Article

TRAUMA, VIOLENCE, & ABUSE

1-17
Forgiveness Therapy for the Promotion of ª The Author(s) 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
Mental Well-Being: A Systematic Review DOI: 10.1177/1524838016637079
tva.sagepub.com
and Meta-Analysis

Sadaf Akhtar1 and Jane Barlow2

Abstract
Interpersonal hurts and violence against the individual have a high prevalence and are associated with a range of long-term
problems in terms of psychological functioning. There is a growing body of research highlighting the role of forgiveness therapy in
improving different aspects of psychological health in populations who have experienced diverse types of hurt, violence, or
trauma. This article reports the findings of a systematic review and meta-analysis of the efficacy of process-based forgiveness
interventions among samples of adolescents and adults who had experienced a range of sources of hurt or violence against them.
Randomized controlled trials were retrieved using electronic databases and an examination of reference sections of previous
reviews; each study was assessed for risk of bias. Standardized mean differences (SMDs) and confidence intervals (CIs) were used
to assess treatment effects. The results suggest that forgiveness interventions are effective in reducing depression (SMD ¼ 0.37,
95% CI [0.68, 0.07]), anger and hostility (SMD ¼ 0.49, 95% CI [0.77, 0.22]), and stress and distress (SMD ¼ 0.66, 95%
CI [0.91, 0.41]) and in promoting positive affect (SMD ¼ 0.29, 95% CI [0.52, 0.06]). There was also evidence of
improvements in state (SMD ¼ 0.55, 95% CI [0.88, 0.21) and trait (SMD ¼ 0.43, 95% CI [0.67, 0.20]) forgiveness. The
findings provide moderately strong evidence to suggest that forgiving a variety of real-life interpersonal offenses can be effective in
promoting different dimensions of mental well-being. Further research is, however, needed.

Keywords
forgiveness therapy, trauma, abuse, violence, interpersonal hurt, mental health, mental well-being

Key Points of the Research Review Introduction

 Previous meta-analyses that assess the effectiveness of Minor or major interpersonal hurts occur frequently, within a
forgiveness therapy in promoting mental health and variety of contexts and due to a multitude of reasons. People
well-being outcomes have significant methodological can experience such hurts as a result of major, overt forms of
limitations. violence such as conflicts within the Middle East (i.e., Pales-
 This review extends previous research by critically tine–Israel) and the Bosnian war. Most hurts, however, result
appraising randomized controlled trial studies and from everyday acts of violence such as bullying, child abuse,
meta-analyzing results for the purpose of assessing the intimate partner violence, and elder abuse (Krug, Dahlberg,
effectiveness of forgiveness interventions on a range of Mercy, Zwi, & Lozano, 2002). Interpersonal hurts can also
aspects of mental health and well-being. occur within otherwise healthy relationships due to violations
 The findings suggest that forgiveness therapy reduces of norms or rules such as, for example, individuals feeling
common mental health problems such as depression, unacknowledged or as a result of rejection (Diblasio, 1998).
stress, and distress and promotes positive emotions. People who experience such hurt can feel a variety of emotions
 The findings also indicate that group-based or individu- such as chronic anger and hostility, which may sometimes lead
ally delivered forgiveness interventions, using the them into a cycle of violence in order to seek revenge (Park,
Enright or REACH model, and administering 12 or more Enright, Essex, Zahn-Waxler, & Klatt, 2013; Shectman, Wade,
sessions result in increases in psychological adjustment.
 While forgiveness interventions appear to be effective in
1
promoting mental health and subjective well-being, fur- Health Sciences, University of Warwick, Coventry, UK
2
ther research is needed that assesses the efficacy of two Warwick Medical School, University of Warwick, Coventry, UK
key process-based forgiveness models, and their effec- Corresponding Author:
tiveness and cost-effectiveness compared with other Sadaf Akhtar, Health Sciences, University of Warwick, Coventry, UK.
methods of treatment for interpersonal hurts. Email: [email protected]

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

2 TRAUMA, VIOLENCE, & ABUSE

& Khoury, 2009). The harboring of chronic anger and hostility decision phase, participants explore meanings of forgiveness,
can also result in physical and mental health problems (Chida consider the possibility of forgiveness as a response, followed
& Steptoe, 2009; Goldman & Wade, 2012). by a commitment to forgive. The third work phase entails
Remaining chronically angry, hostile, or in search of cognitive reframing (i.e., seeing the offender in a new light),
revenge is, however, only one of a number of possible developing empathy and compassion for the offender and
responses. Another response to being hurt is forgiveness, which accepting the pain experienced. In the final deepening phase,
is defined as the decision to let go of negative resentment-based participants are encouraged to find meaning in the suffering
emotions, cognitions, and behaviors and developing positive experienced, recognizing their own past mistakes, which may
regard for an offender, be it compassion, sympathy, or pity have required forgiveness. They are also encouraged to develop
(Enright & Fitzgibbons, 2000; Wade & Worthington, 2005). an awareness of the universality of being hurt as well as finding
A central focus of counseling and therapy is to help clients a new purpose in life as a result of the hurt. These steps are
overcome the negative consequences of experiencing interper- intended to help the participant experience event-specific
sonal hurts (Macaskill, 2005). Over the last 20 years or so, decreased negative affect and increased positive affect (i.e.,
clinicians and researchers have also become increasingly inter- forgiveness; Baskin & Enright, 2004; Wade & Worthington,
ested in the health benefits of forgiveness, largely because of its 2005).
potential for reducing negative thoughts and emotions stem- The second type of process-based forgiveness intervention
ming from interpersonal hurts (Wade, Hoyt, Kidwell, & is the REACH model developed by Worthington (2001).
Worthington, 2013). In addition, improving general population REACH is an acronym for a five-step forgiveness approach.
well-being, such as reducing common mental health problems, First, participants recall the hurt (R). Second, they develop
as well as increasing positive emotions and relationships, is a empathy for the offender (E). Third, participants consider for-
key policy goal in many countries (e.g., Department of Health, giveness as an altruistic gift for the offender (A). Fourth, they
2011). This is largely because well-being is linked to reduced make a commitment to forgive (C). In the final step (H), they
health risk behaviors such as smoking and excessive drinking, hold onto forgiveness in times of difficulty (Wade et al., 2013;
improved learning and educational attainment, greater work Worthington, 2001).
productivity as well as improved physical health (Huppert, The Enright and REACH models are the most widely used
2009; Royal College of Psychiatrists, 2010). Understanding forgiveness interventions. Other authors (Luskin, Ginzburg, &
what promotes mental well-being is therefore vitally important, Thoresen, 2005) have developed six step models of forgiveness
and it is argued that interventions that facilitate positive actions that primarily use cognitive and behavioral therapy. For exam-
and attitudes have a key role to play in enhancing psychological ple, components include defining forgiveness, using positive
health (Huppert, 2009). and negative visualizations (i.e., related to the event), heart-
focused meditation and relaxation techniques, education about
the negative health impact of holding grudges as well as teach-
Forgiveness Interventions ing about cognitive restructuring (i.e., explaining how grie-
A growing number of experimental studies have been con- vances are created and maintained). Another model
ducted to evaluate the extent to which forgiveness programs comprises a decision-based forgiveness intervention developed
promote the psychological health of adolescent and adult popu- by McCullough and Worthington (1995). This comprises 1- to
lations who have experienced interpersonal hurt or violence. 2-hr single sessions in which victims are encouraged to develop
Almost all experimental studies have assessed the effects of empathy for the offender and write letters expressing how they
forgiveness interventions on domains of health such as psycho- felt (Baskin & Enright, 2004).
logical functioning and mental health problems such as depres- All four models described above share some commonalities.
sion, anxiety, or stress. In a limited number of cases, effects on For example, all define forgiveness and emphasize its potential
other dimensions of well-being such as marital satisfaction, benefits as well as encouraging the development of empathy
gratitude, positive affect, self-esteem, hope, and spiritual for the offender. A key distinction, however, is that process-
well-being (Lundahl, Taylor, Stevenson, & Daniel, 2008) have based interventions involve the use of a range of cognitive,
also been examined. affective, and behavioral strategies over a longer period of
Two key models of forgiveness intervention programs have time. Decision-based approaches on the other hand are signif-
been developed and investigated: process-based and decision- icantly shorter in length and seem largely to rely on cognitive
based interventions. While similar in content, process-based components (Baskin & Enright, 2004; Lundahl et al., 2008).
models tend to be one of two types. The first model promoted
by Enright and the Human Development Study Group (1996)
encompasses 20 units and four key phases, which include cog- Evidence of Effectiveness
nitive, affective, and behavioral elements. The first uncovering Three meta-analyses have been carried out to assess the effec-
phase involves identification of psychological defenses, recog- tiveness of forgiveness interventions (Baskin & Enright, 2004;
nition and expression of anger over the offense, and acknowl- Lundahl et al., 2008; Wade et al., 2013), all of which have
edgment and evaluation of the psychological harm caused by significant limitations. Baskin and Enright (2004) included
the offense (e.g., shame, guilt, rumination). In the second nine experimental studies, examining the effectiveness of

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

Akhtar and Barlow 3

process- versus decision-based programs. However, the depen- basis of whether they showed adequate reliability and validity
dent variable ‘‘emotional health’’ comprised a variety of out- such as internal consistency, test–retest reliability, and con-
comes, including positive affect, negative affect, and struct validity. Each of the included scales is listed in the
self-esteem, making it impossible to assess if change was meta-analysis results section of this article.
achieved in all or just some of these domains. The second review
(Lundahl et al., 2008) examined the effectiveness of forgiveness- Search Strategy
based interventions on wider aspects of mental health. How-
ever, the authors also meta-analyzed data from both rando- Electronic searches using Medical Literature Analysis and
mized controlled trials (RCTs) and non-RCTs, did not make Retrieval System Online, PsychINFO, Education Resources
direct comparisons with a no-treatment/wait-list control group, Information Center, and Behavioral Sciences collection were
and used both validated and unvalidated scales. The most carried out in 2014. Search terms such as ‘‘forgive’’ or ‘‘for-
recent meta-analysis was conducted by Wade, Hoyt, Kidwell, giveness’’ as well as terms such as ‘‘RCT’’ were used to narrow
and Worthington (2013) to assess the effects of forgiveness the results of the search. Additional records were also identified
therapy. However, this latter review did not provide estimates by examining the reference sections of previous published
of the effectiveness of forgiveness interventions based on data reviews (Lundahl et al., 2008; Wade et al., 2013) and included
from RCTs alone (although the impact of study design was papers. To assess if studies identified through a search of elec-
found not to have had an impact on outcome). Moreover, tronic databases and other published papers met the inclusion
assessments of outcome were derived from quantitative mea- criteria, titles and abstracts were examined. This was followed
sures without a clear indication as to whether these were vali- by a full-text review of the articles to further assess if they met
dated measures, and only a limited number of aspects of mental the inclusion criteria.
well-being were assessed (depression, anxiety, and hope).
This article reports the findings of an updated systematic Data Extraction and Management
review and meta-analysis of the effectiveness of forgiveness
interventions in improving a variety of aspects of mental well- Data were extracted independently by the first author (S.A.)
being in adolescents and adults who experienced a range of and entered into Review Manager 5. This was subsequently
transgressions, based on data from experimental studies only. checked by the second author (J.B.) for accuracy. Where appro-
priate, study authors were contacted to request missing infor-
mation relating to the risk of bias criteria or to request
Method information about missing data.
Design
A systematic review of the published literature was undertaken Assessment of Risk of Bias in Included Studies
by searching a range of electronic databases to identify studies The guidelines as outlined in the Cochrane Collaboration tool
that met predetermined inclusion criteria. The first author (Higgins & Green, 2008) were used to examine studies for risk
(S.A.) took overall responsibility in designing, conducting, and of bias. Studies were assessed for allocation sequence, blind-
reporting the review. The second author (J.B.) advised on all ing, incomplete outcome data, selective reporting, and other
aspects of the review such as whether studies met the inclusion potential sources of bias (i.e., examination/adjustment of con-
criteria and risk of bias. The second author also checked the founders prior to and during main analysis). In assessing the
review to ensure that all data extracted and inputted for analysis methodological quality of studies, each of the previous char-
were correct. acteristics was assigned one of the three categories: ‘‘low risk,’’
‘‘unclear risk,’’ or ‘‘high risk.’’
Inclusion Criteria
English-language studies using RCT designs in which partici- Measures of Treatment Effect
pants were allocated to an experimental or a waiting-list/no- Standardized mean differences (SMDs) to assess differences in
treatment control group were selected for review. We included outcomes between groups and 95% confidence intervals (CIs)
studies evaluating a process-based forgiveness intervention to assess the precision of results are presented for all analyses.
delivered either on an individual or group basis and which The effect size (SMD) was calculated automatically in Review
assessed the efficacy of the intervention on mental health and Manager 5, which divides the difference in mean outcomes
well-being outcomes. Only standardized and validated mea- between experimental and control groups and divides by the
sures from the selected studies were used to assess key out- pooled standard deviation.
comes pertaining to mental health and well-being. The
standardized scales that were included were measures that
assessed the same overall concept in each study (i.e., depres-
Unit of Analysis Issues
sion, stress) and were administered to all participants complet- One study (Shectman et al., 2009) randomly assigned groups
ing the intervention in the same way, at similar time points and (i.e., students in different classes) while Ripley and Worthing-
scored in the same manner. Scales were also selected on the ton (2002) randomly assigned couples. The remaining studies

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

4 TRAUMA, VIOLENCE, & ABUSE

randomly assigned individuals. Studies that randomly assign studies were excluded because they did not utilize a no-
clusters have limitations resulting from the fact that partici- treatment or waiting-list control group (Al-Mabuk, Enright,
pants within the same clusters may be similar, thus resulting & Cardis, 1995; Greenberg, Warwar, & Malcolm, 2008;
in correlations of observations within clusters (Higgins & Graham, Enright, & Klatt, 2012; Hebl & Enright, 1993; Hui &
Green, 2008). Clustered RCTs can consequently result in an Chau, 2009; Lampton, Oliver, Worthington, & Berry, 2005;
overestimation of the accuracy of the results such as narrow CIs W. F. Lin, Mack, Enright, Krahn, & Baskin, 2004; W. N. Lin,
and a reduced a value, resulting in an increased probability of a Enright, & Klatt, 2013; Osterndorf, Enright, Holter, & Klatt,
Type I error (Higgins & Green, 2008). However, sensitivity 2011; Reed & Enright, 2006); two studies did not randomize
analysis, where the two cluster trials were temporarily removed participants (Baskin & Rhody, 2011; Freedmam & Knupp,
in Analysis 6, did not result in a significant change in the 2003).
overall result. For instance, the overall result for Analysis 6
with the two cluster studies was SMD ¼ 0.43, 95% CI
[0.67, 0.20], p ¼ .0003 and after removing the two studies
Treatment and Control Groups
results remained similar SMD ¼ 0.43, 95% CI [0.68, All included studies used a waiting-list or no-treatment control
0.19], p ¼ .0004. Hence, as both studies presented minimal group design. Nine studies directly compared forgiveness ther-
concern regarding a Type I error and there were no significant apy with a wait-list control condition (Allemand, Steiner, &
differences in results for Analysis 6, it was considered unne- Hill, 2013; Coyle & Enright, 1997; Freedman & Enright, 1996;
cessary to adjust the analysis using intraclass correlation coef- Goldman & Wade, 2012; Luskin et al., 2005; Ripley &
ficient values. Worthington, 2002; S. R. Rye et al., 2012; Toussaint, Peddle,
Cheadle, Sellu, & Luskin, 2010; Wade & Meyer, 2009). Six
Dealing With Missing Data studies directly compared forgiveness treatment with a no-
treatment control condition (DiBlasio & Benda, 2002; Harris
All studies were assessed for missing data such as selective et al., 2006; Park et al., 2013; Rye & Pargament, 2002; M. S.
reporting of outcomes or missing summary data (i.e., standard Rye et al., 2005; Shectman et al., 2009). In two of these studies
deviations) for outcomes as well as dropout rates and whether (M. S. Rye et al., 2005; Rye & Pargament, 2002), the forgive-
authors applied intention-to-treat analysis. Where appropriate, ness intervention was tested among a religious and secular
authors were contacted to request missing summary data. group; the outcome results for both of these groups were there-
fore combined for the meta-analysis and compared with the
Assessment of Heterogeneity control group. In one study (S. R. Rye et al., 2012), the for-
giveness intervention was tested among a gratitude and daily
Evidence of between-study heterogeneity was assessed using
events group; the results were also combined and compared
the I2 and a value from the w2 test. A threshold of I2  50%
with the control group.
combined with a significant p value from the w2 test was set as
Five of the above studies compared a forgiveness treatment,
evidence of substantial heterogeneity. In cases where there
alternative treatment, and a control condition (DiBlasio &
were significant levels of heterogeneity, further analysis was
Benda, 2002; Goldman & Wade, 2012; Park et al., 2013; Rip-
undertaken (i.e., dividing studies into subgroups) or, if appro-
ley & Worthington, 2002; Wade & Meyer, 2009). For the
priate, studies were not combined (Higgins & Green, 2008).
purpose of this review only posttest data from two arms were
included: forgiveness intervention and control group (i.e., wait-
Data Synthesis list/no-treatment control) because we wanted to assess the
When combining studies the decision to use a fixed or random effectiveness of forgiveness treatment in comparison to those
effects model was dependent on the levels of heterogeneity not receiving any treatment, rather than compare their effec-
observed. A fixed effects model was used where there was tiveness with an alternative treatment.
no statistically significant heterogeneity present (i.e., I2  Table 1 provides further details about the samples, offense
50%). In cases where I2  50%, a random effects model was type, sample size, mode of treatment, location, length of inter-
applied. ventions, model type, and mean age of participants for each
included study. The majority of studies did not specify where
the intervention would be delivered. However, three studies
Results (Park et al., 2013; Shectman et al., 2009; Toussaint et al.,
2010) stated that they delivered the intervention in schools and
Results of the Search a correctional facility.
The electronic searches produced 514 records of which 26
appeared to be relevant to the review, based on a search of
titles and abstracts. A search of previous meta-analyses pro-
Outcomes
duced 21 records, most of which were duplicates of the above The 15 included studies administered 78 outcome measures in
studies. A full-text review was then carried out and 15 papers total. However, not all of these scales were included in the
were selected for inclusion, with 12 being excluded. Ten meta-analyses because many of these studies used nonvalidated

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

 Table 1. Key Components of Forgiveness Studies.

N
Length of Inter- Mean
Authors Sample Offense Type Tx Control Mode Location vention (weeks Model Type Age

Freedman and Enright Community sample/ Incest 6 6 Individual US 55 Enright 36

(1996) female incest survivors
Coyle and Enright (1997) Community sample/ Partner’s abortion 5 5 Individual US 12 Enright 28
postabortion men
DiBlasio and Benda (2002) Community sample of Marital hurts, Not stated Not stated Group US 1 Cognitive behavioral Unclear
married couples estrangement approach
Ripley and Worthington Community sample/ Marital enrichment 28 28 Group US 2 REACH 37
(2002) married couples
Rye and Pargament (2002) Christian female college Romantic relationship 39 19 Group US 6 REACH 18
students hurt
Luskin, Ginzburg, and University students Unresolved interpersonal 28 27 Group US 6 Cognitive behavioral 21
Thoresen (2005) hurt approach
Rye et al. (2005) Community and student Anger at ex-spouse 99 50 Group US 8 REACH 45
sample/divorced
Harris et al. (2006) Community samples/ Interpersonal hurt 115 102 Group US 6 Cognitive behavioral 41
adults approach
Allemand et al. (2013) Community and student Unresolved interpersonal 52 26 Group Switzerland 2 REACH 70
sample/older adults hurt
Rye et al. (2012) Community sample/ Anger at ex-spouse 58 41 Group US 4 REACH 49
divorced parents
Goldman and Wade (2012) College students Interpersonal hurt 29 24 Group US 6 REACH 21
Park, Enright, Essex, Zahn- Student sample /female Aggressive victims 16 16 Group South Korea 12 Enright 15

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

Waxler, and Klatt (2013) South Korean
adolescents
Shectman, Wade, and Student sample/Arab Victims of ethnic conflict/ 65 81 Group Israel 12 REACH Unclear
Khoury (2009) Israeli adolescents forgiving Jewish society
Wade and Meyer (2009) Community sample Abuse/betrayal 11 8 Group US 4 REACH 48
Toussaint, Peddle, Cheadle, Community sample/adult Ethnic conflict 13 11 Group Sierra 5 Cognitive behavioral 33
Sellu, and Luskin, (2010) tea Leone approach

5
6 TRAUMA, VIOLENCE, & ABUSE

Figure 1. Risk of bias graph: Review authors’ judgments about each risk of bias item presented as percentages across all included studies.

measures. Three studies, including a total of 10 validated

scales, did not provide posttest means or standard deviations
(DiBlasio & Benda, 2002; Luskin et al., 2005; Toussaint et al.,
2010). Four scales from a further three studies (Freedman &
Enright, 1996; Ripley & Worthington, 2002; Rye & Pargament,
2002) could not be meta-analyzed because there was not a
minimum of two studies assessing the same overall concept.
In other cases, multiple scales measuring similar constructs
were used. In such cases, single scales were selected from these
studies and the decision to select single scales was based on the
following: four studies (not using multiple scales) measured
forgiveness as the development of positive emotions (i.e., com-
passion) toward the offender, while three studies measured
forgiveness as reductions in avoidance or revenge. Of the two
studies that used multiple subscales (Harris et al., 2006; S. R.
Rye et al., 2012), the presence of positive affect (forgiveness)
subscale was chosen. Of the two studies using multiple scales
to assess forgiveness as reductions in event-specific negative
affect (Allemand et al., 2013; Shectman et al., 2009), the
revenge subscale was selected. As a result, there was an almost
equal amount of studies assessing the two related concepts in
the meta-analysis (i.e., six studies assessed forgiveness as
developing positive regard for an offender and five assessed
forgiveness as reductions in event-specific negative affect). In
total, 36 measures were included in the meta-analyses.

Risk of Bias in Included Studies

Figures 1 and 2 (below) present a risk of bias graph and sum-
mary table. Figure 1 assesses seven risk of bias criteria, with
green indicating low risk; yellow, unclear risk; and red, high
risk. Overall, the graph shows that approximately 40% of stud-
ies posed a low risk of bias with regard to detailing the method
of randomization. In 100% of the studies, it was unclear if a
method of allocation concealment was used. All included stud-
ies posed a high risk of bias with regard to ‘‘blinding.’’ About Figure 2. Risk of bias summary: Review authors’ judgments about
60% of studies posed a low risk of bias in relation to incomplete each risk of bias item for each included study.

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

Akhtar and Barlow 7

Table 2. Key Results Organized by Outcome Groups. presents the results for the assessment of the impact of forgive-
2 ness treatment on levels of trait forgiveness.
Outcome n SMD CI I (%)
Due to the fact that Analysis 6 showed substantial levels of
Posttest results: intervention versus control group heterogeneity and involved a large number of studies, subgroup
Depression 415 0.37* [0.68, 0.07] 47 analyses were also carried out to explore the impact of model,
Anxiety 78 1.13 [2.78, 0.53] 80** mode, and number of sessions on state forgiveness (using the
Anger and hostility 517 0.49** [0.77 0.22] 44 same outcome measures as those presented in Analysis 6). For
Stress and distress 267 0.66** [0.91, 0.41] 0
instance, Analysis 8 examined the effects of the Enright model.
Positive affect 318 0.29** [0.52, 0.06] 19
State forgiveness 872 0.43** [0.67, 0.20] 57** Analysis 9 examined the effects of the REACH model. Anal-
Trait forgiveness 317 0.52* [0.97, 0.06] 72 ysis 10 examined the effects of receiving 2–8 sessions. Anal-
Subgroup analyses ysis 11 examined the effects of administering 12þ sessions.
Enright model 54 1.26** [1.86, 0.65] 0 Analysis 12 examined individual treatment effects, while Anal-
REACH model 600 0.33** [0.59, 0.07] 55* ysis 13 tested the efficacy of administering group interventions.
2–8 sessions 672 0.25** [0.41, 0.09] 10 These subgroup analyses were chosen for two reasons. First,
12 sessions or more 200 0.95** [1.36, 0.53] 19
prior research has indicated differential effects of interventions
Individual mode 22 1.64** [2.69, 0.60] 0
Group mode 850 0.37** [0.59, 0.16] 52* due to variation in model type, mode, and number of sessions
(Lundahl et al., 2008; Wade et al., 2013). Second, due to the
Note. CI ¼ confidence interval; SMD ¼ standardized mean difference. limited number of studies it was not possible to explore the
*Significant at the .05 level. **Significant at the .01 level.
effects of other factors (Table 2).

outcome data and approximately 90% of studies were rated as

low risk on levels of selective reporting. Just over 50% of Meta-Analyses
studies were rated as low risk for other sources of bias such Negative Affect Outcomes
as pretest group differences. Figure 2 shows how all included Analysis 1: Depression. Six studies (n ¼ 415) measured depres-
studies were rated on each of the risk of bias criteria. sion (Allemand et al., 2013; Freedman & Enright, 1996; M. S.
Rye et al., 2005; S. R. Rye et al., 2012; Rye & Pargament, 2002;
Wade & Meyer, 2009). Four of these studies used the Beck
Effects of Interventions Depression Inventory or Centre for Epidemiology Studies
Meta-analyses—Forgiveness treatment versus control. Of the 15 Depression Scale. One study (Allemand et al., 2013) measured
studies included in the review, data from only 12 studies were negative affect (i.e., disappointed, sad, anxious, worried, slug-
meta-analyzed. Three studies (DiBlasio & Benda, 2002; Luskin gish, and exhausted). Wade and Meyer (2009) used the Brief
et al., 2005; Toussaint et al., 2010) did not provide posttest Symptom Inventory. The meta-analysis showed a small signif-
scores (means and standard deviations) for any outcome icant change favoring the intervention group (SMD ¼ 0.37,
assessments. 95% CI [0.68, 0.07], p ¼ .02). Between-study heterogeneity
Of the 12 studies included in the meta-analyses, the majority was not significant (I2 ¼ 47%, p ¼ .09; Table 3).
provided data for similar outcome scales, which resulted in 13
Analysis 2: Anxiety. Three studies (n ¼ 78) measured anxiety.
meta-analyses using a total of 36 scales. Meta-analyses of for-
One of these studies (Freedman & Enright, 1996) used the
giveness treatment versus control were carried out for seven
State-Trait Anxiety Scale. Coyle and Enright (1997) adminis-
outcome groups in total: depression, anxiety, anger/hostility,
tered the State Anxiety Scale and Rye and Pargament (2002)
stress/distress, positive affect, levels of state forgiveness, and
used the Costello and Comrey Anxiety Scale. The meta-
levels of trait forgiveness.
analysis showed a nonsignificant difference favoring the inter-
All scales that were combined in the meta-analyses were
vention group (SMD ¼ 1.13, 95% CI [2.78, 0.53], p ¼
measured at comparable time points (i.e., posttest) and only
.18). Between-study heterogeneity was significant (I2 ¼ 80%,
standardized scales were included. The results for all meta-
p ¼ .007; Table 4).
analyses involved the calculation of effect sizes (SMD) with
95% CIs. Results with a minus sign denote that the forgiveness Analysis 3: Anger and hostility. Six studies (n ¼ 517) measured
treatment benefits the experimental group. Only postinterven- anger and hostility. Two of these studies used the State Anger
tion scores (means and standard deviations) were used. In cases Scale (Coyle & Enright, 1997; Park et al., 2013). A further two
of high heterogeneity (I2  50%) and a significant a value from studies administered the Trait Anger Scale (Harris et al., 2006;
the w2 test) a random effects model was used, while for no or M. S. Rye et al., 2005). Goldman and Wade (2012) adminis-
moderate heterogeneity (I2  <50%) a fixed effects model was tered the State Hostility Scale while Rye and Pargament (2002)
applied. used the Hostility Subscale of the Aggression Questionnaire.
Analyses 1–4 (below) present the results for a number of The meta-analysis showed a medium significant effect favor-
negative affect outcomes, and Analysis 5 presents the results ing the intervention group (SMD ¼ 0.49, 95% CI [0.77,
for positive affect. Analysis 6 presents the results for the impact 0.22], p ¼ .0005). Between-study heterogeneity was not sig-
of treatment on levels of state forgiveness while Analysis 7 nificant (I2 ¼ 44%, p ¼ .11; Table 5).

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

8 TRAUMA, VIOLENCE, & ABUSE

Table 3. Effects of Forgiveness Treatment on Levels of Depression.

Table 4. Effects of Forgiveness Treatment on Levels of Anxiety.

Analysis 4: Stress and distress. Two studies (n ¼ 267) mea- compassionate) using Batson’s Empathy Adjectives. S. R. Rye
sured stress and distress (Goldman & Wade, 2012; Harris et al., et al. (2012) administered the Gratitude Questionnaire, while
2006). One study used the Global Severity Index of the Brief Rye and Pargament (2002) used the Anticipation of Future
Symptom Inventory to measure distress, while Harris et al. Subscale from the Miller Hope Scale. The meta-analysis
(2006) used the Perceived Stress Scale. Meta-analysis results showed a small significant effect favoring the intervention
show a large and significant overall effect favoring the inter- group (SMD ¼ 0.29, 95% CI [0.52, 0.06], p ¼ .01).
vention group (SMD ¼ 0.66, 95% CI [0.91, 0.41], p ¼ Between-study heterogeneity was not significant (I2 ¼ 19%,
.00001). There was no between-study heterogeneity (I2 ¼ 0%, p ¼ .29; Table 7).
p ¼ .88; Table 6).
Analysis 6: Levels of state forgiveness. Eleven studies (n ¼ 872)
Analysis 5: Positive affect. Six studies (n ¼ 318) measured measured state forgiveness. Three types of scales were admi-
positive affect. Allemand, Steiner, and Hill (2013) measured nistered in six studies: the Psychological Profile of Forgiveness
satisfaction, happiness, confidence, hopefulness, and energy. Scale (Harris et al., 2006; M. S. Rye et al., 2005; S. R. Rye
Freedman and Enright (1996) used the Hope Scale. Goldman et al., 2012), the Enright Forgiveness Inventory (Coyle &
and Wade (2012) as well as Wade and Meyer (2009) measured Enright, 1997; Park et al., 2013), and the Forgiveness Scale
feelings toward offender (i.e., soft hearted, warmth, (Freedman & Enright, 1996) to assess the absence of negative

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

Akhtar and Barlow 9

Table 5. Effects of Forgiveness Treatment on Levels of Anger and Hostility.

Table 6. Effects of Forgiveness Treatment on Levels of Stress and Distress.

emotions, cognitions, and behavior and the presence of positive were presented separately and thus the revenge subscale was
feelings, thoughts, and behavior toward an offender. In two of selected. The meta-analysis produced statistically significant
the studies that administered the Psychological Profile of For- findings favoring the intervention group (SMD ¼ 0.43,
giveness Scale (Harris et al., 2006; S. R. Rye et al., 2012), 95% CI [0.67, 0.20], p ¼ .0003). Between-study hetero-
authors presented data for the absence of negative and presence geneity was significantly high (I2 ¼ 57%, p ¼ .01; Table 8).
of positive subscales separately; consequently the presence of
positive subscale was selected. Five studies (Allemand et al., Analysis 7: Levels of trait forgiveness. Two studies (n ¼ 317)
2013; Goldman & Wade, 2012; Ripley & Worthington, 2002; measured trait forgiveness using the Forgiveness Likelihood
Shectman et al., 2009; Wade & Meyer, 2009) assessed Scale (Harris et al., 2006; S. R. Rye et al., 2012). The meta-
situation-specific negative affect (i.e., revenge, avoidance) by analysis results showed a significant overall effect favoring the
administering the Transgression-Related Interpersonal Motiva- intervention group (SMD ¼ 0.52, 95% CI [0.97, 0.06],
tions (TRIM) Scale. In two of the latter (Allemand et al., 2013; p ¼ .03). Between-study heterogeneity was not significant
Shectman et al., 2009), the avoidance and revenge subscales (I2 ¼ 72%, p ¼ .06; Table 9).

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

10 TRAUMA, VIOLENCE, & ABUSE

Table 7. Effects of Forgiveness Treatment on Levels of Positive Affect.

Table 8. Effects of Forgiveness Treatment on Levels of State Forgiveness.

Subgroup Analyses thoughts, and behavior toward an offender. Results showed a

large and statistically significant effect favoring the interven-
Analysis 8: Effects of Enright model on levels of state forgiveness.
tion group (SMD ¼ 1.26, 95% CI [1.86, 0.65],
Analysis 8 (n ¼ 54) included three studies (Coyle & Enright,
p ¼ .0001). No between-study heterogeneity was found
1997; Freedman & Enright, 1996; Park et al., 2013) that used
(I2 ¼ 0%, p ¼ .46; Table 10).
the Enright forgiveness model to improve state forgiveness.
The Enright Forgiveness Inventory was administered in all Analysis 9: Effects of REACH model on levels of state forgiveness.
three studies and measured the absence of negative emotions, Seven studies (n ¼ 600) that used the REACH model were
cognitions, and behavior and the presence of positive feelings, assessed for the intervention impact on levels of state

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

Akhtar and Barlow 11

Table 9. Effects of Forgiveness Treatment on Levels of Trait Forgiveness.

Table 10. Effects of Enright Model on Levels of State Forgiveness.

forgiveness. Three of these studies (S. R. Rye et al., 2012; M. S. M. S. Rye et al., 2005; Wade & Meyer, 2009) administered the
Rye et al., 2005; Wade & Meyer, 2009) administered the For- Forgiveness Scale to assess the absence of negative emotions,
giveness Scale to assess the absence of negative emotions, cognitions, and behavior and the presence of positive feelings,
cognitions, and behavior and the presence of positive feelings, thoughts, and behavior toward the offender. The meta-analysis
thoughts, and behavior toward the offender. The remaining showed a statistically significant, albeit small difference favor-
four studies (Allemand et al., 2013; Goldman & Wade, 2012; ing the intervention group (SMD ¼ 0.25, 95% CI [0.41,
Ripley & Worthington, 2002; Shectman et al., 2009) used 0.09], p ¼ .002). Between-study heterogeneity was nonsigni-
the TRIM Scale to measure situation-specific negative affect ficant (I2 ¼ 10%, p ¼ .35; Table 12).
(i.e., revenge). The results showed a small effect favoring the
intervention group (SMD ¼ 0.33, 95% CI [–0.59, 0.07], Analysis 11: Effects of number of sessions on levels of state
p ¼ .01). Between-study heterogeneity was significant forgiveness (12 or more sessions). Four studies (n ¼ 200) that
(I2 ¼ 55%, p ¼ .04; Table 11). administered the forgiveness intervention in 12 or more
sessions were assessed for effects on levels of state forgive-
Analysis 10: Effects of number of sessions on levels of state ness. Three of these studies measured the absence of neg-
forgiveness (2–8 sessions). Seven studies (n ¼ 672) that adminis- ative emotions, cognitions, and behavior and the presence
tered 2–8 sessions were assessed for the effects of the number of positive emotions, thoughts, and behavior toward the
of sessions received on levels of state forgiveness. Three of offender by administering the Psychological Profile of
these studies (Allemand et al., 2013; Goldman & Wade, Forgiveness Scale (Freedman & Enright, 1996) and the
2012; Ripley & Worthington, 2002) used the TRIM Scale to Enright Forgiveness Inventory (Coyle & Enright, 1997;
measure situation-specific negative affect (i.e., revenge), while Park et al., 2013). One study (Shectman et al., 2009) used
the remaining four (Harris et al., 2006; S. R. Rye et al., 2012; the TRIM Scale to measure situation-specific negative

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

12 TRAUMA, VIOLENCE, & ABUSE

Table 11. Effects of REACH Model on Levels of State Forgiveness.

Table 12. Effects of 2–8 Sessions on Levels of State Forgiveness.

affect (i.e., revenge). The meta-analysis showed signifi- assessed for effects on levels of state forgiveness. Both studies
cantly large effects favoring the experimental group measured the absence of negative thoughts, cognitions, and
(SMD ¼ 0.95, 95% CI [–1.36, 0.53], p ¼ .00001). No behaviors and the presence of positive emotions, thoughts, and
between-study heterogeneity was present (I2 ¼ 19%, p ¼ .29; behaviors toward the offender by administering the Psycholo-
Table 13). gical Profile of Forgiveness Scale (Freedman & Enright, 1996)
and the Enright Forgiveness Inventory (Coyle & Enright,
Analysis 12: Individual treatment effects on levels of state 1997). Meta-analysis results indicate a large and statistically
forgiveness. Two studies (n ¼ 22) that administered sessions significant overall effect (SMD ¼ 1.64, 95% CI [2.69,
using an individual format to deliver the treatment were 0.60], p ¼ .002) favoring the experimental group. No

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

Akhtar and Barlow 13

Table 13. Effects of 12 or More Sessions on Levels of State Forgiveness.

Table 14. Effects of Individual Treatment on Levels of State Forgiveness.

between-study heterogeneity was present (I2 ¼ 0%, p ¼ .38; Discussion

Table 14).
Summary of Findings
Analysis 13: Group intervention effects on levels of state Of the 15 studies selected for inclusion in this review, a total of
forgiveness. Nine studies (n ¼ 850) administered the treatment 12 studies and 36 outcome measures were used to carry out 13
using a group mode. Interventions were assessed for effects on meta-analyses. Initially, we combined and analyzed studies
state forgiveness. Four of these studies (Allemand et al., 2013; using broad outcome groups such as negative affect and state
Goldman & Wade, 2012; Ripley & Worthington, 2002; Shect- forgiveness but the results produced medium effects with sub-
man et al., 2009) used the TRIM Scale to measure situation- stantial levels of heterogeneity. This was due to the fact that
specific negative affect (i.e., revenge). The remaining seven while the studies included in the meta-analyses were all eva-
studies measured the absence of negative thoughts, cognitions, luations of process-based interventions, they were diverse in
and behaviors and the presence of positive emotions, thoughts, terms of the model type, mode, number of sessions, cultural
and behaviors by administering the Psychological Profile of context, and the gender and age of participants. In order to
Forgiveness Scale (Freedman & Enright, 1996), the Enright investigate some of the observed heterogeneity, subgroup anal-
Forgiveness Inventory (Coyle & Enright, 1997; Park et al., ysis was undertaken on the basis of model type, group versus
2013), and the Forgiveness Scale (Harris et al., 2006; M. S. individual format, and number of sessions received. It was not
Rye et al., 2005; S. R. Rye et al., 2012; Wade & Meyer, 2009). possible to examine all diversities due to the limited number of
Meta-analysis results showed a significant, albeit small effect studies and in cases where heterogeneity was low, broad out-
favoring the intervention group (SMD ¼ 0.37, 95% CI come groups were formed (i.e., positive affect).
[0.59, 0.16], p ¼ .0008). Significant between-study hetero- With regard to assessing the effectiveness of forgiveness
geneity was present (I2 ¼ 52%, p ¼ .03; Table 15). interventions in reducing negative affect, most studies

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

14 TRAUMA, VIOLENCE, & ABUSE

Table 15. Effects of Group Treatment on Levels of State Forgiveness.

(Analyses 1, 3, and 4) produced small, medium, and large Generalizability

statistically significant effects in favor of the intervention
The studies included in the systematic review used diverse
group, and there was no significant between-study heterogene-
samples of participants. Adolescents, adults, and older adults
ity. For example, small effects were present for depression
as well as male and female participants took part, and interven-
(SMD ¼ 0.37), with a moderate effect observed for anger
tions were tested across cultures (Israel, South Korea, Switzer-
and hostility (SMD ¼ 0.49) and large effects for stress
land, and the United States). Meta-analyses that showed large
and distress (SMD ¼ 0.66). With the exception of anxiety
effects (Analyses 12 and 8) in relation to the impact of treat-
(n ¼ 78), which did not produce a significant overall effect,
ment on levels of psychological adjustment (i.e., forgiveness)
all other meta-analyses assessing negative affect had sam-
also reflected this diversity. However, due to the limited num-
ple sizes between 270 and 500 participants, with resulting
ber of studies it was difficult to investigate further the effects of
small CIs. These results suggest that forgiveness interven-
age, gender, or cultural context on outcomes. In addition,
tions are effective in reducing various components of neg-
although there were some cross-cultural studies, a majority
ative affect.
were conducted in the United States and therefore further
In Meta-analysis 5, a number of measures of positive affect
research is needed that assesses the effects of these interven-
such as gratitude, hope, satisfied/happy/confidence, and empa-
tions in different countries and other cultures and among
thy (i.e., feeling ‘‘softhearted/compassionate’’) were combined.
minority ethnic groups as well as educationally and economi-
Combining five studies produced a total sample size of 318 and
cally diverse samples.
a significant, albeit small effect in favor of the intervention
The studies also evaluated the effectiveness of forgiveness
group. This suggests that forgiveness therapy can enhance
interventions, with people experiencing a range of problems
overall emotional well-being.
such as sexual abuse, abortions, marital hurts, civil conflict,
The findings are to a large degree consistent with previ-
and a range of other hurtful interpersonal experiences, and the
ous research, which suggests that forgiveness programs
findings are therefore generalizable to a range of hurts or abuse.
improve poor mental health, promote positive affect, and
increase levels of forgiveness (Lundahl et al., 2008). How-
ever, while previous research found decreases in levels of
anxiety, the current meta-analysis did not support this result. Moderator Analyses
However, it may be relevant to note that two of the three To examine the impact of treatment on the levels of state for-
studies assessing anxiety produced significant results but giveness, 11 studies were meta-analyzed. The results showed
that the sample sizes were relatively small. In either case, small effects (SMD ¼ 0.43) and substantial heterogeneity. To
further research is warranted. investigate this heterogeneity, we conducted subgroup analyses

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

Akhtar and Barlow 15

that assessed the effects of different models (i.e., Enright vs. Implications for Treatment
REACH), modes (i.e., individually delivered vs. group-based),
Despite the above limitations, the findings of this review indi-
and number of sessions (i.e., 2–8 vs. 12 or more) on levels of
cate that forgiveness interventions can improve mental health
functioning (i.e., state forgiveness). In the majority of cases,
and subjective well-being. This suggests the need to consider
heterogeneity was significantly reduced and results showed
forgiveness therapy as a potentially effective method of helping
significant effect sizes, all benefiting the treatment group. Sub-
people who have experienced a variety of abuses, to improve
group analyses showed that the Enright model (n ¼ 3 studies)
their psychological health, within therapeutic and other set-
produced a larger impact on forgiveness than the REACH (n ¼
tings. These interventions can be used with patients who have
7 studies) model; that more sessions (n ¼ 4 studies) were more
no religious or spiritual inclinations, but the findings suggest
effective than less (n ¼ 7 studies); as were interventions that
the need for clarity concerning core concepts underpinning the
were delivered on an individual (n ¼ 2 studies) compared with
intervention. For example, emphasizing to clients that forgive-
a group (n ¼ 9 studies) basis. There is, however, some con-
ness does not necessarily involve reconciliation, condoning,
founding of these results because the REACH model was only
tolerating, or excusing hurtful behavior, which serves to protect
delivered on a group basis, and it is not therefore possible to
victims of violence from further unhealthy relationships.
know whether this model would be more effective than the
The findings of this review identified differences in out-
Enright model if delivered individually. This points to the
come dependent on the mode of treatment, model used, and
need for further rigorous studies directly comparing these
number of sessions administered. Both REACH and the
different models when delivered using similar formats and
Enright models can be applied in a group format, and the find-
number of sessions, in addition to the need for cost-
ings of this review suggest that this format may be most effec-
effectiveness data. The present review also specifically
tive if the sessions are applied over a longer period of time such
focused on assessing the effectiveness of forgiveness treat-
as 12 or more weeks. The findings also suggest, however, that
ments in comparison with no-treatment control groups, and
individually delivered forgiveness programs, using the Enright
further research that compares forgiveness interventions
model, and again administering 12 or more sessions, may result
with other types of treatments aimed at improving psycho-
in greater increases in psychological adjustment, although fur-
logical adjustment is also needed.
ther research is still needed.
These findings are consistent with previous research,
which showed that individually delivered programs, using
the Enright model of forgiveness and administering more
sessions, seem to be more effective in promoting psycholo- Conclusion
gical well-being (Baskin & Enright, 2004; Lundahl et al., Interpersonal hurts including trauma and abuse are common
2008; Wade et al., 2013). However, as suggested above, in and have a significant impact on the mental well-being and
some cases subgroup analysis revealed that the number of functioning of victims. There is a need to identify effective
treatments administered (i.e., 12 or more) appeared to be the methods of improving the mental well-being of this group. This
factor influencing levels of forgiveness, and there were no review provides moderate quality evidence indicating that
individually administered REACH models with which to process-based forgiveness interventions are effective in
compare them. Thus, further research is needed directly improving mental well-being following a range of significant
comparing different models, modes of treatment, and num- hurts among diverse population groups. These findings suggest
ber of sessions. that forgiveness interventions could have an important role to
play in promoting the general psychological well-being of indi-
Limitations of the Review viduals and populations who experience a range of problems
resulting from having been traumatized. The results also sug-
This review has a number of limitations. First, there was a low gest the need for more research, particularly to assess the
to moderate quality of evidence rating for the included studies impact of different types of forgiveness interventions that vary
due to the potential for high risk of bias. However, this was in length and mode, and their effectiveness in treating adoles-
mostly due to the issue of ‘‘blinding,’’ which is difficult to cents and adults who have experienced different types of abuse
ensure in studies of this nature. Most other risk of bias factors outside a U.S. context. Future research should utilize RCT
were either low (randomization, selective reporting, and other designs and include validated measures that assess a variety
sources of bias) or generally unclear risk (i.e., allocation con- of psychological health outcomes and also assess the efficacy
cealment). Second, the moderator analyses were limited to of different models and modes of treatment.
measures of forgiveness due to the limited number of studies
measuring other outcomes. Third, the review did not include
unpublished papers or non-English-language studies, and most
Implications for Future Policy, Practice, and Research
of the studies were conducted in the United States and a few Both group-based and individually delivered process-based
countries outside of America, suggesting the need for caution forgiveness interventions should be available within mental
in terms of extrapolating the findings to populations from more health settings to promote the mental well-being of patients
diverse or different cultures. who have experienced a range of hurts or abuse.

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

16 TRAUMA, VIOLENCE, & ABUSE

There is a need for further research comparing the different Enright, R. D., & Fitzgibbons, R. P. (2000). Helping clients forgive:
models of process-based forgiveness interventions, and asses- An empirical guide for resolving anger and restoring hope.
sing their effectiveness with other populations (i.e., adoles- Washington, DC: American Psychological Association.
cents, elderly, married couples), other types of interpersonal Enright, R. D., & The Human Development Study Group. (1996).
hurts (e.g., bullying and harassment) and in terms of their Counseling within the forgiveness triad: On forgiving, receiving
effectiveness on other aspects of well-being. forgiveness, and self-forgiveness. Counseling and Values, 40,
There is also a need to compare forgiveness-based interven- 107146.
tions with other methods of supporting victims of abuse, in Freedman, S. R., & Enright, R. D. (1996). Forgiveness as an interven-
terms of what works, for whom, under what circumstances. tion goal with incest survivors. Journal of Consulting and Clinical
Psychology, 64, 983992.
Acknowledgments Freedman, S. R., & Knupp, A. (2003). The impact of forgiveness on
We would like to express our gratitude to Cathy Bennett and Jane adolescent adjustment to parental divorce. Journal of Divorce &
Dennis who offered helpful advice concerning methods of combining Remarriage, 39, 135165.
data where multiple measures of the same outcome have been used. Goldman, B. D., & Wade, N. (2012). Comparison of forgiveness and
anger-reduction group treatments: A randomized controlled trial.
Declaration of Conflicting Interests Psychotherapy Research, 22, 604620.
Graham, V. N., Enright, R. D., & Klatt, J. S. (2012). An educational
The author(s) declared no potential conflicts of interest with respect to
forgiveness intervention for young children of divorce. Journal of
the research, authorship, and/or publication of this article.
Divorce & Marriage, 53, 618638.
Greenberg, L. S., Warwar, S. H., & Malcolm, W. M. (2008). Differ-
Funding
ential effects of emotion-focused therapy and psychoeducation in
The author(s) received no financial support for the research, author- facilitating forgiveness and letting go of emotional injuries. Jour-
ship, and/or publication of this article. nal of Counseling Psychology, 55, 185–196.
Harris, A. H. S., Luskin, F., Norman, S. B., Standard, S., Bruning, J., &
References Evans, S. (2006). Effects of a group forgiveness intervention on
Allemand, M., Steiner, M., & Hill, L. P. (2013). Effects of a forgive- forgiveness, perceived stress, and trait-anger. Journal of Clinical
ness intervention for older adults. Journal of Counselling Psychol- Psychology, 62, 715733.
ogy, 60, 279286. Hebl, J. H., & Enright, R. D. (1993). Forgiveness as a psy-
Al-Mabuk, R. H., Enright, R. D., & Cardis, P. A. (1995). Forgiveness chotherapeutic goal with elderly females. Psychotherapy, 30,
education with parentally love-deprived late adolescents. Journal 658667.
of Moral Education, 24, 427444. Higgins, J. P. T., & Green, S. (2008). Cochrane handbook for sys-
Baskin, T. W., & Enright, R. D. (2004). Intervention studies on for- tematic reviews of interventions. London, England: The Cochrane
giveness: A meta-analysis. Journal of Counseling & Development, Collaboration.
82, 7990. Hui, E. K. P., & Chau, T. S. (2009). The impact of a forgiveness
Baskin, T. W., & Rhody, M. (2011). Supporting special needs adop- intervention with Hong Kong Chinese children hurt in interperso-
tive couples: Assessing an intervention to enhance forgiveness, nal relationships. British Journal of Guidance & Counselling, 37,
increase marital satisfaction, and prevent depression. The Counsel- 141156.
ing Psychologist, 39, 123. Huppert, F. A. (2009). Psychological well-being: Evidence regarding
Chida, Y., & Steptoe, A. (2009). The association of anger and hostility its causes and consequences. Applied Psychology: Health and
with future coronary heart disease: A meta-analytic review of pro- Well-being, 1, 137164.
spective evidence. Journal of the American College of Cardiology, Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, Z. A., & Lozano, R.
53, 936946. (Eds.). (2002). World report on violence and health. Geneva, Swit-
Coyle, C. T., & Enright, R. D. (1997). Forgiveness intervention with zerland: World Health Organization.
postabortion men. Journal of Consulting and Clinical Psychology, Lampton, C., Oliver, G. J., Worthington, E. L., & Berry, J. W. (2005).
65, 10421046. Helping Christian college students become more forgiving: An
Department of Health. (2011). No health without mental health: A intervention study to promote forgiveness as part of a program to
Cross-Government Mental Health Outcomes Strategy for People shape Christian character. Journal of Psychology and Theology,
of All Ages. Retrieved from https://www.gov.uk/government/ 33, 278290.
uploads/system/uploads/attachment_data/file/138253/dh_ Lin, W. F., Mack, D., Enright, R. D., Krahn, D., & Baskin, T. W.
124058.pdf (2004). Effects of forgiveness therapy on anger, mood, and vulner-
DiBlasio, F. A. (1998). The use of a decision-based forgiveness inter- ability to substance use among inpatient substance-dependent cli-
vention within intergenerational family therapy. Journal of Family ents. Journal of Consulting and Clinical Psychology, 72,
Therapy, 20, 7794. 11141121.
DiBlasio, F. A., & Benda, B. B. (2002). The effect of forgiveness Lin, W. N., Enright, R. D., & Klatt, J. S. (2013). A forgiveness inter-
treatment on self-esteem of spouses: Initial experimental results. vention for Taiwanese young adults with insecure attachment.
Marriage & Family: A Christian Journal, 5, 511523. Contemporary Family Therapy, 35, 105120.

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016

Akhtar and Barlow 17

Lundahl, W. B., Taylor, J. M., Stevenson, R., & Daniel, K. R. (2008). intervention designed to help divorced parents forgive their ex-
Process-based forgiveness interventions: A meta-analytic review. spouse. Journal of Divorce & Marriage, 53, 231245.
Research on Social Work Practice, 18, 465. Shectman, Z., Wade, N., & Khoury, A. (2009). Effectiveness of a
Luskin, F. M., Ginzburg, K., & Thoresen, C. E. (2005). The efficacy of forgiveness program for Arab Israeli adolescents in Israel: An
forgiveness intervention in college age adults: Randomized con- empirical trial. Peace and Conflict, 15, 415438.
trolled study. Humboldt Journal of Social Relations, 29, 163183. Toussaint, L., Peddle, N., Cheadle, A., Sellu, A., & Luskin, F. (2010).
Macaskill, A. (2005). The treatment of forgiveness in counselling and Striving for peace through forgiveness in Sierra Leone: Effective-
therapy. Counselling Psychology Review, 20, 2633. ness of a psychoeducational forgiveness intervention. Retrieved
McCullough, M. E., & Worthington, E. L. Jr. (1995). Promoting for- from http://learningtoforgive.com/wp/docs/Sierra_Leone_Forgive
giveness: The comparison of two brief psychoeducational inter- ness_Project.pdf
ventions with a wait-list control. Counselling and Values, 40, Wade, N., & Worthington, L. E. (2005). In search of common core: A
5568. content analysis of interventions to promote forgiveness. Psy-
Osterndorf, C. L., Enright, R. D., Holter, A. C., & Klatt, J. S. (2011). chotherapy: Theory, Research, Practice, Training, 42, 160–177.
Treating adult children of alcoholics through forgiveness therapy. Wade, N. G., & Meyer, E. J. (2009). Comparison of brief group
Alcoholism Treatment Quarterly, 29, 274292. interventions to promote forgiveness: A pilot study. International
Park, J., Enright, R. D., Essex, M. J., Zahn-Waxler, C., & Klatt, J. S. Journal of Group Psychotherapy, 59, 199220.
(2013). Forgiveness intervention for female South Korean adoles- Wade, N. G., Hoyt, W. T., Kidwell, E. M., & Worthington, E. L.
cent aggressive victims. Journal of Applied Developmental Psy- (2013). Efficacy of psychotherapeutic interventions to promote
chology, 34, 268–276. forgiveness: A meta-analysis. Journal of Consulting and Clinical
Reed, G. L., & Enright, R. D. (2006). The effects of forgiveness Psychology, 82, 154157.
therapy on depression, anxiety, and posttraumatic stress for women Worthington, E. L. Jr. (2001). Five steps to forgiveness: The art and
after spousal emotional abuse. Journal of Consulting and Clinical science of forgiving. New York, NY: Crown.
Psychology, 74, 920929.
Ripley, J. S., & Worthington, E. L. (2002). Hope-focused and
forgiveness-based group interventions to promote marital enrich-
ment. Journal of Counseling and Development, 80, 452463. Author Biographies
Royal College of Psychiatrists. (2010). No health without public men- Sadaf Akhtar (PhD, University of Warwick) is a health and social
tal health: The case for action. Retrieved from http://www.rcpsy scientist, and her primary research interests are in understanding bar-
ch.ac.uk/pdf/Position%20Statement%204%20website.pdf riers to and factors promoting human health and well-being, including
Rye, M. S., & Pargament, K. I. (2002). Forgiveness and romantic trauma and violence, religion/spirituality, and forgiveness.
relationships in college: Can it heal the wounded heart? Journal
Jane Barlow (PhD, Nuffield College, Oxford) is a professor of public
of Clinical Psychology, 58, 419441.
health in the early years and pro-dean for Research at the University of
Rye, M. S., Pargament, K. I., Pan, W., Yingling, D. W., Shogren, K. A.
Warwick. She is the director of Warwick Infant and Family Well-
, & Ito, M. (2005). Can group interventions facilitate forgiveness of Being Unit at Warwick Medical School. Her main research interest
an ex-spouse? A Randomized Clinical Trial. Journal of Consulting is the role of early parenting in the etiology of mental health problems
and Clinical Psychology, 73, 880892. and in particular the evaluation of early interventions aimed at
Rye, S. R., Fleri, M. A., Moore, D. C., Worthington, L. E., Wade, G. improving parenting practices, particularly during pregnancy and the
N., Sandage, J. S., & Cook, M. K. (2012). Evaluation of an postnatal period.

Downloaded from tva.sagepub.com at UNIVERSITE DE SHERBROOKE on November 12, 2016