each round of the game each player can choose to either cooperate with the other player or “defect.” If both players cooperate they each receive a monetary reward, let’s say $1. If one defects and one cooperates, the one who defects gets $2 and the one who cooperates gets nothing. Can you guess what happens when both players defect? They each get 50¢.

This game has been studied endlessly because it so obviously captures important truths about interactions with people we have to deal with on a regular basis. Obviously it is best in the long run for the two individuals to develop enough trust in each other so that they cooperate on every turn. But if you are playing with someone who has a penchant for taking advantage of nice people, you will go broke always cooperating, essentially forgiving the other player his or her repeated attempts to take advantage of you. When people can’t find a way to cooperate they both lose, but not as much as a player who insists on being cooperative even when the other player doesn’t reciprocate. Recent research suggests something even more ominous. Players who always cooperate, regardless of the response of the other player, actually promote the development of defection in the game-mates. Without intending to, they bring out the worst in other people. ¹³

These findings may help explain what seems to me to be the darkest side of forgiveness, which is that—as in the PD game—unexamined forgiveness can actually make the world a worse place for the person who forgives too easily and frequently, and for those who are forgiven. For example, a study that followed young adults through the first years of their marriages found that a tendency to easily forgive one’s partner early in the relationship was associated with increased psychological and physiological aggression from partner over time; whereas withholding forgiveness actually seemed to make the errant marriage partner behave better over time. ¹⁴ How much resentment and flat-out hatred this type of hard-nosed approach generated was not investigated. But here again the prisoner’s dilemma suggests something disturbing. One might be able to force a partner to behave better by withholding forgiveness, but this type of strategy—known as “tit-for-tat” in the PD game makes the emergence of long-term cooperation between players very difficult to achieve. ¹³

Another study of forgiveness early in marriage really helps clarify whether forgiving one’s partner will lead to one feeling better or worse about oneself as time passes. ¹⁵ It turns out that the key factor in whether one’s self-respect goes up or down is how the spouse responds to having transgressed in the first place. If the partner works hard to make amends and is an agreeable person who can signal that one will be safe and valued in the relationship moving forward, then the ability to forgive bolsters self-esteem and obviously helps the relationship. If the spouse interprets one’s forgiveness as a sign of weakness and takes advantage of it, one is likely to feel more and more like a “doormat” (which is actually in the title of this study) with all the loss of self-worth and esteem that this entails. But again, there is a complication. A very large, recent study found that people who endorse using this type of “conditional forgiveness” in their daily lives are at increased risk of death from all sorts of natural causes than are those who forgive more and less often. ²

Finally, although self-acceptance and forgiveness are hot therapeutic topics and often seen to be unqualified goods, a recent study suggests that forgiving oneself too easily can carries its own disadvantages. This study found a strong relationship between the degree to which people forgave themselves for failing to quit smoking and their actual ability to quit. The more people forgave themselves, the less likely they were to be able to kick the habit. ¹⁶

What Predicts Forgiveness?

Forgiveness always occurs in a context that includes the person doing the forgiving and the person or people toward whom the forgiveness is directed. As you might expect, the likelihood that forgiveness will occur depends on the character and circumstances of the person doing the forgiving and the context in which the forgiving must occur. ¹⁷

We’ve already mentioned one factor that greatly increases the likelihood that forgiveness will bring forth emotional well-being, and that is the character and behavior of the person who has done the transgression. The same behavioral and characterological factors also greatly influence whether forgiveness will occur in the first place. Said simply, people are far more likely to forgive someone who is agreeable in general, who apologizes sincerely, and who demonstrates a willingness to make amends. ¹⁷ People are also more likely to forgive someone with whom they have a close and committed relationship, especially if the relationship is emotionally satisfying. ¹⁷

Regardless of the situation, some people are more likely to forgive than others. What predicts this? We’ve already mentioned several of these factors as the fruits of forgiveness (see above), but they also seem to promote a tendency to forgive. Factors associated with being more forgiving include being an empathetic and agreeable person, having high emotional intelligence, being able to see things from others’ point of view, and being in a position of power in the relationship that requires forgiveness. ^17,18 On the other hand, people who are depressed, angry, or neurotic are less likely than others to forgive. ¹⁷ People who are hypercompetitive have trouble forgiving whereas those with a more balanced sense of competition driven by a desire for personal development are actually more likely than people without this trait to forgive others. ¹⁹ Finally, you would think that people with a strong need to have a sense of belonging would be especially likely to forgive, but in fact the opposite is the case. ²⁰

Health and Neurobiology of Forgiveness

Most studies examining health-relevant physiological effects of forgiveness have focused on cardiovascular measures. The news here is good. Multiple studies suggest that forgiveness lowers blood pressure and heart rate and in general protects the vascular endothelium from the damaging consequences of psychological stress. ²¹ Forgiveness appears to proffer these benefits primarily through its ability to protect against depressed moods.

Surprisingly, we know a good deal less about how forgiveness affects brain functioning, and nothing—to my knowledge—about how and if it affects brain structure. In terms of brain functioning, forgiveness seems to require activation of a number of brain areas known to be important for sense of self, as well as the ability to accurately recognize the subjectivity and emotional experiences of other people. Often referred to as the “default mode network” these areas are located in midline cortical and subcortical areas that tend to be more active when people are “thinking about nothing in particular” (meaning that they are usually thinking about themselves in one way or other) and that have been repeatedly implicated in the pathophysiology of depression. ²²

Because my area of research focuses on brain—immune system interactions, I searched diligently to identify studies that had examined the effects of forgiveness on immune or inflammatory functioning, and found none that addressed this issue specifically (please submit a comment if you know of, or find, studies I’ve missed). Perhaps the closest work I know of comes from our research group. We have spent several years studying the immune effects of a contemplative practice derived from Tibetan Buddhism known as compassion meditation. Practicing acceptance and forgiveness of others is an important part of the practice. Interestingly, we have shown that people who learn and practice compassion meditation have reduced inflammatory and autonomic responses to a laboratory psychosocial stressor, and reduced cortisol and CRP (C-reactive protein; an inflammatory marker) at rest, although these changes were not associated with self-reported increases in ability to forgive others. ^23,24

Therapeutic Potential of Forgiveness

If forgiveness appears, overall, to promote emotional well-being and physical health, one might predict that teaching people to be more forgiving might be of benefit, and this appears to be the case. ¹⁷ Of direct relevance to your question about forgiveness and PTSD, a recent study found that when compared to a treatment comprised of anger validation and assertiveness/interpersonal skill building training, forgiveness therapy resulted in significantly greater improvements in depression, anxiety, posttraumatic stress symptoms, and self-esteem in women who had suffered long-term emotional abuse from a partner. ²⁵ Forgiveness interventions have also been shown to reduce myocardial perfusion defects in response to stress, ²⁶ and to help patients with substance abuse histories to maintain sobriety. ²⁷ Interestingly, despite the traditional association of forgiveness with religious practices, secular forgiveness interventions have been reported to be more effective than explicitly religious/spiritual assumptions and principles. ⁵

Forgiveness as a Wellness Strategy: One Size Does Not Fit All

If one theme emerges from the information we have provided it is this: forgiveness appears to have huge potential benefits for health, but it is not something that should be prescribed or applied blindly as an unmitigated good for all who come to us for aid. Most people are likely to benefit immensely from learning to be more accepting of others and more forgiving of those who anger them and/or do them wrong. But it is just as true that many other people use forgiveness as a way of avoiding difficult, but necessary, confrontations with those who are abusing or taking advantage of themselves. Being unforgiving of the self is a recipe for despair and depression, but being overly slack on one’s weaknesses can lead to various forms of behavioral stasis that can poison the mind and the body.

I think there are two bottom lines here. First, each patient or client must be assessed in terms of his or her unique personality and social situation, prior to making any type of blanket prescriptions in regards to forgiveness as a wellness strategy. Second, what really seems to matter about forgiveness in terms of health benefits is the internal state it produces when it is done right. And by done right, I mean, when it arises from a position of internal strength and well-being that allows one to be less angry at others while at the same time not allowing them to take advantage or behave in inappropriate ways towards oneself. This type of forgiveness does not make one a push-over and does not always mean that relationships will be re-established after major transgressions. It only means that one will make these types of choices from a more rational and empathic internal state that is less likely to bring misery and illness to oneself. When appropriate, this is the type of forgiveness we should help our patients learn to cultivate.

References

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