Forgiveness Therapies: Dangerous or Healing?

Forgiveness Therapies: Dangerous or Healing?Forgiveness is a new and growing target in therapies. Researchers typically define forgiveness as including two components: (1) choosing to treat someone who has wronged you as a valuable human (“decisional forgiveness”) and (2) translating negative emotions, such as resentment, into positive, other-oriented emotions, such as compassion (“emotional forgiveness”). Therapies designed to promote forgiveness typically devote a significant portion of time to first supporting clients in processing their emotions, and also include exercises, such as letter writing, designed to promote empathy and other positive emotions towards the offender in a safe atmosphere.

Forgiveness Is Not Reconciliation

Importantly, in this definition, forgiveness is distinct from reconciliation. Common understandings of forgiveness, on the other hand, may conflate the two concepts. Promoting a form of forgiveness that conflates forgiveness with reconciliation could be dangerous. For example, in a sample of 121 women in domestic violence shelters, forgiveness correlated with intentions to return to the abuser and with perceptions of the abuser’s actions as less malicious. Thus, if forgiveness is a target of therapy, clinicians must be careful to also help clients establish safe boundaries, and view forgiveness as a personal, rather than interpersonal, act.

Do Clients Seek Forgiveness-Promoting Therapies?

A significant portion of clients appear to want to work on forgiveness in therapy. In a study of 59 clients at university counseling centers, researchers found that a significant portion (75%) of those who had been hurt in the past wanted to forgive. Peoples’ willingness to work on forgiveness in therapy corresponded with the amount of time they had seen their therapist, suggesting that forgiveness is best to target later on in therapy.

Most of the research on therapies promoting forgiveness includes participants who decide to participate in an intervention explicitly designed to promote forgiveness. Peoples’ decision to participate in these forgiveness interventions does not appear to depend on the severity of the offense they experienced; for example, survivors of incest have participated in studies of forgiveness-promoting therapies.

Are Forgiveness Therapies Effective?

Therapies targeting forgiveness are consistently more effective than wait-list and attentional controls, and are successful at not only promoting more forgiveness, but also improvements in overall mental health outcomes, such as anxiety and depression.

In some cases, these therapies have outperformed standard treatments (e.g. here and here). For example, in one study, a treatment with an empathy component was more effective at promoting forgiveness than a similar treatment without an empathy component. In another study, inpatients randomly assigned to an individual therapy incorporating forgiveness experienced greater increases in forgiveness and self-esteem and greater decreases in depression, anxiety and anger than those assigned to a standard substance use treatment group.

However, these findings are not conclusive. It’s important to consider that the participants in these studies are people with a desire to forgive. Researchers partial to the therapy under investigation also typically conduct these studies in which the forgiveness-promoting therapy outperforms the standard therapy, leaving open the possibility that an allegiance to the therapy contributes to these findings.

Some researchers argue that common factors, such as social support, are more integral to therapies than are specific ingredients, such as forgiveness. For example, in one study comparing relaxation training, a forgiveness intervention based upon theoretical components (e.g. empathy building), and a forgiveness intervention not based upon theoretical components, researchers found that all were equivalently effective at changing participants’ levels of forgiveness. Other researchers have similarly found that, when compared to a standard treatment, interventions promoting forgiveness led to similar improvements in forgiveness and mental health measures. Studies in which forgiveness therapies do not outperform standard therapies are typically shorter in duration, and group-based, leaving open the possibility that duration and therapy modality are important factors.

Clinical Take-Away

The safest conclusion to draw from existing research is that forgiveness can be a useful target in therapy for those who are open to forgiveness. These clients are highly likely to benefit from evidence-based techniques that encourage forgiveness. The research is less extensive on those who are less open to forgiveness, but it’s possible that they are likely to benefit as well. For example, Christian clients in both religious and non-religious settings rated a moderate to high amount of comfort with forgiveness-promoting interventions, and surveys of clinicians indicate that clinicians tend to believe forgiveness can be brought up ethically and effectively within therapy. Forgiveness is correlated with a variety of physical and mental health benefits (e.g. here and here). In one study, amongst college women, forgiveness related to a specific offense predicted less psychological distress four months later. Therapies targeting forgiveness involve helping clients process their own emotions and are typically effective if the forgiveness-promoting component is incorporated into therapy later on. As with any therapy, therapists must empower clients to make choices that best align with their own unique set of values and acknowledge that forgiveness is but one way that a client can respond to a situation or a person.

Incorporating Forgiveness into Clinical Practice

Worthington’s REACH model of forgiveness is one example of a well-established model that outlines steps therapists can take to help clients forgive in therapy. Each letter in the acronym outlines a key step in the forgiveness process: R (Recall the event), E (Empathy for the transgressor), A (give forgiveness as an Altruistic gift), C (Commit to the forgiveness through a written and/or spoken statement) and H (Hold onto forgiveness in moments of doubt). Portland Psychotherapy is hosting a training workshop with Dr. Worthington September 28th, 2019 for those therapists interested in learning more. If you would like to sign-up or read more about this workshop, please go to Eventbrite.

Further Learning

Written by Christina Chwyl, B.A.

Harnessing the Power of the Therapeutic Relationship

“Dealing with others is dealing with ourselves, dealing with others.” 

–Norman Fischer

Creating intense and curative therapeutic relationships is a fundamental skill for meaningful therapy. Strong relationships like this can engage people in ways that challenge and can perhaps even frighten them.  This means that therapy can involve exposure to avoided thoughts, emotions and sensations for the client AND the therapist.

“Exposure therapy typically elicits a temporary increase in patients’ negative affect in order to facilitate new learning. This may in turn increase therapist discomfort as therapists interact with the patient and are confronted with their own uncomfortable subjective experiences.” (Scherr, Herbert and Foreman, 2015).

The authors of this study found that therapists with high levels of avoidance tended to avoid doing exposure therapy. Powerful therapy requires us choosing to lean into risking vulnerability instead of leaning back and doing therapy to the client.   Easier said than done. Doing therapy can be disturbing and we rarely receive explicit training on what to do when we are struggling. When we find the courage to open up about our challenges in consultation, we might hear solutions, be given articles to read, or have our behaviors analyzed by the other clinician. Rarely do we hear, “Yeah, me too. As a matter of fact, about an hour ago.”

Thankfully, two third wave behavioral therapies (Functional Analytic Psychotherapy and Acceptance and Commitment Therapy) blend quite nicely and give us clear guidance on how to continue to move toward that vulnerable edge of growth.  With them, we can accept our own human urge to avoid distress and stay the course, especially when deep pain arises in the therapy.

Functional Analytic Psychotherapy (FAP)

Bob Kohlenberg and Mavis Tsai, at the University of Washington developed FAP. As behavior analysts, they noticed some clients improved much more than others.  They found that in sessions where the client experienced great change, the relationship was pivotal. FAP focuses on interpersonal flexibility.  The power of FAP is responding to our client’s behaviors moment-to-moment in session. To do this, we need to consider our clients in the context of their lives and their histories.  For example, consider a client with a pervasive and persistent pattern of complaining which affects his relationships. Telling us that they don’t like something about the therapy could be an instance of that unworkable behavior.  For another client, it might be a risky move toward intimacy.  FAP terms these ‘clinically relevant behaviors’ or CRB for short.

FAP gives a framework for how to be most effective with our clients through a set of rules or guidelines. When we follow FAP rules with our clients, we can find ourselves risking and challenging ourselves to engage in an honest and undefended way.

Here’s a simplified version of those rules:  Be aware, courageous and loving with our clients. Again, easier said than done.

Acceptance and Commitment Therapy (ACT)

ACT was developed by Steve Hayes at the University of Reno, and focuses on intrapersonal flexibility. Humans don’t like risk, so we need something to help us when we are in that shaky ambiguity of pushing our comfort zones.  ACT helps us find our ground as we engage in emotionally vulnerable ways with the people we serve.  As human beings with our own histories, it’s certain that we will have painful reactions in the therapy session.  Accepting this as normal, staying in the present moment with those reactions, touching into our values and taking action allows us to follow the FAP rules of engagement.   ACT helps us hold a stance of open curiosity, so that we can engage in the messy work of human intimacy.

Doing effective and meaningful work as a therapist is not easy. Thankfully, Steve Hayes, Bob Kohlenberg and Mavis Tsai have given us tools that provide a scaffold for us to create transformation with our clients.   I’m excited to share how you can get the most out of these two therapies and make your work more powerful.  We’ll be working in depth on blending these two powerful therapies and applying them to your most challenging clients.  Come join us.

 

Harnessing the Power of the Therapeutic Ralationship Using ACT & FAP

  • 2-day workshop led by Joanne Steinwachs, LCSW
  • March 4 – 5, 2016, from 8:30 am – 4:30 pm
  • sponsored by Portland Psychotherapy


Joanne Steinwachs LCSWJoanne Steinwachs LCSW is a social worker in private practice in Denver, CO. She is a peer reviewed ACT trainer and a recognized FAP trainer. To learn more about her training and therapy practice, go to www.joannesteinwachslcsw.com.

 

 

Resource Development for Insomnia Treatment

Resource Development for Insomnia Treatment

Do you practice CBT for Insomnia? 

Would you like to be involved in a community effort to create a needed resource?

In the field of behavioral sleep medicine (BSM), the sleep diary is an essential and ubiquitous tool. While there has been progress in creating a standard sleep diary form, there has not yet been any advances in providing practitioners with a common and easy to use interface for this standard.

This has left providers stuck with the task of calculating sleep data in inefficient  ways such as by pen and paper or ‘re-inventing the wheel’ by creating their own  means of calculating and tracking the data via MS excel or MS access. Large  amounts of time and creativity are lost as people’s efforts to tackle this problem are not shared with the community.

To address this problem Dr. Scott Rower is leading a team of people in the BSM community to create a simple and accessible user interface based on the standardized consensus sleep diary.  This freely available webpage will allow any provider the ability to calculate their patient’s sleep data in order to inform treatment decision making.

Want to get involved?  Learn more here.

This project is funded through an internal grant at Portland Psychotherapy Clinic, Research & Training Center

5 Excellent Reasons to Treat Insomnia

5 Excellent Reasons to Treat Insomnia

1. Insomnia can cause depression.

A collection of research suggests that untreated insomnia doubles the chance of developing depression, as a causal factor (4 sources – one, two, three, four)

2. Insomnia often does not resolve once the depression is treated or without focused insomnia treatment (source 1; source 2)

3. Untreated insomnia more than doubles the chance of relapse of depression and other mental health diagnoses.  (source 1; source 2)

4. Effective, short-term, focused insomnia treatment exists

Cognitive Therapy for Insomnia (CBT-I) produces significant, sustained relief that is comparable to medications in the short-term & more effective in the long-term (4 meta-analyses – onetwo, three, four).

5. Insomnia represents a significant factor in non-response to treatment (source).

Conclusion

Insomnia is a major factor in clinical response and vulnerability to mental illness.  It does not tend to improve without focused treatment.  Treatment exists & over 30 years of evidence suggests that CBT-I is the most effective. 

Cognitive Behavioral Therapy Superior to Antipsychotics for OCD

Cognitive Behavioral Therapy Superior to Antipsychotics for OCD

A practice I’m seeing more often that concerns me is the addition of antipsychotic medications on top of antidepressants when the antidepressants aren’t working. If someone isn’t showing improvement on an antidepressant alone, a prescriber may add an antipsychotic medication—the idea being it will increase the effectiveness of the antidepressant. The research for this is a little questionable, especially as the side effects for antipsychotics can be pretty bad. I’ve felt strongly enough about this issue that I wrote an editorial about it that the Oregonian published in 2012.

Antipsychotics and obsessive-compulsive disorder

In previous post, I wrote about a study that found that giving an antipsychotic in people with posttraumatic stress disorder (PTSD) provided no additional improvement. A recent study looked at whether adding an antipsychotic medication would be helpful to people with obsessive-compulsive disorder (OCD). Results are extremely clear that the answer is, “No!”

As I’ve written before, the most effective treatment for OCD is cognitive behavioral therapy (CBT) with exposure and response (or ritual) prevention (EX/RP). (Note: in other posts, I abbreviate exposure and response prevention as “ERP” but use “EX/RP” here to remain consistent with the article.) There is some research that suggests that antidepressant medication can have a small impact on OCD-related problems, but EX/RP remains the gold standard treatment

Another study showing that CBT does the best with OCD

A 2013 study in JAMA Psychiatry examined a group of people with OCD who were already taking an antidepressant but were still experiencing moderate or worse OCD symptoms. These individuals were divided into 3 treatment groups.

  1. Some received psychotherapy—cognitive behavioral therapy with EX/RP.
  2. Some received an antipsychotic—Risperidone.
  3. Some received a placebo (i.e., inactive) pill.

CBT with ERP was much more effective

The results were striking. The researchers found that only 23% of people showed improvement on the antipsychotic; moreover, this result is even less impressive given that 15% showed improvement on the placebo (e.g., sugar pill). In fact, statistical analysis suggests there was no difference between the antipsychotic and the placebo—this means that the antipsychotic and a sugar pill performed about equally.

By contrast, 80% of people who received cognitive behavioral therapy with EX/RP improved.

80% vs. 23% is a big difference, especially since the latter is more of a placebo effect than a response to an active treatment.

One quibble

In the Conclusion section of the abstract, the writers make a subtle statement that really bothered me:

Patients with OCD receiving SRIs who continue to have clinically significant symptoms should be offered EX/RP before antipsychotics given its superior efficacy and less negative adverse effect profile.” [bolding is mine.]

 

This statement implies that, even though EX/RP is superior to antipsychotics, that antipsychotics are still a viable treatment. This seems a bit disingenuous, however, as the researchers’ own analyses indicate that whatever improvement antipsychotics demonstrated was likely a placebo effect.

If anything, a sugar pill should be offered before an antipsychotic since they are equally effective, and the former has fewer side effects.

Concluding thoughts

Although I think this is an important study because it makes it clear that adding antipsychotic medication is unlikely to be of much help for someone with OCD, the superiority of ERP over medication for OCD isn’t new information.

There’s already a solid base of research that suggests the EX/RP is superior to antidepressant medication for OCD. Giving an antidepressant to someone receiving EX/RP for OCD neither helps nor hinders treatment. This study makes it pretty clear that antipsychotics should not be considered for people with OCD.

UPCOMING TRAINING EVENTS