Forgiveness, Psychological Stress, and Heart Disease Risk

Introduction: Defining Forgiveness

The concept of forgiveness has become progressively connected with the modern world. However, the theory of forgiveness was previously rejected as an inappropriate religious perception in a political and capitalist society. After the Second World War, as the world fractured into aggressive wars and unrelenting low-level conflicts, forgiveness's potential for healing civil society began to be examined in both popular and academic discourse.

In spite of this increased attention, forgiveness may be one of the least understood — yet potentially most essential — actions necessary for human civilization to break the cycle of aggression. The very fact that it is being discussed signals that tremendous suffering has taken place. Given that the most dreadful acts of religious, emotional, and physical aggression have occurred among the same people attempting to rebuild societies after conflict, it is reasonable to ask: How is forgiveness achievable? Is it essential for reconciliation? And most importantly, how do former enemies find a way to coexist?

"Forgiveness" as a word may be as difficult to define as the word "love." Just like love, forgiveness has an ineffable quality that, despite all efforts, resists full comprehension. According to Brakenhielm (1993), part of the difficulty in defining forgiveness is that it is inherently ambiguous. There are many conceptions of forgiveness, not just one. To define what forgiveness is — as distinct from what it is not — is not easily accomplished. Nevertheless, the discussion below offers an overview of how this complex concept may be understood from both psychological and theological perspectives.

Defining forgiveness is approximately as challenging as determining its function in reconciliation. The concept of forgiveness was for a long time almost entirely associated with religious language. It occupied a prominent place in the early traditions of the New Testament as a powerful social and individual act; however, forgiveness rarely, if ever, reached an impressive position in the principles the church required its worldly congregations to follow. The Protestant Reformation also struggled to integrate a socialized form of forgiveness, reinforcing instead the concept of divine authority over human forgiveness — emphasizing the individual's relationship with a higher power rather than with other human beings (Shriver, 1995). Within Judaism, human beings are called to emulate divine forgiveness, and forgiveness is regarded as an ethical responsibility (Enright, 1992).

John Bowker noted that virtually all religions have their own understanding of suffering and atonement. Each can be seen as setting the stage for some form of forgiveness. The Islamic approach tends to seek justice as a means of restoring peace, forgiveness, and reconciliation (Goleman, 1997). Buddhists begin from a sense of self that wishes to be liberated from distress and considers itself deserving of contentment. Followers recognize the causes of both suffering and pleasure, and actively pursue paths leading to happiness as a means to avoid distress and psychological suffering (Shriver, 1995).

A more politically centered understanding of forgiveness portrays it — together with hope — as a means of introducing a new beginning by transforming social, political, and economic structures at the national level. It has been described as a cooperative turning away from the past that neither ignores past evil nor simply pardons it. Forgiveness neither disregards justice nor reduces justice to vengeance; rather, it insists on the humanity of enemies even as it holds them accountable for cruel actions, and values the kind of justice that restores political community over the kind that destroys it.

In 1992, Robert Enright, together with his colleagues Elizabeth Gassin and Ching-Ru Wu, published the results of a five-year study conducted among adults in the United States, outlining an eighteen-step process of forgiveness. The steps are as follows:

Acknowledgment of a wrongdoing, or remembering without forgetting; renunciation of vengeance; and the intention to seek genuine renewal of human associations are among its most significant values. Donald Shriver contends that precisely because it simultaneously confronts moral reality, history, and the human costs flowing from the exercise of hostility, forgiveness is a word for a multidimensional process that is deeply political (Enright, 1992).

Genuine forgiveness can be seen as a complex and protracted evolutionary process — separate from, yet also intertwined with, justice, confession, truth, and reconciliation. Its enactment belongs entirely to the victim and is a courageous and powerful act of unconditional acknowledgment and love, which can be understood as an effort to discontinue the transmission of hatred from one generation to the next.

An authentic collective and individual willingness to endeavor to release the wounds of the past, accompanied by hope and determination to make a new beginning, can be argued to be a starting point in this process. Yet what is the emotional genealogy of forgiveness? What is the foundation of feeling that makes it possible? Recent development of a psychological "process model," along with research into interpersonal forgiveness, represents some of the most promising work thus far in illuminating the internal human dynamics of forgiveness.

Recognizing the potential for enormous individual differences in this process, it was understood that some steps might be omitted while others might be repeated multiple times. The first two steps involve recognizing psychological defenses — such as denial or repression — that had been used to conceal the pain of the wound. This recognition frequently leads to anger. Steps 3–7 explore the additional emotional and psychological distress that may result in a changed understanding of appropriate justice or in a perception that life is not fair. Steps 8–10 represent the turning points in the process of discovering alternatives to vengeance. A commitment to forgive is typically a conscious decision to forgive the wrongdoer, possibly influenced by a change of heart.

The final steps, 11–18, bring the victim through the process of reframing the harm — viewing it in a new way — while beginning to develop sympathy and compassion toward the wrongdoer. Step 14 may be the most critical step in post-conflict situations for breaking future cycles of aggression. It suggests that the person is prepared to accept the pain that justice tells him or her should never have been theirs, and that this courageous integration of hurt prevents that pain from being transmitted to future generations through displacement. In steps 15–18, the offended party acknowledges personal faults and perhaps grows in compassion toward the offender, along with a willingness to allow the harm to become part of their history. The consequence is an abandonment of bitterness and the emergence of unconditional love (Arendt, 1958). On the whole, the key to achieving forgiveness appears to be the offended party's willingness to explore the range of alternatives within the process and to persevere until genuine forgiveness is reached (Tavuchis, 1991).

The relationship between anger, vengeance, and forgiveness is particularly important in understanding the role of forgiveness in rebuilding a society after conflict. It can be argued that anger — a comprehensible response to grave offense — is the root emotion underlying both forgiveness and vengeance, each of which can be seen as opposite sides of the same coin. Hannah Arendt documented this duality, maintaining that vengeance was self-perpetuating and endless, while forgiveness broke the cruel cycle. Forgiveness is the precise reverse of revenge, which works as a reaction to an initial intrusion, whereby, far from putting an end to the costs of the first transgression, everyone remains bound to the process.

To Arendt, vengeance was an automatic response to a wrongdoing, while the act of forgiveness was not. Forgiving, in other words, is the only reaction that does not simply re-act but acts anew and without prior condition, unconstrained by the act that provoked it. Without being forgiven and released from the consequences of what we have done, our capacity to act would be confined to a single deed from which we could never recover; we would remain the victims of its consequences forever (Simmel, 1991).

Tavuchis references the complex lesson regarding anger and apology, wherein the victim cultivates a sense of righteous anger and resentment, which gives rise to the demand for an apology — and thus a call for forgiveness (Allen, 1997). While this anger may prompt an apology, it is widely understood that an apology is not obligatory — nor always possible, especially if the wrongdoer is deceased or otherwise unreachable — for forgiveness to occur.

Sociologist Georg Simmel also felt that the psychological and sociological character of reconciliation shared a common foundation of anger with the dynamics of forgiveness. In his view, forgiving does not assume any carelessness of feeling or lack of capacity for conflict. It too is illuminated in all its clarity after the most intensely felt wrong and the most passionate resistance. Thus, in both reconciliation and forgiving lies something unreasonable — something like a denial of what one was a moment before.

Simmel further states that this inexplicable impulse of the soul, which makes such processes depend precisely and completely on the measures that oppose them, is perhaps most clearly revealed in forgiving. He adds that forgiving is probably the only emotional process that we consider entirely subject to the will — for otherwise, the plea for forgiveness would be meaningless. A plea can only move the victim toward something over which the will has authority. That the victim spare the defeated enemy or renounce vengeance against someone who has affronted him or her can reasonably be brought about through an appeal: it depends on the will. But that the victim actually forgives — that the feeling of rivalry, hatred, and separateness gives way to a different feeling — a mere resolution seems as powerless in this regard as it is with feelings in general. In practice, however, Simmel notes that the circumstances are different, and cases where the victim cannot forgive even with the best will are extremely rare (Naithaui, 1998).

If one understands the basis of the forgiveness dynamic to be fury and rage — with its potential consequences of either forgiveness or vengeance — then an alternative perspective on the role of religion-based ritualistic hostility in social "healing" emerges. Tim Allen described such a case in northern Uganda, encountered during fieldwork in the late 1980s and early 1990s among the Madi. In one instance, a woman accused of being a witch was tormented and murdered along with her children by a group of drunken men. Other, more documented examples involved individuals — typically women — accused of witchcraft, given a hasty public trial, and executed.

The consequences of each killing seemed to produce a form of social cohesion, which led Allen to suggest the hypothesis that persecution and assassination can become necessary for the establishment of interpersonal accountability and the restoration of viable community life. While it is too early to judge what role this type of ritualistic killing truly plays, one is struck, reading the account, that it has far more in common with psychological scapegoating and anger directed toward vengeance than with forgiveness and reconciliation (Naithaui, 1998).

Psychological and Theological Perspectives on Forgiveness

Furthermore, Nietzsche maintained that those who forgive are weak and incapable of asserting their right to a fair resolution. Enright and colleagues argued that Nietzsche may have been describing a mode of passive forgiveness stemming from low self-esteem — perhaps a form of what they termed "Style 3 or 5" — in which the victim feels powerless to achieve justice, rather than an intrinsic forgiveness that values forgiveness in and of itself and demonstrates self-acceptance, psychological strength, and respect for others, despite the presence of anger.

Responding to the criticism that forgiveness amounts to a surrender of social justice, the authors maintain that social justice and interpersonal forgiveness can coexist, and that a forgiving person can certainly serve on a jury and ensure that justice is served. While forgiveness prepares humanity to receive the released wrongdoer, it does not obligate society to hastily unlock the prison door. Opposing the charge that forgiveness perpetuates injustice, they declare that forgiveness is being confused with reconciliation. Forgiveness is an internal liberation involving one individual. Reconciliation, by contrast, involves two people coming together behaviorally (McCullough, 1997).

Forgiveness is the source of power behind an apology. While forgiveness belongs exclusively to the offended party, an apology belongs entirely to the wrongdoer and is a characteristic negotiation between both. Examining the process of apology as a speech act that seeks forgiveness, Nicholas Tavuchis, in his book Mea Culpa, describes the relationship between the two. He states: something happens; something is said or done that is understood and assessed as hateful, rude, or damaging. An apology is called for; somebody says sorry; the apology is accepted; the wrongdoer is forgiven; and life goes on as if nothing had happened. His emphasis on the "as if" in that declaration acknowledges that some tension and lingering resistance may remain; however, on the surface, the social slate is wiped clean, even though the act itself cannot be negated (Tavuchis, 1991).

Thomas Scheff describes the significance of the apology-forgiveness relationship as the elimination of a threat to the social bond — a bond in which harmony triumphs over estrangement — which can occur equally in both modern and traditional societies. He notes that contemporary societies tend toward independence and separation, where individuals cannot know each other because they are too remote, and also toward conformity and engulfment, where individuals cannot know each other and disclose themselves because loyalty and conformity demand that significant parts of the self — fundamental wishes, feelings, and thoughts — may be hidden, even from the person himself or herself. Secrecy, dishonesty, and self-deception go hand in hand, as both arrangements are equally estranged (Scheff, 1994).

Both Tavuchis — who maintains that one must also feel genuinely sorry in the form of grief or sorrow — and Scheff — for whom humiliation is the driving emotion — agree that the authenticity of an apology is the key to its success. Both would agree with Erving Goffman's account, which holds that in its fullest form, a confession contains several elements: an expression of humiliation and embarrassment; a demonstration that one understands what behavior was expected and empathizes with the application of negative sanctions; a verbal rejection, denial, and renunciation of the incorrect behavior, along with criticism of the self that so acted; an affirmation of the correct behavior and a declaration of the intent to follow it; and the presentation of an apology along with the offer of recompense.

At the same time, a genuine apology may help facilitate the process of forgiveness. In an additional U.S. study of interpersonal forgiving, McCullough et al. established that an apology frequently activated first compassion, then forgiveness toward the offender; however, its occurrence is not essential to initiate the process of forgiveness (Tavuchis, 1991).

There has been a growing literature on interpersonal forgiveness from a variety of psychological perspectives over the past fifteen years. According to Bonar (1989), the need for forgiveness can be explicated within the major systems of psychology. The psychological definition of forgiveness tends to focus on forgiveness as an action or an attitude on the part of the forgiver, as well as the benefits of forgiving and the role of forgiveness in psychotherapy.

This overview of the psychological understanding of forgiveness begins with the work of Enright and his colleagues. They defined forgiveness from the perspective of cognitive development, and their work provided the structure for discussion, as it appeared to be the most broadly expressed and clearly articulated definition in the psychological literature.

Additionally, their definition has been operationalized in the Enright Forgiveness Inventory (Subkoviak, Enright et al., 1992), providing a means of quantitatively gauging levels of interpersonal forgiveness in the emotional, behavioral, and cognitive realms. Their description of forgiveness has been considered in combination with other psychological understandings of forgiveness, including those that incorporate the spiritual dimension.

According to Enright and the Human Development Study Group, forgiveness is "the overcoming of negative affect and judgment toward the offender, not by denying oneself the right to such affect and judgment, but by endeavoring to view the offender with compassion, benevolence, and even love, while recognizing that he or she has forfeited the right to them." The key components of this definition are:

a) One who forgives has experienced a deep hurt, resulting in bitterness; b) the offended person has a moral right to resentment but overcomes it nonetheless; c) a new response to the other accrues, including sympathy and love; d) this loving response takes place despite the understanding that there is no obligation to love the offender (Subkoviak, Enright, Wu, Gassin, Freedman, Olson, & Sarinopoulos, 1992, p. 3).

Furthermore, they detailed that forgiveness comprises cognitive, affective, and behavioral dimensions — how another person feels about an individual's forgiving, and thinks and behaves toward him or her. The psychological response involves the absence of negative affect, judgment, and actions toward the offender, and the presence of positive affect, judgment, and actions (Subkoviak, Enright, et al., 1992).

Other definitions of forgiveness from a psychological viewpoint share aspects of the Enright definition. Gorsuch and Hao (1993) added that an accurate and complete definition of forgiveness would require integration not only of the cognitive, emotional, and behavioral components but also the motivational, mystical, volitional, devotional, and interpersonal features of forgiveness. However, they did not specify what these additional components would look like, and some of their categories overlap with the behavioral, cognitive, and affective dimensions of the Enright definition.

Pingleton (1989) agreed that the spiritual dimension of forgiveness is vital, along with the volitional component. Monbourquette (1992) added that along with the volitional element, all the remaining human faculties are engaged in forgiving another person — heart, intelligence, compassion, opinion, thoughts, trust, and belief.

According to Gartner (1988), mature forgiveness is not the substitution of negative detestable feelings with loving ones, and would therefore seem to differ from the affective aspect of the Enright definition. He defines mature forgiveness from an object relations perspective as an integrated, balanced vision that includes both good and bad characteristics of self and others. In the case of a survivor of sexual abuse, for example, Gartner would argue that forgiveness allows the survivor to hold both the good and bad features of the perpetrator in view — fully acknowledging the evil of the abuse while not losing sight of the perpetrator's humanity.

Canale (1990) examined forgiveness as a therapeutic agent in psychotherapy and focused on the cognitive aspect of forgiveness, understanding it in the context of cognitive reformulation that accompanies the emotional work of dealing with hurt and hatred in therapy.

As defined by Studzinski (1986), forgiveness is a voluntary process in which the forgiver chooses not to retaliate but instead responds to the offender in a tender way. Walters (1984) also views forgiveness as a voluntary process that generally requires courage and multiple acts of the will to accomplish. He describes forgiveness as vital because of the harms of not forgiving, stating that to forgive is to relinquish all charges against the offender — including releasing the emotional penalty of the hurt. In Walters' view, the person who has been hurt has two choices: to be consumed by hatred, which leads to death, or to forgive, which leads to healing and life.

Forgiveness in the psychological literature is further described as: "a powerful therapeutic intervention and as an intellectual exercise in which the patient makes a decision to forgive" (Fitzgibbons, 1986); "a voluntary act and a decision and choice about how one deals with the past" (Hope, 1987); "a letting-go of a record of wrongs and a need for vengeance and releasing associated negative feelings such as bitterness and resentment" (DiBlasio, 1992); and "the accomplishment of mastery over a wound and the process through which an injured person first fights off, then embraces, then conquers a situation that nearly destroyed him" (Flanigan, 1992).

Psychosocial Risk Factors for Coronary Heart Disease

The psychological literature on forgiveness tends to focus on the gains of forgiveness for the forgiver and the task of forgiveness in the healing and therapeutic process. A few researchers — Rowe, Halling, Davies, Leifer, Powers, and van Bronkhorst (1989) — have adopted a primarily phenomenological perspective to recognize, based on their research, that the experience of forgiveness is spiritual, transpersonal, and interpersonal. According to their analysis, since forgiveness has qualities that go beyond one's relationship with the person being forgiven and releases the forgiver to herself and the world in a new way, it possesses more than merely interpersonal quality. In this view, they describe the experience of forgiving others in terms of its qualities of gift and grace, and it may be because of this quality — intrinsic to forgiveness — that it is described as a link between psychology and theology.

One of the leading philosophers of the 20th century, Hannah Arendt, attributed the discovery of the role of forgiveness in the realm of human affairs to Jesus of Nazareth (Arendt, 1958). The theological understandings of forgiveness are rooted in the Hebrew and Christian Scriptures, both of which provide numerous cases of interpersonal forgiveness (Gladson, 1992; Pingleton, 1989). Interpersonal forgiveness is understood theologically within the framework of divine forgiveness and in reference to the problem of sin and evil. From a pastoral theological perspective, forgiveness may be understood as something one discovers rather than something one does or holds as an attitude.

As portrayed in the Christian Scriptures and the teachings of Jesus, the primary theological understanding of interpersonal forgiveness is that interpersonal and divine forgiveness are inextricably related. Theologically, one cannot regard the forgiveness of another person outside the framework of God's forgiveness. According to Soares-Prabhu (1986), the reason the Christian Scriptures repeatedly relate human forgiveness to God's forgiveness is that a human being's willingness to forgive others is not "just a happy trait of character or an acquired psychological disposition. It is a religious attitude rooted in the core Christian experience of an utterly forgiving God" (p. 59). Rubio (1986) further emphasized that every experience of forgiveness has God as its ultimate context, and can only be fully explained in relation to God.

Another central aspect of understanding forgiveness from a theological perspective is placing it within the framework of sin and evil. In Sobrino's (1986) analysis of Latin America as a place of sin and forgiveness, sin is a physical evil for the victim and a moral evil for the sinner. The task of forgiveness is to try to liberate the perpetrator from sin and to transform him or her. The primary message concerning forgiveness for Sobrino is that for the deepest healing of the sinner to take place, no other force has the power of love and forgiveness — the way Jesus acted and many Christians act: "forgiving with love in the hope that this love will transform the sinner" (p. 51).

Dumortier (1993) described forgiveness as the ability to imagine a future that would not be a continuation of the past while simultaneously acknowledging that the past is part of one's life. He perceived the strength of forgiveness as living in the tension between an inerasable past and a promising future. Thus, forgiveness, in his view, opens one to that promising future through a God of compassion.

Hubaut (1992) understands forgiveness — as exposed and incarnated by Jesus Christ — as not possible on a purely human level. He argued that forgiveness, as understood through the Gospels, presupposes that human beings enter a new dimension of human relations called "the gratuitousness of God and the generous love of Christ."

Finally, Patton (1985) addressed this issue from a pastoral theological perspective in his work Is Human Forgiveness Possible? He described human forgiveness as:

"not doing something but discovering something — that I am more like those who have hurt me than different from them. I am able to forgive when I discover that I am in no position to forgive. Although the experience of God's forgiveness may involve confession of, and the sense of being forgiven for, specific sins, at its heart it is the recognition of my reception into the community of sinners — those affirmed by God as his children." (p. 16)

For Patton, forgiveness is something that is discovered. However, the vision of forgiveness as discovered differs from traditional theological understandings, since those tend to focus on forgiveness as an action or an attitude — something a person does or possesses — reducing forgiveness "theologically into a work of achievement, and psychologically into a behavioral technique of reducing the pain of self-injury" (Patton, 1985, p. 185).

A broad research literature in the behavioral sciences and medicine suggests that psychological and social factors may play a direct role in organic and inorganic heart disease. However, many experts in the medical and scientific community regard this evidence with skepticism. This section analytically reviews research on the impact of psychological and psychosocial causes on the development and outcome of heart disease, with particular emphasis on studies drawing conclusive and demonstrable results regarding heart disease morbidity or mortality. Five main variables recognized as likely psychosocial risk factors for heart disease are addressed: acute and chronic stress; hostility; depression; social support; and socioeconomic status. Evidence regarding the effectiveness of psychosocial interventions is also highlighted.

The following declaration from an editorial in the New England Journal of Medicine reflects the skeptical view held by many in the medical community:

"The confirmation for mental state as a reason and treatment of today's plagues is not much better than it was for the sufferings of earlier centuries… In brief, the literature holds few scientifically healthy studies of the relation, if there is one, amid mental condition and disease… It is time to admit that our faith in disease as a direct reflection of mental state is mainly myths" (Angell, 1985).

There is, however, a substantial collected behavioral science literature in health psychology and related subjects that proposes conflicting conclusions — at the very least regarding the influence of psychological issues on disease processes (Baum & Posluszny 1999; Cohen & Herbert 1996; Kiecolt-Glaser et al. 2002; Krantz et al. 1985; Schneiderman et al. 2001). This editorial consequently stimulated substantial controversy in the behavioral science community and has remained a topic of ongoing discussion (Am. Psychosom. Soc. 2001).

What conclusions can be drawn from this difference of opinion between behavioral scientists and some in the biomedical community? A careful assessment of the available research literature with respect to coronary artery disease (CAD) — comprising atherosclerosis and its clinical manifestations, including myocardial infarction (heart attack) and sudden cardiac death — is warranted, as CAD is among the most extensively researched subjects in health psychology.

Behavioral research on cardiovascular disorders began with epidemiological reports documenting the many environmental and behavioral lifestyle factors involved in the etiology and pathogenesis of CAD. More recently, the ability to combine behavioral research methodologies with techniques and procedures in cardiology and medicine to examine the pathophysiology of coronary heart disease has led to increased progress in the field. Additionally, a body of evidence suggests that identifying and treating psychosocial stress in CAD patients may reduce subsequent morbidity and mortality.

Below is a comprehensive assessment of five key variables recognized as probable psychological and psychosocial risk factors for the onset and development of CAD: acute and chronic stress; behavioral characteristics of aggression and depression; social support; and socioeconomic status. Evidence regarding the effectiveness of psychosocial interventions in CAD patients is also presented.