Spirituality, Religious Wisdom, and the Care of the Patient

Forgiveness: Spiritual and Medical Implications

Christina M. Puchalski, M.D.
cpuchalski@gwish.org

Christina Puchalski is the Founder and Director of the George Washington Institute for Spirituality and Health and Assistant Professor of Medicine at the George Washington University School of Medicine. She has received awards from the John Templeton Foundation, The Association of American Medical Colleges, The National Catholic Press Association, and the Health Care Foundation of New Jersey for her efforts to incorporate spiritual and humanistic perspectives into physician education and training. She is a secular associate of the Carmelite Order, an order that focuses on prayer and a contemplative relationship with God.

Forgiveness plays an important role in each of our lives on a personal as well as a relational and societal one.  On a personal level, forgiveness of self can help us achieve an inner peace as well as peace with others and with God.  Wrongdoing against others and ourselves can result in guilt and resentment.  This can then lead to self-recrimination and self-loathing; it also can create a distance or disconnect from self and others.  Resentment can give away to hate and intolerance.  Forgiveness is the first stage of self-love and acceptance.  It is also the basic building block of loving relationships with others.

On a societal level, we face social injustice, urban crime, terrorist acts and war.  These realities of society can also lead to resentment, territorialism and hatred.  While many of these aspects of our society are wrong and perhaps even warrant a justifiable anger and hatred until we can forgive even the most horrendous of these acts, how can we as a society, or as a civilization, live together in peace?  Thus, forgiveness is the basic building block of a tolerant society.

There have been many studies looking at the role of forgiveness in health.  Unforgiving persons have increased anxiety symptoms, increased paranoia, increased narcissism, increased frequency of psycho-somatic complications, increased incidence of heart disease and less resistance to physical illness.[i]  Pargament has found that people who are unable to forgive themselves or others also have an increased incidence of depression and callousness toward others.[ii]  The act of forgiveness can result in less anxiety and depression, better health outcomes, increased coping with stress, and increased closeness to God and others.[iii]

There have been numerous studies looking at forgiveness interventions.[iv]   The interventions involved counseling and exercises which were used to help people move from anger and resentment towards forgiveness.  In one study, incest survivors who experienced the forgiveness intervention had at the end of the intervention increased abilities to forgive others, increased hopefulness and decreased levels of anxiety and depression.[v]  In another study, college students were randomized to a group that received a forgiveness education program and another group who studied human relations.[vi]  The group that received the forgiveness education program showed higher levels of hope and an increased willingness to forgive others.  This greater self-forgiveness was associated with increased self-esteem, lower levels of anxiety, lower levels of depression and a more positive view of their patient.

In many of these studies, it was shown that people who are able to forgive are more likely to have better interpersonal functioning and therefore social support.[vii]  In terms of social support, there is a large body of literature that demonstrated the value of social support.  Social support has been shown to reduce cardiovascular risks, promote faster recovery and increased survival rates from several types of cancer.[viii]  Therefore, forgiveness, since it improved interpersonal functioning, might mediate these better health outcomes through the ability of people to have increased social support.

From my own clinical experience, I frequently encounter in my patients themes of self-loathing arising from guilt about a perceived or actual wrongdoing.  For example, patients come to understand their illness as a punishment from God.  This perception may hinder the ability of that patient to heal or to seek appropriate treatment.  Stress is known to affect blood pressure.[ix]  Patients who harbor resentment and guilt often talk about feeling stressed and pressure.  In several of my patients, their hypertension becomes difficult to manage in part because of the impact of stress on their blood pressure.  Self-loathing, then, can result from an inability to forgive self or hatred and resentment of others.  An inability to forgive others can lead t a lack of self-care.  People are less inclined to exercise, eat properly, and to value themselves.  This, in turn, leads to increased health problems.

A landmark study called The Stanford Forgiveness Project led by Carl Thoresen, PhD and his associates from Stanford University, designed a forgiveness intervention, piloted it, and then tested it.[x]  The intervention is a workshop that involves six one-hour sessions utilizing simple visualizations and behavior modification techniques that enable participants to see how their minds create and maintain grievance stories from past negative experiences.  Participants learn how they damage themselves psychologically and physiologically when they continually replay these stories.  Finally, participants learn how to give up their grievances by taking them less personally and looking at the offending person in a more positive light.  In their pilot, some of the participants chose to hold onto grievances and not forgive offenders but the majority who decided for forgiveness had a measurable improvement in their physical and emotional health and in their interpersonal relationships.[xi]

To test the effectiveness of this model, five women from Northern Ireland were invited to participate in the workshop.  Three were Protestant and two were Catholic.  Each had experienced suffering and losses in their country.  As a result, they were experiencing grief reaction and depression.  After one week of the forgiveness intervention, all five improved on measures of depression, forgiveness, hurt and stress.[xii]

These studies show that forgiveness helps people move from hatred of offenders to love and care of them, from ruminating about past offenses to understanding and feeling empathy with their offenders and from avoiding people who have hurt them to communicating directly with them.

Forgiveness, therefore, is a better way of coping.  It involves a transformation in motivation.  For example, holding on to anger might create a distance from others.  Maintaining a distance from others who may have hurt one, may come from a motivation for self-preservation.  Closeness to others may involve risk and openness and therefore a possibility of being hurt.

By changing one's motivation from self-preservation to openness to others allows for healing of old hurts and leads to more whole relationships.  Forgiveness is an integral part of this process.

What helps a person in the Christian tradition change their motivation from being angry, hateful and even isolative to being loving and open to others and self?  Healing and transformation occurs when we deepen the virtues of faith, love and hope in our lives.  With faith and love, hope is the normally expected fruit of Christian prayer, especially contemplative prayer.  One adjunct of healing then is through prayer.

Hope then gives birth to change.  Without hope, there is no possibility of changing.  There is no future without hope.  The inability to forgive blocks hope and that is why it sets the stage for depression; it is the reason the data indicates an increase in depression in people who cannot forgive.

St. John of the Cross, a 16th Century Carmelite mystic, wrote that "Attachment to a hurt arising from a past event blocks the inflow of hope into our lives."[xiii]  So, without forgiving, we cannot feel God's presence.  Harboring resentment and hatred of self or others even while praying blocks one to the openness that comes from prayer and from relating to God.  This creates a barrier between the person and God, between two people and between the person and the self.

Sin is an estrangement between God and ourselves.  Reconciliation is the fruit of forgiveness.  It brings us back together with God and others.  The Sacrament of Reconciliation in Catholicism is an encounter between God and ourselves.  The celebration of that Sacrament of Reconciliation has always stressed the social dimension of sin and forgiveness.  Forgiveness is the act of being restored to a good relationship with God, others and self, following a period or incident of sin or alienation.  So, when someone feels they have been wronged, or that they themselves have wronged someone, that results in an alienation between people or an alienation between self and God.  Forgiveness brings wholeness back to these relationships.

So important is forgiveness in Christianity that it is central to the Christian identity as described in the Lord's Prayer. "forgive us our trespasses as we forgive those who trespass against us." [xiv]  Kevin Kavanaugh, OCD, a Carmelite priest and translator of the works of St. John of the Cross and Teresa of Avila, two of the great Carmelite mystics, wrote that "The Lord's Prayer's simplicity and forceful condensation of Jesus' spirit and message make it the unequaled expression of Christian prayer." [xv]  The Lord's Prayer set the criterion for forgiveness in the Christian tradition.

Forgiveness is the sinner's transformation acceptance of the unconditional mercy of God through Jesus Christ and the subsequent extremely of that expression to another person by accepting them.  So as we are forgiven by God, so do we also forgive others.  We ask God to forgive us as we forgive others.

In the New Testament, [xvi] Peter asks Jesus how often we should forgive others:

"Then Peter came up and said to him 'Lord, how often should my brother sin against me an I forgive him?  As many as seven times?' Jesus said to him, 'I do not say seven times but seventy times seven.'" (Matthew 18: 21-22)

There is no limit to our forgiving others because there is no limit to God's forgiveness.

St. Teresa of Avila writes of our being forgiven by God as an experience in which we become aware of our sinfulness and in that sinfulness we become humble.  Our humility is a truthful awareness of our sinfulness and our humanity.  This leads to a greater understanding and acceptance of others.  We bond to each other in our sinfulness, in our humanness.  For we see that none of us is free of sin.  Each of us is capable of sin.  Teresa says that should make us more able to forgive others of their sinfulness because of our awareness of our own sinfulness.  Teresa defines humility as the implicit understanding we have that when someone wrongs us we know that we too have wronged others at some time in our life.[xvii]  So as God forgives us, so we forgive others.

St. Teresa says that God because he is merciful he forgives us and forgives us without limit.  Thus, it is in our encounters with God where he forgives us that we experience the brilliance and intimacy of his mercy.  It follows that we should then forgive others in the same way.  It is the grace of our loving encounter with God that gives us the ability to be merciful and forgiving of others.

"I cannot believe that a soul that comes so close to mercy itself when it realizes what it is and the great deal God has pardoned it of, would fail to pardon its offender immediately, in complete ease and with a readiness to remain on very good terms with that person.  Such a soul is mindful of the gift and favor granted by God, by which it saw signs of great love; and it rejoices that an opportunity is offered whereby it can show the Lord some love." [xviii]

St. Teresa states clearly that if we are forgiven by God as we are, we should just turn around and forgive others, remain on good terms with them and in so doing, we show our love to God.  Teresa wrote this in terms of our healing and well-being and how we should act.  "We should remember then to only recall God's mercy and not wallow in self-pity and grudges." [xix] And Paul taught that "love does not brood over anyone." 20

This goes back to the data that suggests that people who hold onto grudges do not do as well in health outcomes.  Teresa offers us a way to let go of those grudges and forgive others and ourselves.

Contemplative prayer is a profound communication with God.  In this type of prayer, we experience God's mercy and the fullness of His presence in our lives.  In prayer and the encounter of God's mercy, we forgive others and self as God forgives us.  This then opens us to hope and therefore healing.  St. John of the Cross writes:

"Being now satisfied in this union with God insofar as is possible in this life, she has neither anything to hope for from this world nor anything to deserve, spiritually for she has the awareness and experience of the fullness of God's riches."21

One's desires are totally satisfied because of this complete union with God.

In conclusion, an inability to forgive creates a barrier between each other, God and ourselves.  In the Christian tradition, we experience God's mercy in his forgiveness of us.  The awareness in prayer of God's merciful love leads us to the realization that we are also called to forgive others and ourselves.  Christ says, "Love one another as I have loved you."22 This enforces the concept that forgiveness is the first step toward self love and love of others.  Thus, forgiveness can result in greater peace of mind, healing of old emotional wounds, peace with others and the possibility of better relationships.

St. Therese of Lisieux noted that after a particular confession she experienced peace.  "My general confession left a great deal of peace in my soul and God did not permit the lightest cloud to come and trouble me."23  Thus, forgiveness is at the heart of healing.

A lifestyle characterized by forgiveness is often thought to be also characterized by love, empathy, humility and gratitude.  All of these virtues enable a person to live a more profoundly Christian life and, in general, I think greater richness in relationships with others and with God.  Reconciliation implies the active power of love to open up the channels that enable people to relate to one another in love.  Forgiveness therefore is the first step toward self-love and is thus the building block of loving relationships and eventually a tolerant society.  Thus, on the social level, forgiveness may be the critical element needed for world peace.  As Kevin Culligan, OCD writes, "Forgiveness may ultimately be the most powerful weapon for breaking the dreadful cycle of violence."24

So whether one speaks of forgiveness from a medical perspective, a religious perspective, or simply from the human perspective, it is critical to our lives as people and to our society as a whole.


[i] Worthington, E.L. (ed.) Dimensions of Forgiveness:  Psychological Research & Theological Perspectives (Templeton Foundation Press; 1997).
[ii] Pargament, K.L., et al. J Sci Stud Religion 1998;37:710-724
[iii] Worthington, E.L. (ed.) Dimensions of Forgiveness:  Psychological Research & Theological Perspectives (Templeton Foundation Press; 1997).
[iv] Worthington, E.L. in Dimensions of Forgiveness (Templeton Foundation Press; 1998), p. 107.
[v] Freedman, S.R., Enright, R.D., Journal of Counseling and Clinical Psychology 1996;64:983-992.
[vi] Al-Mabuk, R.H., Enright, R.D., Landis, P.A. Journal of Moral Education 1995;24:427-446.
[vii] Plante, TG, Sherman, AC (eds) Faith & Health: Psychological Perspectives.  The Guilford Press, 2001. p. 111
[viii] Koenig, HG, McCullough, ME and Larson, DB.  Handbook of Religion and Health p. 238-240. Oxford University Press (2001)
[ix] Stuart, E., et. al. Nonpharmacologic Treatment of Hypertension:  A multiple risk-factor approach. J Cardiovascular Nursing 1987;1:1-14.
[x] McCullough, ME, Pargarment, K., and Thoresen, C., Forgiveness:  Theory, Research and Practice (Guilford Publications, Inc; 1999).
[xi] Ibid.
[xii] Ibid.
[xiii] St. John of the Cross, The Spiritual Canticle
[xiv] Matthew 18:21-22. The New Testament
[xv] Kavanaugh, Keiran (ed.) St. Teresa of Aliva: The Way of Perfection p. 417 (2000) ICS Publication Institute of Carmelite Studies, Washington, DC.
[xvi] Matthew 18:22, The New Testament
[xvii] Kavanaugh, Keiran (ed.) St. Teresa of Aliva: The Way of Perfection p. 399-417 (2000) ICS Publication Institute of Carmelite Studies, Washington, DC.
[xviii] Kavanaugh, Keiran (ed.) St. Teresa of Aliva: The Way of Perfection p. 405 (2000) ICS Publication Institute of Carmelite Studies, Washington, DC.
[xix] Kavanaugh, Keiran (ed.) St. Teresa of Aliva: The Way of Perfection p. 410 (2000) ICS Publication Institute of Carmelite Studies, Washington, DC.
20 Cor 13:5. The New Testament.
21 St. John of the Cross, The Spiritual Canticle.
22 John 13:34, The New Testament.
23 John Clarke (ed). St. Therese of Lisieux, Story of a Soul. ICS Publication Institute of Carmelite Studies.  Washington, DC. P. 76.
24 Culligan, Kevin, "Prayer and Forgiveness:  Can Psychology Help?"  Spiritual Life 2002;89:78.

David Novak, Reconciliation at the End of Life
Forgiveness: Introduction
Table of Contents

Published: September 17, 2002