Using Forgiveness as an Intervention for Healing in Women Who Experience Abuse

Forgiveness Education has been used effectively in psychology with many populations who have experienced betrayals. Most health care providers focus on the physical and some psycho-social aspects of the patient. However, including the patient's religious and spiritual beliefs and practices are often neglected. Most patients in America are religious with Christianity being the most frequent type. Health care providers need to treat and care for patients holistically. Including a patient's religious beliefs and practices in the plan of care can be beneficial to healing. Parish nurses can also use forgiveness education with female parishioners who experienced abuse. Discussion including the development of a new measure: the Christian Women's Forgiveness Measure is explored.


Gravity of the Problem
Abuse involving women continues to be a major concern for health care providers [1]. The most common forms of abuse are physical and sexual [2]. Currently, one in four women experience physical and or sexual assault by an intimate partner. Eighty-five percent of domestic violence victims are women with females between the ages of 20-24 being at the greatest risk. The economic impact to society exceeds $5.8 billion each year with $4.1 billion incurred in direct medical and mental health care. Women who experience abuse, depending on the type, can suffer both short term and long term physical and mental health consequences [3]. Examples of short term consequences would include broken bones, wounds, and contusions from physical abuse, and stress and anxiety from emotional abuse. Examples of long term physical consequences would include permanent musculoskeletal damage, disfigurement, and brain damage from physical abuse. Long term mental health consequences could include post-traumatic stress disorder and depression.

How Betrayals Harm Our Health
When a women experiences betrayal and realizes it she often experiences feelings of shame, anger and hopelessness [4]. Her body in response to these feelings releases six toxic hormones, including 1) cortisol, 2) cortisone, 3) norepinephrine, 4) epinephrine, 5) prolactin and 6) testosterone that harm the cardiovascular and immune systems [5]. Consequently every time she relives the incident in her mind her body again releases those same hormones. Over a life time a woman can experience several betrayals resulting in her replaying many harmful memories. The accumulative effect of these negative hormones on the cardiovascular and immune system can lead to hypertension, coronary artery disease, increased clotting time, cancer, and increase in number and type of symptoms and illnesses [5][6][7]. However, other types of abuse besides physical and sexual occur and can be just as devastating to women [8]. Other forms of abuse include emotional, economic and spiritual. In addition, it is not just intimate partners who abuse women; betrayals can involve parents, children, co-workers, friends, clergy, and strangers. Examples of betrayals include 1) a 75 year old women whose 50 year old son molested a neighbour girl. Because the son had no place to live after he was released from prison he had to live with his parents. His small children were not allowed to go visit their grandmother's home due to his sex predator designation. The woman also felt uncomfortable at Church, since surely she must not have raised her son with Christian values; 2) An eight month pregnant woman who was thrown out of a moving car by her angry husband; 3) the female employee who did not get promoted due to office gossip; 4) the female child who was blamed for her little sister's rape by neighbour boys who were visiting her home; and 5) A woman who went into hiding after becoming romantically involved with a man who stole her life savings, who was not only a thief, but a serial killer. He eventually was captured and currently is incarcerated.
Much scholarly work has involved defining, assessing, and referring abused women to helping agencies such as the police, battered wife shelters, and counsellors [9,10]. However, not much has been discussed regarding specific interventions that could help abused women heal from their abusive betrayals. No doubt women who are in danger need to remove themselves from their abusers. However, other types of abuse may not require the woman to physically leave. Yet, interventions need to be available for the woman to cope with those that have betrayed her.

The Role of Religion in Caring for Patients
It is amazing that abuse is still a significant problem for women in the United States when seventy-eight percent of our society identifies either with a Christian denomination or with Christian beliefs [11]. Forgiveness and salvation are two of the main tenets of Christianity [12]. Because of their beliefs and practices, forgiving may be easier for Christians than those who belong to other religious groups, or none at all [13]. This is because the concept of forgiveness is not included in their dogma or it is not valued. For the Christian if forgiving another seems impossible they have the ability to give that burden to God and lay it at the feet of the cross. The mystery of the Trinity: Father, Son and Holy Spirit allows for Christians in pain from betrayal and abuse to find refuge and healing [12].

Forgiveness as an Intervention
Regardless, as health care workers, we should take religious beliefs and practices into consideration when dealing with women and their health care needs [14]. Religious beliefs may keep women in abusive relationships whether at home, work or in a faith community. Christian women in particular may find it difficult to leave an abusive relationship based on their misunderstanding of Biblical teachings. Certainly forgiveness can be understood in both secular and religious circles [15,16]. However, Christian parish nurses are interested in working with Christian women who need help in healing from their abusive relationships [8]. Since female parish nurses are well situated within their congregations they have entre into the experience of women that male pastors do not. This is especially foremost if abused women belong to denominations that do not ordain women and share religious power equally among men.
Forgiveness as an intervention to help the abused heal is available and its efficacy has been researched for over thirty years [4,17]. Forgiveness education has demonstrated that it can improve not only mental health, but also physical health [7]. However, misunderstanding the phenomenon of forgiveness may keep women trapped in unhealthy relationships [8]. An example of this is with some feminists who object to the idea of forgiving on the grounds doing so further violates an abused woman's right to be justifiably angry and may compromise obtaining justice [18].
Forgiveness is not a free pass for the abuser to get away with harming the woman. It is not forgetting, excusing, condoning or pardoning the abusive behaviour [4]. Ultimately, the abused relinquishes expectations of compensation by the perpetrator, think, feels and acts more positively towards the abuser [4]. However, the woman does not give up their right to justice; wither legally or from God. Most importantly forgiveness is not reconciliation. Forgiveness is a moral decision a woman makes from with-in. It is an intrapsychic experience that ultimately allows her to release the shame, anger and hopelessness she feels [19]. Reconciliation requires the abuser to repent: to say they are sorry and change their behaviours, so the abuse does not occur again [20]. The abused can forgive without the assistance or acknowledgment of wrongdoing on behalf of the abuser, since most abusers are not sorry for what they do, and may believe the woman deserved the abuse she received [4].
Forgiveness is a process that consists of several stages resulting in the abused woman being transformed by the experience that results in her letting go of anger and ultimately being able to think more positively of the offender [4]. It is important to remember that humans are complex beings with many facets to their personalities. Most have some desirable qualities and cannot be defined by one or two bad behaviours or personality traits. Research has consistently demonstrated that forgiveness is inversely related to anger and depression [4]. Robert Enright has been one of the leading researchers of forgiveness education, but the Enright Forgiveness Inventory (EFI) is secular based. If women are influenced by their religious convictions it could be beneficial to take another approach.

The Christian Womens' Forgiveness Measure (CWFM)
Parish nurses, also known as faith based nurses, could assist with forgiveness education with their parishioners. Quenstedt-Moe has developed a 93 item measure based on Christian scripture. An unpublished study involving 272 female college students over a two year period demonstrated the Christian Womens' Forgiveness Measure (CWFM) to have a Cronbach's Alpha of .89 demonstrating the measure is very reliable [21]. The items comprise six main categories which include 1) What Forgiveness is not, 2) Christian Women and the Bible, 3) Battered Christian Women and the Bible, 4) Emotions and Christianity, 5) Health and Forgiveness, and 6) Steps towards Forgiveness. Efforts to develop a Bible study type intervention over a six to eight week period will be developed in the near future. Future studies will include a pre and post-test design using randomized experimental and control groups (wait listed group). After the data is collected the wait listed group will also receive the intervention. It is important to give the wait listed group the intervention because they are vulnerable to the pain and distress they have experienced from the betrayal (s). To leave them in their pain and distress would be cruel and could lead them to experience further harm both emotionally and physically.
By dispelling misunderstandings of the messages of Scripture, women will be taught how precious they are in God's sight. They will learn how to forgive through a moderate Christian perspective using their beliefs and practices. The steps to healthy forgiving as posited by Enright & Gibbons will be infused and revised with the emphasis on Christian beliefs and practices. Women will be taught the following: 1) Defining the Injury; 2) Claiming the Injury; 3) Accountability of Those Involved; 4) Empowerment; 5) Choosing to Forgive; and 6) Transformation: The Emergence of a New Self. The topic involving Empowerment is an area that parish nurses can particularly assist with, as it encompasses aspects of body, mind and spiritual care. Women's religious beliefs and practices can be strengthened through praying, journal writing, scripture reading, baptism, communion, and worship.
The ultimate purpose of the research is to bring God's word to women, so they understand where they stand in the sight of God and others. That through practicing forgiveness their health will be restored when they are betrayed and abused, and that they can hopefully move forward in reconciling with their abusers, when appropriate. Parish nurses are one group of professionals that can deliver forgiveness education to their congregations and along with clergy and others ministering, can help provide healing and proactive education to prevent women from experiencing the unhealthy effects of betrayal. Certainly, other faith based parish nurses (e;g; Hindu, Jewish, etc) will develop their own forgiveness education tools that reflect their particular religious beliefs and practices.