The Effects of Forgiveness Therapy on Depression, Anxiety, and Post traumatic Stress for Women After Spousal Emotional Abuse

The Effects of Forgiveness Therapy on Depression, Anxiety, and Post traumatic Stress for Women After Spousal Emotional Abuse

The Effects of Forgiveness Therapy on Depression, Anxiety, and Post traumatic Stress for Women After Spousal Emotional Abuse

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Emotionally abused women experience negative psychological outcomes long after the abusive spousal relationship has ended. This study compares forgiveness therapy (FT) with an alternative treatment (AT; anger validation, assertiveness, interpersonal skill building) for emotionally abused women who had been permanently separated for 2 or more years (M � 5.00 years, SD � 2.61; n � 10 per group). Participants, who were matched, yoked, and randomized to treatment group, met individually with the intervener. Mean intervention time was 7.95 months (SD � 2.61). The relative efficacy of FT and AT was assessed at p � .05. Participants in FT experienced significantly greater improvement than AT participants in depression, trait anxiety, posttraumatic stress symptoms, self-esteem, forgiveness, environmental mas- tery, and finding meaning in suffering, with gains maintained at follow-up (M � 8.35 months, SD � 1.53). FT has implications for the long-term recovery of postrelationship emotionally abused women.

Keywords: spousal emotional abuse, forgiveness therapy, depression, anxiety, posttraumatic stress

Spousal emotional abuse is a significant problem, with approx- imately 35% of women reporting such abuse from a spouse or romantic partner (O’Leary, 1999); in addition, women often dem- onstrate negative psychological outcomes long after this abuse. Despite the frequent calls for efficacious therapies for these women, no empirically validated treatments have been clearly established (Enns, Campbell, & Courtois, 1997; Mancoske, Stan- difer, & Cauley, 1994; Miller, Veltkamp, & Kraus, 1997; Paul, 2004), and the literature still demonstrates a focus on the definition of and screening for spousal emotional abuse rather than empirical testing of therapeutic strategies (Follingstad, 2000; Gondolf, Heck- ert, & Kimmel, 2002; Tjaden, 2004).

Spousal psychological abuse represents a painful betrayal of trust, leading to serious negative psychological outcomes for the abused partner (Dutton & Painter, 1993; Sackett & Saunders, 1999). According to Sackett and Saunders (1999), spousal psycho- logical abuse functions with the purpose of causing emotional pain to the spouse and establishing an unequal distribution of power in the relationship. Sackett and Saunders (1999) have demonstrated negative outcomes of emotional abuse that are distinct from the impact of physical battery.

Follingstad, Rutledge, Berg, Hause, and Polek (1990) and Sack- ett and Saunders (1999) have identified at least seven categories of spousal psychological abuse: criticizing, ridiculing, jealous con- trol, purposeful ignoring, threats of abandonment, threats of harm, and damage to personal property, with ridicule associated most

strongly with negative outcomes of psychological abuse. More- over, Follingstad et al. (1990) found that 72% of participants reported that emotional abuse had a more negative impact than physical abuse. The negative psychological outcomes of spousal psychological abuse include depression (O’Leary, 1999; Pimlott- Kubiak & Cortina, 2003; Sackett & Saunders, 1999), anxiety (Dutton & Painter, 1993), posttraumatic stress disorder (Astin, Lawrence, & Foy, 1993; Enns et al., 1997; Pimlott-Kubiak & Cortina, 2003; Woods, 2000), low self-esteem (Aguilar & Night- ingale, 1994), learned helplessness (Follingstad et al., 1990; Lau- nius & Lindquist, 1988), and an ongoing, debilitating resentment of the abuser (Seagull & Seagull, 1991). A number of researchers (Astin et al., 1993; Dutton & Painter, 1993; Sackett & Saunders, 1999; Woods, 2000) have demonstrated that these negative out- comes last well beyond the end of the abusive relationship.

Considering the serious, enduring impact on the psychological health of the emotionally abused partner, the theoretical and em- pirical literature on efficacious postrelationship, postcrisis treat- ment for spousal psychological abuse is sparse. There is a lack of empirical evidence for the efficacy of one treatment that is cur- rently recommended for these women: brief therapy with a focus on anger validation (with subsequent mourning of associated losses from the abuse), assertive limit-setting, and interpersonal skill building. Neither Mancoske et al. (1994) nor Rubin (1991) provided clear empirical support for the efficacy of this brief therapy for emotionally abused women. A review of the current literature did not produce empirical evidence for the efficacy of other therapeutic approaches for emotionally abused women.

One promising new area of treatment is forgiveness therapy (FT). Research on FT has established a causal relation between forgiving an injustice and both the amelioration of anxiety and depression and an improvement in self-esteem (Al-Mabuk, En- right, & Cardis, 1995; Coyle & Enright, 1997; Freedman & En- right, 1996; Lin, Enright, Mack, Krahn, & Baskin, 2004; Rye et al., 2005). FT directly targets ongoing resentment, which can lead to

Gayle L. Reed and Robert D. Enright, Department of Educational Psychology, University of Wisconsin—Madison.

Correspondence concerning this article should be addressed to Gayle L. Reed, who is now at Educational Outreach, the University of Wisconsin Extension—Madison, 1050 University Avenue, Madison, WI 53706– 1386, and LLC Forgiveness Recovery Programs, 1715 Carns Drive, Mad- ison, WI 53719; www.forgivenessrecovery.com. E-mail: gaylelreed@ charter.net

Journal of Consulting and Clinical Psychology Copyright 2006 by the American Psychological Association 2006, Vol. 74, No. 5, 920–929 0022-006X/06/$12.00 DOI: 10.1037/0022-006X.74.5.920

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depression, anxiety, and other negative psychological outcomes (Enright & Fitzgibbons, 2000), and it has been shown in one study to ameliorate the negative emotional effects of incest (Freedman & Enright, 1996). FT posits that although anger is a justifiable, initial problem-solving response to severe wrongdoing, as in the case of emotional abuse, lingering resentment can compromise a person’s emotional health and decision making.

In helping clients move toward forgiveness, clinicians need to differentiate forgiving (see Enright & Fitzgibbons, 2000, for a discussion of defining forgiveness) from condoning, excusing, pardoning, forgetting, and reconciling. Forgiveness is a decision to give up resentment and to respond with goodwill (benevolence based on a desire for the ultimate welfare of the other person; North, 1987) toward the wrongdoer. Current research (see Rye et al., 2005) operationalizes forgiveness similarly as refraining from negative responses to the wrongdoer and fostering positive re- sponses to him or her while also clearly distinguishing forgiveness from pardon and reconciliation. For women who have experienced spousal emotional abuse, FT promotes the reclamation of valued personal qualities, such as compassion, without neglecting the injustice of the abuse or encouraging interactions with the former partner, which may result in further abuse. FT assists the emotion- ally abused woman to examine the injustice of the abuse, consider forgiveness as an option, make the decision to forgive, do the hard work of forgiving (grieve the pain from the injustice, reframe the wrongdoer, relinquish resentment, and develop goodwill), find meaning in the unjust suffering, and discover psychological release and new purpose. These aspects of FT fall within the four phases of the Enright forgiveness process (Enright & Fitzgibbons, 2000)—uncovering, decision, work, and discovery—currently used in treatment and research.

Robust results have been found in randomized experiments with FT. Lin et al. (2004), in their FT experiment in a drug rehabilita- tion unit, following Hedges and Olkin (1985), reported an effect size of 1.58 across all dependent measures after adjusting for intercorrelations among variables. Similar effect sizes (1.44 and 1.42, respectively) were reported in Freedman and Enright (1996) and in Coyle and Enright (1997). In all three studies, the sample sizes were relatively small, ranging from 10–14 participants per study. Other randomized experiments with FT have been reported (e.g., Rye et al., 2005). See Baskin and Enright (2004) for a meta-analysis of FT.

Women who have experienced spousal emotional abuse present at least two unique challenges for recovery. First, learned help- lessness (Sackett & Saunders, 1999) develops as a pattern of self-blame in response to the criticism and ridicule by the abusive spouse and often remains well beyond the end of the abusive relationship (Dutton & Painter, 1993). “If only I had done this to please him” quickly deteriorates in the ongoing, unpredictable stress of the abusive relationship to “I am trying to prevent this, but nothing is working” and remains in a residual “Maybe I am worthless and none of my decisions are valid.” Therefore, any treatment for these women should demonstrate outcomes in prac- tical decision making and moral decision making. This study tests these outcomes (environmental mastery and finding meaning in suffering) and suggests that FT ameliorates this problem more successfully than an alternative treatment (AT).

Second, Seagull and Seagull (1991) described an obstacle to recovery for emotionally abused women labeled accusatory suf-

fering, which entails maintaining resentment and victim status. The assumption in accusatory suffering is that healing the wounds of the abuse will somehow let the perpetrator off the hook. At a deeper level, accusatory suffering may be seen as a defense against the fear that the woman is somehow responsible for her own victimization, a fear that is often inculcated by the victimizer (Sackett & Saunders, 1999). Seagull and Seagull (1991) argued that although accusatory suffering (resentment and victim status) may function as a temporary strategy to help the woman adapt to the extreme experience of spousal emotional abuse, it seriously hinders substantial postrelationship, postcrisis recovery. There- fore, any treatment for these women should demonstrate a change in victim status. This study tests this outcome (story measure) and suggests that FT is more successful than AT.

One current therapeutic approach recommended and tested in the literature (Enns et al., 1997; Mancoske et al., 1994; Miller et al., 1997) for postrelationship, postcrisis emotionally abused women includes anger validation about the wrongdoing of abuse, assertiveness, and interpersonal skill building (AT). During an early period of separation from the abusive relationship (perhaps 1 to 2 years), anger validation likely helps emotionally abused women confirm the injustice of the abusive spouse’s behavior and thus provides support for the woman’s choice to escape the abu- sive relationship. Moreover, as validation of anger after such a deep, personal injustice can be an important step toward helping women uncover and mourn the pain (Mancoske et al., 1994) from this unjust injury, the uncovering phase of FT addresses this as well. However, we suggest that anger validation (even with the subsequent mourning) over time without the inclusion of work toward forgiveness may inadvertently promote the accusatory suf- fering described by Seagull and Seagull (1991) and thus contribute to the debilitating resentment that maintains and likely even in- creases the negative psychological outcomes of the abuse.

FT does have an overall, targeted focus on decreasing this resentment toward the abusing former partner, which Seagull and Seagull (1991) suggested hinders optimal recovery. Moreover, the mourning work done in FT is for the specific purpose of aiding the recovering women to successfully relinquish resentment and re- venge toward the former abuser and to develop goodwill. It is important, again, to reiterate that FT does not require nor encour- age reconciliation (a critical concern that likely prevents recom- mendation of forgiveness in recovery strategies; Herman, 1997). FT, therefore, makes a safe and distinct contribution to postrela- tionship, postcrisis therapy for emotionally abused women by promoting the practice of a specific moral quality (choosing for- giveness, relinquishing resentment, developing goodwill) as a way of integrating the past traumatic experience of emotional abuse with current positive, empowering moral choices (Astin et al., 1993; Frankl, 1969; Reed, 1998). FT thus likely effectively ame- liorates the negative psychological outcomes of emotional abuse because engagement in the forgiveness process does decrease resentment toward the former abuser (along with concomitant depression, anxiety, and low self-esteem, which are associated with emotional abuse; Sackett & Saunders, 1999) and validates the positive, moral decision to replace resentment with goodwill (thus addressing the learned helplessness associated with emotional abuse; Follingstad et al., 1990).

We therefore hypothesized that individuals who participated in FT would demonstrate less depression, anxiety, and posttraumatic

921FORGIVENESS THERAPY AFTER SPOUSAL EMOTIONAL ABUSE

stress symptoms and more self-esteem, environmental mastery, and finding meaning in suffering than those who engaged in the more standard therapeutic procedure (AT), which does not directly target the amelioration of this resentment. To have as fair a comparison as possible between FT and AT, we addressed meth- odological problems in past AT studies for both treatment condi- tions by having a single presenting problem (psychological abuse), a single living arrangement (permanent separation from the abu- sive partner), postcrisis treatment (all women had been separated at least 2 years from the former abuser), and criterion ending (rather than brief therapy at 4–6 weeks).

Method

Participant Sample

The participants were 20 psychologically abused women in a Midwest city who had been divorced or permanently separated for at least 2 years from their spouse or romantic partner. They ranged in age from 32 to 54 years (M � 44.95, SD � 7.01). Regarding ethnicity, 18 (90%) self-reported as European Americans, 1 (5%) was Hispanic American, and 1 (5%) was Native American. Educational levels included 4 (20%) with a high school diploma or general equivalency diploma, 6 (30%) with some college education or an associate’s degree, 4 (20%) who were college graduates, 3 (15%) who had some postgraduate education, and 3 (15%) who had postgraduate degrees. Three (15%) of the participants were unemployed, 5 (25%) had part-time employment, and 12 (60%) had full-time employment. One participant (5%) held a job in service, 7 (35%) worked in clerical jobs, 2 (10%) worked in business or sales, and 7 (35%) had professional careers. Six (30%) participants had no children living with them, whereas 14 (70%) had one to four resident children. Five (25%) of the participants had remarried, and 15 (75%) had not remarried or started a new relationship with a live-in partner. These participants were all self-selecting volunteers; 2 (10%) responded to recruitment flyers (posted in domestic abuse resource centers), and 18 (90%) responded to newspaper advertisements (for women between the ages of 25 and 55 who had experienced spousal psychological abuse but not physical abuse and who had been permanently separated for at least 2 years).

The participants reported the following psychological abuse: Eighteen participants (90%) reported criticizing, 20 participants (100%) reported ridiculing, 15 participants (75%) reported jealous control, 20 participants (100%) reported purposeful ignoring, 5 participants (25%) reported threats of abandonment, 6 participants (30%) reported threats of personal harm, and 4 participants (20%) reported threats of harm to property or pets. Six (30%) participants also disclosed experiences of sexual abuse (5 described ridicule followed by demands for sexual favors, and 1 described threats of physical harm combined with demands for sexual favors).

We set the criterion that women be 2 years postseparation to prevent promoting “false forgiveness” (e.g., “He won’t do it again”), which often occurs in the abuse cycle. Also, working on forgiveness too early in a separation might mistakenly encourage a woman to feel empathy and compassion for her abusive former partner in a way that would foster old patterns of reuniting, including inappropriate dependence on the part of the former partner and subsequent harm from further abuse. Actual time since separation ranged from 2 to 10 years (M � 5.00 years, SD � 2.61).

Design

A matched, yoked, and randomized experimental and control group design was used, with 10 pairs formed after screening interviews and pretest measures. Participants in each pair were matched as closely as possible on age, duration of the abusive relationship, and time since permanent separation or divorce. Correlations for matching variables

within pairs were duration of abuse (r � .91, p � .0001), time since permanent separation (r � .72, p � .02), and age (r � .76, p � .01). Duration of the abusive relationship ranged from 1 to 31 years (M � 16.65 years, SD � 9.01). Contact with the former partner (regarding children) ranged from no contact to more than once per week, with a moderate correlation between matched pairs of .356. Following matching, 1 partic- ipant from each pair was randomly selected for FT, and the other was assigned to AT.

Testing Procedure

Screening. Screening measures included the Psychological Abuse Sur- vey (Follingstad, 2000; Follingstad et al., 1990; Sackett & Saunders, 1999), a posttraumatic stress symptom checklist (PTSS; from the Diagnostic and Statistical Manual of Mental Disorders; 4th ed.; DSM–IV; American Psychiatric Association, 1994), and a psychological screening checklist. A participant was included in the study if she demonstrated psychological abuse in at least three categories with a score of at least four and demon- strated at least three symptoms on the PTSS checklist. A score of 41 or higher on the Psychological Abuse Survey was considered indicative of a present and serious pattern of emotional abuse. All participants reported scores of 41 or above.

A participant was excluded from the study if she demonstrated current involvement in an abusive relationship, described a history of childhood physical abuse, or demonstrated evidence of significant ongoing psychiat- ric illness, such as suicidal ideation or psychosis. We excluded persons with a history of childhood abuse to fairly focus treatment (AT or FT) on only one major wrongdoing (i.e., the spousal emotional abuse). Exclusion for suicidal ideation and psychosis was done as such women would likely be better served with crisis care or counseling with the availability of psychiatric medical treatment. Appropriate referrals were offered.

Dependent variables. Before administration of any pretest measure, all participants read and signed informed consent forms approved by the research program’s human subjects board and consistent with American Psychological Association standards. Then a brief description of the study was offered. The participants were told that the purpose of the study was to promote coping strategies for women who had experienced emotional abuse and that it included weekly 1-hr individualized therapy sessions. Each participant was then invited to fill out the nine pretest measures.