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.

Introducing ACT With Compassion

Dear reader,

We feel a bit like a rude guest, who has forgotten to introduce you to their friend. If you’re reading this post, you’re probably a therapist looking for resources to learn and grow professionally. We think you might be interested in meeting this friend, “ACT With Compassion,” a website dedicated to helping therapists who are interested in bringing more compassion and effectiveness to their work with clients struggling with self-criticism and shame. Actwithcompassion.com is created by therapists at Portland Psychotherapy and is a place where we:

  • List all the latest training events for therapists that we can find that relate to things like self-compassion, compassion-focused therapy, and working with shame prone clients
  • Publish original resources for therapists (e.g. handouts, and exercises) that we’ve created that therapists can use in their practices to help clients with self-criticism and shame
  • Write blog posts about research and resources related to shame, self-criticism and self-compassion.

In our free time, we travel around the web, curating content (e.g. readings, videos, and measures) on self-compassion, shame and self-criticism. It’s possible that actwithcompassion.com might just become your go-to place for book and audio recommendations on these topics.

We apologize for the tardy introduction, but do hope you will become acquainted soon.

Sincerely,
Portland Psychotherapy

Written by Christina Chwyl, B.A.

Creation of an Institutional Review Board (IRB) for Practice-Based Research

“Science and everyday life cannot and should not be separated.” — Rosalind Franklin

Research in Clinical Practice

Clinical psychologists typically pursue either research or practice. While researchers typically have minimal contact with clients, practitioners typically have minimal access to resources that make research possible. For clinicians who do conduct research, few do so in settings in which they treat clients (i.e. “practice settings”). Instead, clinical research typically occurs in academic institutions, hospitals and research agencies (e.g. the National Institutes of Health). Yet, research conducted in practice settings could have unique benefits. Researchers would have on-the-ground insights into mental health and wellness, and could incorporate this knowledge into their research interests, hypotheses and designs. Clinicians would have insights into state of the art approaches to therapy, grounded in science. Ideally this would allow clinical psychologists to be true “scientist-practitioners” knowledgeable about both the research and practice of evidence-based treatments.

Importance of Research Ethics Review

One of the research resources that people in clinical practice do not typically have access to is an institutional review board (IRB) which reviews the ethics of research projects. These review boards are typically only available to people in academic and medical settings. Even though not all research needs to be reviewed by an IRB, review by these independent, non-biased third parties is an important step in insuring that research protects the right of participants who kindly offer their time to these endeavors. This review process also shows journals that researchers have taken steps to ensure their research is ethical, thus increasing the chance the journals will accept paper submissions and allowing researchers to more easily share their findings through peer-reviewed publications. The dissemination of research through peer-reviewed publications is key in improving therapies, and the collective knowledge of the clinical psychology field, in the long-run.

Institutional Review Board Options

Team members at Portland Psychotherapy and the organizations listed below banded together to create a nonprofit called the Behavioral Health Research Collective (BHRC) to host an independent IRB to review our research. The options for clinicians seeking to conduct research with an ethics committee are limited. Clinicians can pay a private IRB to review their research (however, this option is expensive). Alternatively, clinicians can attempt to obtain a faculty position at a university to gain IRB access, however, access to these IRBs are not always granted. Finally, clinicians can collaborate with people who do have access to an IRB, but this can limit the independence of their own research ideas.

Founding members of the BHRC:

Center for Cognitive and Dialectical Behavior Therapy, New York, NY
Cognitive-Behavioral Therapy Center of Western North Carolina, PA, Asheville, NC
Evidence-Based Practice Institute (EBPI), Seattle, WA
Evidence Based Treatment Centers of Seattle (EBTCS), Seattle, WAOakland Cognitive Behavior Therapy Center, Oakland, CA

The Behavioral Health Research Collective IRB

The Behavioral Health Research Collective IRB provides an alternative. The board is hosted by a separate, non-profit entity and its members are familiar with so that they can behavioral research that provides expert reviews of the ethics of research and liability protection. Currently, the BHRC IRB provides guidance for seven evidence-based behavioral health care organizations located in six states (CA, NC, NY, OH, OR, and WA). These organizations pay the board a low annual fee to cover standard operating expenses.

Board members who review the research do so as volunteers. Over the past 6 years, they have reviewed 28 protocols submitted by psychologists working outside traditional research settings. More detailed information about the BHRC IRB can be found in our article, “Overcoming a Primary Barrier to Practice-Based Research: Access to Independent Ethics Review” and our new website.

We hope that by sharing this information, others will create similar IRBs. This type of ethics board helps remove a barrier to conducting research in practice settings by making it easier and more affordable to have research reviewed by an ethics board. We believe that clinical research and practice are intrinsically intertwined, and that practice-based researchers are in a unique position to tackle the challenges of developing and disseminating improved treatments.

Acknowledgments

Thanks to Dr. Travis Osborne for his huge contributions in getting this up and running and for serving as the BHRC IRB Chair, and to Dr. Brian Thompson for helping the whole three-and-a-half-year undertaking get started. The creation of the BHRC IRB wouldn’t be possible without their contributions and support!

By Christina Chwyl, B.A., Research Coordinator

 

UPCOMING TRAINING EVENTS