Journal Article Review

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timer Asked: Aug 18th, 2014

Question Description

You will write 1 Journal Article Reviews, which will be based upon your choices from the professional, peer-reviewed journalarticles provided. No outside articles will be accepted. Each Journal Article Summary must be 3–5 double-spacedpages (not including the title and reference pages) and created in a Microsoft Word document. Use the following guidelines to create your paper: 

Use the following guidelines to create your paper:

1. Provide an APA-style title page: making sure you show the title of the article reviewed (must be 12 words or less), your name, and the institution [Liberty University]. They should be double spaced. You should also have the 6th edition running head in the appropriate place and a page number on every page. Please note that the running head on the cover page is different from the one on the subsequent pages. Cover page is the place that many students tend to make mistakes and get points deducted.

After the cover page, you must divide your paper into sections with the following centered/bolded Level 1 headings:  Summary, Reflection, and Application. They should be centered and bolded. Everything should be double spaced. Please do not leave extra space between sections except the Reference section which should start with a new page. If you are not sure about the format, please check the APA manual.  

2. Develop a brief (at least 1 full page) summary of the article in your own words. Do not copy and paste from the journal article--this is plagiarism! Simply provide a brief description in your own words of the topic under consideration in the article. If the article describes a research study, include brief statements in your own words about the hypotheses, methods, results, discussion, and implications. Do not provide detailed descriptions of the test measures or statistical methods used, if any. Short quotations from the article are acceptable, but they should not be more than 1 - 2 sentences. Direct quotations from the article should also be properly cited. This section should take up about a third of your Journal Article Review. Do not reference any additional articles in your summary. Do not use any personal pronouns in this section. You can usually find the major points of the article from the abstract, although not always the case. The key is to read the article several times and try to fully understand and grasp the themes of the article. And then use your own words to state the main concepts of the article. After you do that, compare your summary with the author's abstract and see whether you miss any main points of the article. Of course, you should always check your content with the rubric and see whether you miss anything.

3. About the Reflection Section: In your own words, interact (1 full page) with the article.  Appropriate comments for this part of the paper should include, but are not limited to, your initial response to the article; comments (in your own words) regarding the study's design or methodology (if applicable); insights you gained from reading the article; your reasons for being interested in this particular article; any other readings that you may plan to do based upon having read the article; and other thoughts you have that might further enhance the discussion of your article. Every point on the rubric needs to be covered or points will be deducted, which means your reflection needs to have everything required by the rubric, as I mentioned above. This section should constitute approximately a third of your Journal Article Review.  Again, there is no need to reference any other article. First person pronouns can be used in this section.

4. The final Application section is how you would apply (1 page) the information you have learned to a potential and specific counseling case. This could be in a church or clinical session. Develop this section as if you are a pastor or clinician and your parishioner or client has come to you with a problem, needing your help.Be specific on the situation and how you are going to apply what you learned from the article in helping the client or counselee. Give the client name, presenting problems, counseling process, etc. Please do not simply describe a general condition. Points will be deducted if the case is not specific enough. Also, make sure that you apply the main concepts and techniques (if applicable) from the article to the case. First person pronouns can be used in this section.

5. Provide the complete reference citation for the article being summarized on a Reference page in compliance with APA standards. This means you need to be aware of how and when you periods, spacing, italics, use or non-use of issue number, etc. Do not bold the reference title. Do not simply "copy and paste" the reference from an electronic source. The article under review should be the only source you cite and put in the reference. No other article or any other source should be used. Since you are not allowed to use any other source, which means ideas from other source cannot be cited, you cannot use any ideas other than the article or your own. Otherwise it will be considered plagiarism. More specific rules on plagiarism will be posted in a following announcement.

Take note of these most common mistakes I have seen from grading student papers:

*Not using proper spacing (double spacing with a default setting of 0-0 = even spacing throughout your papers)

*Not using the proper 1-inch APA margins

*Not using a 6th edition APA Running head

*Not following the directions carefully.

*Falling short of the one-full page requirement for each section!!!!! You can exceed (but not too much) the page requirement, but not short of it.

*Not using New Times Romans/size 12

*Using personal pronouns in the Summary section. A no-no!

*Using 2nd person pronouns in your paper. A no-no! No you, your, yourself

*Forgetting the reference page

*Use contraction in the text. No contraction should be used in a formal writing.

HERE IS THE  INSTRUCTIONS FOR  Journal_Article_Review_Instructions(1).docx 

HERE ARE TWO ARTICLES YOU CAN PICK EITHER ONE OF THEM 

14843007.pdf 

920.pdf 

COUN 506 JOURNAL ARTICLE REVIEW INSTRUCTIONS You will write 1 Journal Article Reviews, which will be based upon your choices from the professional, peer-reviewed journal articles provided. No outside articles will be accepted. Each Journal Article Summary must be 3–5 double-spaced pages (not including the title and reference pages) and created in a Microsoft Word document. Use the following guidelines to create your paper: 1. Provide an APA-style title page including your name, the paper title (referring to the article title), and the institutional affiliation (Liberty University). Keep in mind that current APA recommends the title length not to exceed 12 words. Use the running head in the appropriate place and a page number on every page. Divide your summary into sections with the following Level 1 headings: Summary, Reflection, and Application (review the APA Manual for guidance if needed). 2. Develop a 1-page summary of the article in your own words. Do not copy and paste from the journal article—this is plagiarism! Provide a brief description of the topic under consideration in the article. If the article describes a research study, include brief statements about the hypotheses, methods, results, discussion, and implications. If any test measures or statistical methods used are given in the article, do not provide detailed descriptions of these. Short direct quotations from the article are acceptable, but they may not be more than 1–2 sentences each and must be properly cited. This section is the foundation of your Journal Article Review (at least a third of your paper). Make sure you include the core points from the article, even if it means a longer section. Do not reference any additional articles in your summary. 3. In your own words, reflect (in 1 page) on the article. Appropriate comments for this part of the paper could include, but are not limited to, your initial response to the article, comments (in your own words) regarding the study's design or methodology (if any), insights you gained from reading the article, your reasons for being interested in this particular article, any other readings that you may plan to do based upon having read the article, and other thoughts you have that might further enhance the discussion of your article. This section should constitute approximately a third of your Journal Article Review. Again, do not reference any other article. 4. In your final section, write in 1 page how you would apply the information you have learned to a potential counseling setting. This could be in a church or clinical session. Develop this section as if you are a pastor or clinician and your parishioner or client has come to you with a problem, needing your help. You may want to pick one of the following “normal” problems for this section: depression, grief, substance abuse, spousal infidelity, unforgiveness, etc. 5. Provide the complete reference citation for the article being summarized on a reference page in compliance with current APA standards. Be aware of how and when you use periods, spacing, italics, use or non-use of issue number, etc. Do not copy and paste the reference from an electronic source.
Therapists' Integration of Religion and Spirituality in Counseiing: A Meta-Analysis Donald F. Walker, Richard L. Gorsuch, and Siang-Yang Tan The authors conducted a 26-study meta-analysis of 5,759 therapists and their integration of religion and spirifuaiity in counseiing. Most therapists consider spirituaiity relevant to their iives but rareiy engage in spirituai practices or participate in organized religion. Marriage and famiiy therapists consider spirituaiity more reievant and participate in organized religion to a greater degree than therapists from other professions. Across professions, most therapists surveyed (over 80%) rareiy discuss spirituai or reiigious issues in training, in mixed sampies of reiigious and secular therapists, therapists' reiigious faith was associated with using religious and spiritual techniques in counseiing frequently, willingness to discuss religion in therapy, and theoretical orientation. T herapists' integration of religion and spirituality in counseling has been evaluated in 26 studies of 5,759 psychotherapists from the fields of clinical and counseling psychology, psychiatry, social work, and pastoral counseling. We suggest that it is now appropriate to perform a metaanalysis of the existing research. We discuss the relevance of religion and spirituality to counseling, review methods of integrating religion and spirituality in coimseling, and conduct a meta-analysis of studies concerning therapists' integration of religion and spirituality into counseling. Relevance of Religion and Spirituality to Counseling In the area of multicultural theory, psychologists have continued to call for psychological treatments and interventions that are culturally sensitive and relevant and that integrate aspects of client culture into the counseling process (D. W. Sue & Sue, 1999; S. Sue, 1999). In addition, psychologists have increasingly recognized that religion and spirituality are relevant aspects of client diversity that psychologists should be able to recognize while treating religious or spiritual clients with sensitivity (Ridley, Baker, & Hill, 2001; D. W. Sue, Bingham, Porche-Burke, & Vasquez, 1999). Richards and Bergin (2000) have proposed that the integration of religious and spiritual culture in counseling is conceptually similar to the dynamics of more general multicultural counseling attitudes and skills previously advanced by other multicultural researchers (e.g., D. W. Sue & Sue, 1999). Richards and Bergin (2000) further suggested that multicultural competent attitudes and skills regarding religion and spirituality encompass several domains. Donald F. Walker, Richard L. Gorsuch, and Siang-Yang Tan, Graduate School of Psychology, Fuller Theological Seminary. A portion of this research was presented at the 2001 annual meeting of the American Psychological Association, San Francisco. Correspondence concerning this article should be addressed to Donald F. Walker, Fuller Theological Seminary, Graduate School of Psychology, 180 N. Oakland Avenue, Pasadena, CA 91101 (e-mail: dfwalker@hotmail.com). Counseiing and Vaiues • October 2004 • Voiume 49 69 Among the domains of multicultiaral attitudes and skills most pertinent to this study are (a) an awareness of one's own cultural heritage, (b) respect and comfort with other cultures and values that differ from one's own, and (c) an awareness of one's helping style and how this style could affect clients from other cultural backgrounds. Hence, knowledge of religion and spirituality is an important element of therapists' multicviltural competency. Religion and spirituality are important aspects of multicultural competency for therapists to consider given the religious culture in America. Researchers have found that more than 90% of Americans claim either a Protestant or Catholic religious affiliation (Keller, 2000), 40% of Americans attend religious services on a weekly basis, and more than two thirds of Americans consider personal spiritual practices to be an important part of their daily lives (Hoge, 1996). Thus, it is important for counselors to understand how their own religious and spiritual culture may differ from that of the general populace and the clients whom they serve. This meta-analysis has several aims. One purpose of this study was to examine via meta-analysis the spiritual and religious culture and values of counselors. We use this information to suggest ways in which therapists' religious cultures may differ from those of their clients and to explore how such differences might be constructively approached in counseling. A second purpose of this study was to explore via meta-analysis links between the personal religiousness of counselors and therapists and several counseling-related variables. We use this information to understand across studies how therapists' religiousness relates to their helping style with clients from varying religious and spiritual backgrounds. Methods of Integrating Religion and Spirituality in Counseling One issue that has been problematic when discussing methods of integrating religion and spirituality in counseling has been agreeing on exactly what is being integrated. Pargament (1999), for example, noted that psychologists of religion rarely agree on specific definitions of religion and spirituality. However, on a broad level, religion has typically been defined as that which is more organizational, ritual, and ideological, whereas spirituality has typically been defined as that which is more personal, affective, and experiential (Pargament, 1999; Richards & Bergin, 1997). In this study, the same broad definitions will be used when referring to religion and spirituality. Therapists have proposed several different methods of integrating religious and spiritual culture into counseling. According to Tan (1996), explicit integration refers to a more overt approach that directly and systematically deals with spiritual or religious issues in therapy, and uses spiritual resources like prayer, Scripture or sacred texts, referrals to church or other religious groups or lay counselors, and other religious practices, (p. 368) Tan noted that this approach to coimseling emphasizes both therapist and client spirituality and integrates counseling with some form of spiritual direction. Another approach to integrating religion and spirituality in counseling is the implicit integration of religion or spirituality. Implicit integration is "a more covert approach that does not initiate the discussion of religious or spiritual is70 Counseling and Values • October 2004 • Volume 49 sues and does not openly, directly, or systematically use spiritual resources like prayer and Scripture or other sacred texts, in therapy" (Tan, 1996, p. 368). An example of implicit integration is basing therapeutic values on theistic principles from an organized religion. Implicit integration maybe the preferred mode of integration for therapists who profess a religious faith or engage in spiritual practices but who are not trained in the explicit integration of religion and spirituality. Shafranske (1996) conducted a review of training in explicit and implicit integration. His review suggested that "education and training within the area of psychology and religion appears to be very limited" (p. 160) and that the majority of therapists never discuss religious or spiritual issues in their clinical training. Richards and Bergin (1997) noted that such therapists run the risk of practicing outside the boundaries of professional competence or imposing their own values on religious or spiritual clients. Shafranske (1996) suggested that most therapists' approach to the integration of religion and spirituality in psychotherapy was not based on graduate trairung in the area but centered primarily on the personal religious and spiritual experience of the therapist. A third form of integration is intrapersonal integration, which refers to the manner in which a therapist uses his or her personal religious or spiritual experience in counseling (Tan, 1987). An example of intrapersonal integration is silently praying for a client during counseling. This study attempts to determine how therapists practice their religion and spirituality and to determine the degree to which the personal religious faith of therapists is associated with the use of religion and spirituality in counseling. This is accomplished through the use of meta-analysis. The Use of Meta-Analysis as a Statistical Technique Although meta-analysis often involves aggregating results from experimental studies, it can also be used in aggregating correlational data, as was done in this meta-analysis. As Rosenthal (1991) explained, the only constraint in determining the relationship between two variables is that therelationshipbe of interest to the investigator. The investigator deterrrvines relationships between variables by obtairung an estimate of the effect size between two variables, which some studies do not provide along with their tests of significance (Rosenthal, 1991). In these instances, the test of sigriificance that is provided (whether yj^, t, or F) is transformed to an r for the purpose of computing an overall averaged r across studies. Hvmter and Schmidt (1990) noted that one criticism of the meta-analysis of correlations is that it typically provides a slightly downward bias in the estimate of population correlations. In practical terms, this is not problematic; if anything, such correlations are more conservative estimates of the relationship between two variables. In the current meta-analysis, we considered several issues to be relevant. The first issue we considered was the personal religion and spirituality of therapists. As mentioned earlier, this information is used to determine how different the culture of counselors might be from their clients and, thus, how the need for respect for, and comfort dealing with, cultures other than one's own might present Counseling and Values • October 2004 • Volume 49 71 in a counseling situation. A second issue we considered concerned therapists' personal religiousness and their use of explicit integration of religion and spirituality in counseling. This information is used to inform how therapists' personal religiousness may relate to their helping styles with religious clients. Finally, we made comparisons, where possible, between samples that were identified as containing explicitly religious therapists and sample groups that may have contained a mix of secular and religious therapists. We also made comparisons between therapists from different professional backgrounds to understand how each of the multicultural competencies (respect for cultures other than one's own, one's helping style as a therapist) might be different across professions. Method Literature Search We identified studies for inclusion in the meta-analysis using literature searches in the PsycINFO and Dissertation Abstracts International databases using the search terms counseling and religion, counseling and spirituality, psychotherapy and religion, a n d psychotherapy and spirituality. We sought unpublished studies, such as unpublished doctoral dissertatior^, in order to reduce die "file drawer problem" identified by Rosenthal (1979), in which the meta-analysis indicates a higher effect size than actually exists because studies with nonsigruJficant effects have not been located. We identified 40 studies through the literature search. Of those studies, we eliminated six dissertations because they were not empirical. We eliminated three other empirical dissertations because they did not contain variables of interest. We eliminated a final dissertation because it was not available, and the author did not respond to an e-mail message that had been sent. We eliminated 2 published studies by explicitly Christian therapists (Ball & Goodyear, 1991; Worthington, Dupont, Berry, & Duncan, 1988) because they were methodologically different from the other studies, making it impossible to include them in the meta-analysis. Two studies (Bergin & Jensen, 1990; Jensen & Bergin, 1988) were of the same sample. We considered these to be 1 study. One study (Sorenson & Hales, 2002) was a new analysis of two samples already included in the total data set, so this study was reviewed but not included in the analyses. Thus, the final number of studies included in the analyses was 26. Demographic Characteristics of the Total Sample We aggregated the demographic characteristics of the total sample across studies to describe the sample. Regarding professional backgrounds, clinical and counseling psychologists composed 44.15% of the total sample, explicitly Christian counselors 21.30%, marriage and family therapists 14%, social workers 5.85%, psychiatrists 4.32%, explicitly Mormon psychotherapists 3.54%, psychotherapists 2.77%, licensed professional counselors 1.82%, and pastoral counselors 1.71%. (Percentages do not total 100 due to rounding.) With respect to gender, men composed 58.11% of the sample, and women composed 41.89% of the sample. The sample ranged in age from 22 to 89 years, with a mean age of 46.1. Only five studies reported the race of the therapist sample. The authors of those five studies estimated 72 Counseling and Values • October 2004 •Volume 49 the percentage of White therapists to be 83% to 95% (Bilgrave & Deluty, 1998,2002; Case & McMinn, 2001; Forbes, 1995; Sheridan, Bullis, Adcock, Berlin, & Miller, 1992). Computation of Effect Size First, we converted all relationships of interest to an r, and then we calculated a weighted overall averaged r by weighting each individual correlation by the sample size associated with each individual study. Second, we calculated the overall significance level of each correlation by the method of adding z scores. Following the technique proposed by Rosenthal (1991), we added z scores from samples and then divided the sum of the z scores by the square root of the number of studies. Third, we compared the significance of several correlations using Fisher's test of significance between independent correlations (Cohen & Cohen, 1983). We used appendixes from Cohen and Cohen to transform correlations to z scores. Then, we divided the difference between the z equivalents by the standard error to obtain a normal curve deviate. We used appendixes provided in Cohen and Cohen to obtain the p value for the significance test. Finally, we added the raw scores from some items of interest (such as religious denomination) across studies. Results Personal Religion and Spirituality of Therapists Religious affiliations of therapists from mixed samples were provided in 18 studies of 3,813 therapists. The majority of therapists in these samples were Protestant (34.51%), Jewish (19.61%), or Catholic (13.89%). Religious denominations among therapists from different professional backgrovinds are presented in Table 1. Clinical and counseling psychologists were more likely to be either an agnostic (x^ = 10.27, p < .005) or atheist (x^ = 27.19, p < .005) when compared with marriage and family therapists but were not more likely to be either an atheist or agnostic when compared with social workers. Clinical and counseling psychologists were also more likely to endorse no religion than either marriage and family therapists (X^ = 34.13, p < .0001) or social workers (x^ = 7.98, p < .01). Five studies (N = 1,738) of therapists from mixed samples and 2 studies (N = 762) of explicitly religious therapists reported frequency of therapists' participation in organized religion or church activities. Among therapists from mixed samples, 21.1% reported being inactive, whereas 44.8% reported being active. Among explicitly religious therapists, only 8.79% reported being inactive, compared with a majority (82.54%) who reported being active. With respect to professional background, more marriage and family therapists were active (59.58%, 2 studies, N = 438) than either secular clinical and counseling psychologists (39.75%, 5 studies, N = 1,122) or psychiatrists (32%, 1 study, N = 71). Psychiatrists also endorsed inactive (68%) more frequently than either clinical and counseling psychologists (54.63%) or marriage and family therapists (16.21%). Possible reasons for these findings may have been that 15% of the sample in Winston's (1991) study of marriage and family therapists was composed of pastoral counselors, as well as the fact that psychiatrists were represented in only a small, single sample. Counseling and Values • October 2004 • Volume 49 73 TABLE 1 Differences in Religious Denomination by Professional Background Psychoiogists* Affiliation Protestant Jewish Catholic Atheist Agnostic No religion Other N 593 339 250 31 74 270 297 % 35.85 20.49 15.11 1.87 4.47 16.32 17.96 Marriage and Famiiy Therapists" N 433 110 126 3 6 71 117 % 50.0 12.7 14.6 0.03 0.07 8.2 13.5 Sociai Workers' N % 109 56 32 3 6 27 39 40.1 20.6 11.8 1.1 2.2 9.9 14.3 Note. Percentages do not total 100 due to rounding. °Ten studies. ""Six studies. 'Three studies. Six studies (JV = 1,678) were used to calculate frequency of personal spiritual practices (such as prayer or meditation). We observed large differences between therapists from mixed samples (4 studies, N=916) and explicitly religious (2 studies, N = 762) therapists. Among therapists from mixed samples, 40.6% reported engaging in personal spiritual practices on a weekly or daily basis compared with 78.8% of explicitly religioustiierapists.Among therapists from mixed samples, 45.5% reported engaging in personal spiritual practices infrequently or never compared with orJy 9.1% of explicitly religious therapists. Religion and Spirituality in Counseling To determine how often therapists use religious or spiritual techniques in counseling, we added responses and then averaged them across eight studies (total N = 2,253). Four studies (N = 1,102) of therapists from mixed samples reported on the number of therapists who had previously used a religious or spiritual technique in therapy. The majority of therapists from mixed samples (66.6%) reported using prayer in therapy; 64.1% reported using religious language, metaphors, and concepts in therapy; and a minority (44.4%) reported using scripture in therapy. Four studies (N = 1,037) reported explicitly religious therapists' frequency of using spiritual or religious techniques with religious clients rather than the percentage of those therapists who had used a technique before. Among explicitly religious therapists, forgiveness was used in 42.2% of therapy cases, use of scripture/teaching of biblical concepts in 39.2%, confrontation of sin in 32.6%, and religious imagery in 18.2% of therapy cases. Prayer is a spiritual technique that has been studied in several ways among explicitly religious therapists. Three studies (N = 1,097) reported that 73.6% of explicitly religious therapists prayed for their clients outside of session. Five studies (N= 1,372) reported therapists' frequency of in-session prayer with clients. In those five studies, therapists used in-session prayer in 29.1% of therapy cases. We calculated separate overall averaged rs for therapists from mixed samples and explicitly religious therapists to determine the relationship between thera74 Counseling and Values • October 2004 • Volume 49 pists' personal religious faith and therapists' frequency of use of religious and spiritual techniques in counseling. Authors of the studies that examined therapists' use of religious and spiritual techniques in counseling typically summed a list of individual religious and spiritual techniques and then correlated that scale with a self-report measure of either religious attitudes or religious behaviors. The overall averaged r among therapists from mixed samples (using six studies, N = 873) was .24, p < .0002. The correlation among explicitly religious therapists was higher, overall averaged r = .41, p < .0001. We also calculated separate overall averaged rs for therapists from different professional backgrounds to determine the relationship between therapists' personal religious faith and use of spiritual techniques in counseling. The overall averaged r for marriage and family therapists was .12, p = .005. The correlation among clinical psychologists was higher, overall averaged r = .30, p < .001. We conducted a series of tests of the difference between correlations using Fisher's comparison of r (Cohen & Cohen, 1983). The correlation between personal faith and therapists' use of spiritual techniques among explicitly religious therapists was significantly higher than the same correlation among therapists from mixed samples, p < .0001. Only one study (Forbes, 1995) computed a correlatiori between training in religious and spiritual issues and use of spiritual techniques in therapy (r = .38). This correlation was not statistically significantly different from the correlation between personal faith and use of spiritual techniques among explicitly religious therapists {p = .12). Finally, the correlation between personal religious faith and use of spiritual techruques among marriage and family therapists in mixed samples was compared with the same correlation among clinical psychologists from mixed samples. This correlation was significantly higher for clinical psychologists {p = .004). Finally, we calculated the frequency with which therapists from mixed samples discussed religion and spirituality issues during training using four studies {N = 1,156). The majority of therapists (82%) reported that they never or rarely discussed religious or spiritual issues in training, 13.6 % stated that they sometimes did, and 4.3% reported they discussed them often. Relationship of Personal Religion to Counseling-Related Variables We calculated the relationship between therapists' personal religiousness and opermess to discussing religious issues in counseling using an overall averaged r. The overall averaged r among therapists from mixed samples (3 studies, N = 216) was equal to .37, p < .02, compared with an overall averaged r of .39, p = .007, using all 4 studies, and with .40 in the Jones, Watson, and Wolfram (1992) study of religious therapists. These correlations were not statistically different. Finally, we calculated an overall averaged r between the personal religious faith of the therapist and therapist theoretical orientation among therapists from mixed samples (5 studies, N = 1,474). This correlation was equal to .25, p < .001. (As noted earlier, Sorenson & Hales, 2002, performed a reanalysis of two data sets already included in the meta-analysis. As part of an analysis of covariance including other variables, they found that religious therapists trained at secular programs were significantly more likely, F[l, 396] = 19.82, Counseling and Values • October 2004 "Volume 49 75 p < .001, to use explicit religious and spiritual interventior\s thari were religious therapists trained at explicitly religious training programs.) Discussion One issue we examined in this study was the religious and spiritual cultural heritage of psychotherapists. The results confirm that the religious and spiritual cultural heritage of psychotherapists differs from that of the average American. Indeed, the majority of therapists from mixed samples were affiliated with a religious denomination but were largely inactive within organized religion. This contrasts sharply with the general U.S. population, because approximately 40% of Americans attend church on a weekly basis (Hoge, 1996). In addition, although the majority of psychotherapists claim that spirituality is relevant to them, most engage in personal spiritual practices infrequently, whereas approximately two thirds of Americans consider spiritual practices such as prayer an important part of their daily lives (Hoge, 1996). Thus, if a therapist comes from a religious and spiritual cultural heritage that differs from the client's, he or she should consider the potential impact of their cultural differences on the course of treatment. Therapists' religious cultural heritage may be an especially salient issue for clinical and counseling psychologists, who were more likely to endorse atheism, agnosticism, or no religion than either marriage and family therapists or social workers. Among Americans claiming a religious affiliation, the majority of them (56.6%) are Protestant, followed by Catholic (37.8%), with people from Jewish, Muslim, Buddhist, or other religious backgrounds composing the remaining 5.5% of religious people in America (Keller, 2000). Thus, religious cultural differences with regard to denomination (as well as the beliefs and practices associated with being in a denomination) between client and therapist are likely to exist, particularly for clinical and counseling psychologists. Clinical and counseling psychologists who find it difficult to understand the cultural heritage of clients who practice their spirituality within the context of an organized religion may wish to consult with explicitly religious therapists on such therapy cases. Explicitly religious therapists were more similar to the majority of Americans, as measured by previous polls (e.g., GaUup & Lindsay, 1999), with respect to religious affiliations and personal spiritual practices. Thus, explicitly religious therapists may be a particularly valuable resource for therapy cases with religious clients when the consulting therapist does not have a good understanding of the cultural heritage of the client. It is clear from the results that personal religiousness on the part of both explicitly religious therapists and therapists from mixed samples was associated with being able to integrate religion and spirituality into several aspects of counseling (e.g., the use of spirituality, being willing to discuss religious issues, even choice of theoretical orientation). Given the lack of training regarding the integration of religion and spirituality into counseling, it seems that most integration of religion and spirituality in covmseUng occurs through intrapersonal integration as a result of therapists' own religious or spiritual experience. As such, it seems that 76 Counseling and Values • October 2004 "Volume 49 explicitly religious therapists (who engage more frequently in religious and spiritual practices), rather than nonreligious therapists, would be better equipped in some Instances to provide religious and spiritual interventions for clients. One danger in providing religious and spiritual interventions is that the lack of formal training to supplement therapists' personal religious or spiritual experience creates a risk of therapists imposing their own values or applying religious and spiritual interventions inappropriately. Given that therapists do use their own personal religious and spiritual experience in integrating religion and spirituality into counseling, additional training, when offered, should address how to make appropriate use of one's own religious and spiritual experience when integrating religion and spirituality into counseling, as well as training regarding clients' religious backgrounds and the appropriateness of various religious and spiritual interventions with clients from differing religious backgrounds. Training need not occur solely in the classroom but could also be effectively provided in the context of supervision or consultation on therapy cases involving religious and spiritual issues. There are a few explicitly religious graduate training programs in clinical psychology that have been accredited by the American Psychological Association. It is hoped that graduates of such programs would be equipped to provide appropriate consultation and/or supervision. However, the efficacy of these training programs in helping therapists integrate religion and spirituality into counseling above and beyond drawing on their own personal religious and spiritual experiences has yet to be documented. The results indicate that many therapists are already making use of reUgion and spirituality in therapy. Therapists from mixed samples reported a much larger percentage using religious and spiritual techniques in therapy than the percentage of explicitly religious therapists reported using religious or spiritual techniques in therapy. However, studies of explicitly religious therapists reported how often they used a technique rather than the number of participants in the sainple who had ever used a technique at aU, as was done in studies using mixed samples of therapists. Thus, the different research questions make direct comparisons between therapists difficult. However, one noteworthy trend across both groups of therapists is that scripture and prayer were spiritual techniques that were commonly used by both groups. This finding suggests that prayer and scripture, in particular, are religious and spiritual interventions that therapists should receive training on for counseling. Limitations of the Current Study and Suggestions for Future Research The first limitation of the study is that we analyzed two major variables that had varying degrees of relatedness. Rosenthal (1991) referred to this common limitation of meta-analysis studies as the problem of heterogeneity of method. As did Glass (1978), Rosenthal also referred to this as the "apples and oranges issue" and suggested that they are good things to mix when attempting to generalize to fruit. Counseling and Values • October 2004 •Volume 49 77 One variable was the diverse professional background of the therapists in the meta-analysis. The analyses indicated differences among therapists in the areas of religious denomination and organized religion and in the relationship between personal religious faith and use of spirituality in therapy. It would have been preferable to make explicit comparisons of therapists from different professional backgrounds for every analysis. This limitation was unavoidable, because some major primary studies grouped therapists together and some analyses did not have a sufficient number of representatives from various professions to allow for explicit comparisons. Other variables with varying degrees of relatedness were the religious and spiritual variables used in the analyses. We aggregated each of these individual variables to represent global religious and spiritual constructs, but we might have obtained larger effect sizes had there been a greater degree of specificity between independent and dependent variables in the analyses. A second limitation of the study was the possible sampling bias of therapists from mixed samples. Because most studies designated as being a mixed sample did not explicitly state whether they were sampling therapists from explicitly religious programs along with therapists from secular programs, it is difficult to know just how religious the therapists in some of these samples were. This was less problematic when authors reported the number of explicitly religious therapists in their sample (e.g., Kochems, 1983; Winston, 1991). In such cases, it would have also been desirable to split the samples and analyze them separately, but the primary studies themselves have not done so. A final limitation was the use of small subsamples of the data to perform analyses. This is a common practice when examining different independent and dependent variables in meta-analyses of correlations, because not all studies using correlations will use the same independent or dependent variables in the analysis. However, it would have been desirable to have more studies available on which to do some of the analyses, particularly when attempting to compare religious and secular therapists and therapists from different professional backgrounds. The small number of published studies is informative because it leads to the conclusion that the field could clearly benefit from additional research regarding therapists' integration of religion and spirituality in counseling. Most important, we suggest that studies are needed that relate meaningful variables to therapists' use of religion and spirituality in counseling with a variety of religious clients. Therapists' frequency and competency of use of spiritual techniques need to be assessed, rather than whether a therapist has used a technique, as some studies have done. Such precision will allow further refinement and training for therapists who see religious and spiritual clients. Only two studies (Forbes, 1995; Sorenson & Hales, 2002) have examined the relationship of any training variables to therapists' ability to integrate aspects of clients' religion and spirituality in therapy. Therapist variables associated with the integration of religion and spirituality in counseling have also yet to be identified. As these and other variables are identified, clients who participate in organized religion can look forward to counseling services that actively and effectively use their religious culture. 78 Counseling and Values • October 2004 • Volume 49 References References marked with an asterisk indicate studies included in the meta-analysis. Ball, R., & Goodyear, R. K. (1991). Self-reported professional practices of Christian psychotherapists, journal of Psychology and Christianity, 2, 144-153. *Bergin, A. E., & Jensen, J. P. (1990). Religiosity of psychotherapists: A national survey. Psychotherapy, 27, 3-7. *Bilgrave, D. P., & Deluty, R. H. (1998). Religious beliefs and therapeutic orientations of clinical and counseling psychologists. Journal for the Scientific Study of Religion, 37, 329-349. *Bilgrave, D. P., & Deluty, R. H. (2002). Religious beliefs and political ideologies as predictors of psychotherapeutic orientations of clinical and counseling psychologists. Psychotherapy, 39, 245-260. *Case, P. W., & McMinn, M. R. (2001). Spiritual coping and well-functioning among psychologists, journal of Psychology and Theology, 29, 29-40. Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum. *Diblasio, F. A. (1993). 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Mental health values of professional therapists: A national interdisciplinary survey. Professional Psychology: Research and Practice, 19, 290-297. *Jones, S. L., Watson, E. J., & Wolfram, T. J. (1992). Results of the Rech Conference Survey on religious faith and professional psychology, journal of Psychology and Theology, 20, 147-158. *Kahle, P. A. (1998). The influence of the person of the therapist on the integration of spirituality and psychotherapy. Unpublished doctoral dissertation, Texas Woman's University, Denton. Keller, R. R. (2000). Religious diversity in North America. In P. S. Richards & A. E. Bergin (Eds.), Handbook of psychotherapy and religious diversity (pp. 27-56). Washington, DC: American Psychological Association. *Kively, L. R. (1986). Therapist attitude toward including religious issues in therapy, journal of Psychology and Christianity, 5, 37-45. •Kochems, T. P. (1983). The relationship of background variables to the experiences and values of psychotherapists in managing religious material. Unpublished doctoral dissertation. The George Washington University, Washington, DC. Counseling and Values • October 2004 • Volume 49 79 *Lange, M. A. (1983). Prayer and psychotherapy: Beliefs and practice. Journal of Psychology and Christianity, 2(3), 36-49. »Moon, G. W., Willis, D. E., Bailey, J. W., & Kwansy, J. C. (1993). Self-reported use of Christian spiritual guidance techniques by Christian psychotherapists, pastoral counselors, and spiritual directors, journal of Psychology and Christianity. 12, 24-37. Pargament, K. (1999). The psychology of religion and spirituality? Yes and no. International Journal for the Psychology of Religion, 9. 3-16. *Prest, L. A., Russel, R., & D'Souza, H. (1999). Spirituality and religion in training, practice, and person development. Journal of Family Therapy, 21, 60-77. Richards, P. S., & Bergin, A. E. (1997). A spiritual strategy for counseling and psychotherapy. Washington, DC; American Psychological Association. Richards, P. S., & Bergin, A. E. (2000). Handbook of psychotherapy and religious diversity. Washington, DC: American Psychological Association. •Richards, P. S., & Potts, R. W. (1995). Using spiritual interventions in psychotherapy: Practices, successes, failures, and ethical concerns of Mormon psychotherapists. Professional Psychology: Research and Practice. 26, 163-170. Ridley, C. R., Baker, D. M., & Hill, C. L. (2001). Critical issues concerning cultural competence. The Counseling Psychologist. 29. 822-832. Rosenthal, R. (1979). The file drawer problem and tolerance for null results. Psychological Bulletin. 86. 638-641. Rosenthal, R. (1991). Meta-analytic procedures for social science research (Rev. ed.). Newbury Park, CA: Sage. Shafranske, E. P. (1996). Religious beliefs, affiliations, and practices of clinical psychologists. In E. P. 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Patterns of religious experience among psychotherapists and their relation to theoretical orientation. Unpublished doctoral dissertation. University of Chicago, Chicago. Sorenson, R., & Hales, S. (2002). Comparing evangelical Protestant psychologists trained at secular versus religiously affiliated programs. Psychotherapy. 39. 163-170. Sue, D. W., Bingham, R., Porche-Burke, L., & Vasquez, M. (1999). The diversification of psychology: A multicultural revolution. American Psychologist. 54. 1061-1069. Sue, D. W., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3rd ed.). New York: Wiley. Sue, S. (1999). Science, ethnicity, and bias: Where have we gone wrong? American Psychologist. 54. 1070-1077. Tan, S. Y. (1987). Intrapersonal integration: The servant's spirituality. Journal of Psychology and Christianity. 6. 34-39. Tan, S. Y. (1996). Religion in clinical practice: Explicit and implicit integration. In E. P. Shafranske (Ed.), Religion and the clinical practice of psychology (pp. 365-390). Washington, DC: American Psychological Association. •Winston, A. (1991). Family therapists, religiosity. & spirituality: A survey of personal and professional beliefs and practices. Unpublished doctoral dissertation. The Union Institute, Cincinnati, OH. Worthington, E. L., Jr., Dupont, P. D., Berry, J. T, & Duncan, L. A. (1988). Christian therapists' and clients' perceptions of religious psychotherapy in private and agency settings. Journal of Psychology and Theology. 16. 282-293. 80 Counseling and Values • October 2004 • Volume 49
Journal of Consulting and Clinical Psychology 2006, Vol. 74, No. 5, 920 –929 Copyright 2006 by the American Psychological Association 0022-006X/06/$12.00 DOI: 10.1037/0022-006X.74.5.920 The Effects of Forgiveness Therapy on Depression, Anxiety, and Posttraumatic Stress for Women After Spousal Emotional Abuse Gayle L. Reed and Robert D. Enright This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. University of Wisconsin—Madison Emotionally abused women experience negative psychological outcomes long after the abusive spousal relationship has ended. This study compares forgiveness therapy (FT) with an alternative treatment (AT; anger validation, assertiveness, interpersonal skill building) for emotionally abused women who had been permanently separated for 2 or more years (M ⫽ 5.00 years, SD ⫽ 2.61; n ⫽ 10 per group). Participants, who were matched, yoked, and randomized to treatment group, met individually with the intervener. Mean intervention time was 7.95 months (SD ⫽ 2.61). The relative efficacy of FT and AT was assessed at p ⬍ .05. Participants in FT experienced significantly greater improvement than AT participants in depression, trait anxiety, posttraumatic stress symptoms, self-esteem, forgiveness, environmental mastery, and finding meaning in suffering, with gains maintained at follow-up (M ⫽ 8.35 months, SD ⫽ 1.53). FT has implications for the long-term recovery of postrelationship emotionally abused women. Keywords: spousal emotional abuse, forgiveness therapy, depression, anxiety, posttraumatic stress strongly with negative outcomes of psychological abuse. Moreover, Follingstad et al. (1990) found that 72% of participants reported that emotional abuse had a more negative impact than physical abuse. The negative psychological outcomes of spousal psychological abuse include depression (O’Leary, 1999; PimlottKubiak & Cortina, 2003; Sackett & Saunders, 1999), anxiety (Dutton & Painter, 1993), posttraumatic stress disorder (Astin, Lawrence, & Foy, 1993; Enns et al., 1997; Pimlott-Kubiak & Cortina, 2003; Woods, 2000), low self-esteem (Aguilar & Nightingale, 1994), learned helplessness (Follingstad et al., 1990; Launius & Lindquist, 1988), and an ongoing, debilitating resentment of the abuser (Seagull & Seagull, 1991). A number of researchers (Astin et al., 1993; Dutton & Painter, 1993; Sackett & Saunders, 1999; Woods, 2000) have demonstrated that these negative outcomes last well beyond the end of the abusive relationship. Considering the serious, enduring impact on the psychological health of the emotionally abused partner, the theoretical and empirical literature on efficacious postrelationship, postcrisis treatment for spousal psychological abuse is sparse. There is a lack of empirical evidence for the efficacy of one treatment that is currently recommended for these women: brief therapy with a focus on anger validation (with subsequent mourning of associated losses from the abuse), assertive limit-setting, and interpersonal skill building. Neither Mancoske et al. (1994) nor Rubin (1991) provided clear empirical support for the efficacy of this brief therapy for emotionally abused women. A review of the current literature did not produce empirical evidence for the efficacy of other therapeutic approaches for emotionally abused women. One promising new area of treatment is forgiveness therapy (FT). Research on FT has established a causal relation between forgiving an injustice and both the amelioration of anxiety and depression and an improvement in self-esteem (Al-Mabuk, Enright, & Cardis, 1995; Coyle & Enright, 1997; Freedman & Enright, 1996; Lin, Enright, Mack, Krahn, & Baskin, 2004; Rye et al., 2005). FT directly targets ongoing resentment, which can lead to Spousal emotional abuse is a significant problem, with approximately 35% of women reporting such abuse from a spouse or romantic partner (O’Leary, 1999); in addition, women often demonstrate negative psychological outcomes long after this abuse. Despite the frequent calls for efficacious therapies for these women, no empirically validated treatments have been clearly established (Enns, Campbell, & Courtois, 1997; Mancoske, Standifer, & Cauley, 1994; Miller, Veltkamp, & Kraus, 1997; Paul, 2004), and the literature still demonstrates a focus on the definition of and screening for spousal emotional abuse rather than empirical testing of therapeutic strategies (Follingstad, 2000; Gondolf, Heckert, & Kimmel, 2002; Tjaden, 2004). Spousal psychological abuse represents a painful betrayal of trust, leading to serious negative psychological outcomes for the abused partner (Dutton & Painter, 1993; Sackett & Saunders, 1999). According to Sackett and Saunders (1999), spousal psychological abuse functions with the purpose of causing emotional pain to the spouse and establishing an unequal distribution of power in the relationship. Sackett and Saunders (1999) have demonstrated negative outcomes of emotional abuse that are distinct from the impact of physical battery. Follingstad, Rutledge, Berg, Hause, and Polek (1990) and Sackett and Saunders (1999) have identified at least seven categories of spousal psychological abuse: criticizing, ridiculing, jealous control, purposeful ignoring, threats of abandonment, threats of harm, and damage to personal property, with ridicule associated most Gayle L. Reed and Robert D. Enright, Department of Educational Psychology, University of Wisconsin—Madison. Correspondence concerning this article should be addressed to Gayle L. Reed, who is now at Educational Outreach, the University of Wisconsin Extension—Madison, 1050 University Avenue, Madison, WI 53706 – 1386, and LLC Forgiveness Recovery Programs, 1715 Carns Drive, Madison, WI 53719; www.forgivenessrecovery.com. E-mail: gaylelreed@ charter.net 920 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. FORGIVENESS THERAPY AFTER SPOUSAL EMOTIONAL ABUSE depression, anxiety, and other negative psychological outcomes (Enright & Fitzgibbons, 2000), and it has been shown in one study to ameliorate the negative emotional effects of incest (Freedman & Enright, 1996). FT posits that although anger is a justifiable, initial problem-solving response to severe wrongdoing, as in the case of emotional abuse, lingering resentment can compromise a person’s emotional health and decision making. In helping clients move toward forgiveness, clinicians need to differentiate forgiving (see Enright & Fitzgibbons, 2000, for a discussion of defining forgiveness) from condoning, excusing, pardoning, forgetting, and reconciling. Forgiveness is a decision to give up resentment and to respond with goodwill (benevolence based on a desire for the ultimate welfare of the other person; North, 1987) toward the wrongdoer. Current research (see Rye et al., 2005) operationalizes forgiveness similarly as refraining from negative responses to the wrongdoer and fostering positive responses to him or her while also clearly distinguishing forgiveness from pardon and reconciliation. For women who have experienced spousal emotional abuse, FT promotes the reclamation of valued personal qualities, such as compassion, without neglecting the injustice of the abuse or encouraging interactions with the former partner, which may result in further abuse. FT assists the emotionally abused woman to examine the injustice of the abuse, consider forgiveness as an option, make the decision to forgive, do the hard work of forgiving (grieve the pain from the injustice, reframe the wrongdoer, relinquish resentment, and develop goodwill), find meaning in the unjust suffering, and discover psychological release and new purpose. These aspects of FT fall within the four phases of the Enright forgiveness process (Enright & Fitzgibbons, 2000)— uncovering, decision, work, and discovery— currently used in treatment and research. Robust results have been found in randomized experiments with FT. Lin et al. (2004), in their FT experiment in a drug rehabilitation unit, following Hedges and Olkin (1985), reported an effect size of 1.58 across all dependent measures after adjusting for intercorrelations among variables. Similar effect sizes (1.44 and 1.42, respectively) were reported in Freedman and Enright (1996) and in Coyle and Enright (1997). In all three studies, the sample sizes were relatively small, ranging from 10 –14 participants per study. Other randomized experiments with FT have been reported (e.g., Rye et al., 2005). See Baskin and Enright (2004) for a meta-analysis of FT. Women who have experienced spousal emotional abuse present at least two unique challenges for recovery. First, learned helplessness (Sackett & Saunders, 1999) develops as a pattern of self-blame in response to the criticism and ridicule by the abusive spouse and often remains well beyond the end of the abusive relationship (Dutton & Painter, 1993). “If only I had done this to please him” quickly deteriorates in the ongoing, unpredictable stress of the abusive relationship to “I am trying to prevent this, but nothing is working” and remains in a residual “Maybe I am worthless and none of my decisions are valid.” Therefore, any treatment for these women should demonstrate outcomes in practical decision making and moral decision making. This study tests these outcomes (environmental mastery and finding meaning in suffering) and suggests that FT ameliorates this problem more successfully than an alternative treatment (AT). Second, Seagull and Seagull (1991) described an obstacle to recovery for emotionally abused women labeled accusatory suf- 921 fering, which entails maintaining resentment and victim status. The assumption in accusatory suffering is that healing the wounds of the abuse will somehow let the perpetrator off the hook. At a deeper level, accusatory suffering may be seen as a defense against the fear that the woman is somehow responsible for her own victimization, a fear that is often inculcated by the victimizer (Sackett & Saunders, 1999). Seagull and Seagull (1991) argued that although accusatory suffering (resentment and victim status) may function as a temporary strategy to help the woman adapt to the extreme experience of spousal emotional abuse, it seriously hinders substantial postrelationship, postcrisis recovery. Therefore, any treatment for these women should demonstrate a change in victim status. This study tests this outcome (story measure) and suggests that FT is more successful than AT. One current therapeutic approach recommended and tested in the literature (Enns et al., 1997; Mancoske et al., 1994; Miller et al., 1997) for postrelationship, postcrisis emotionally abused women includes anger validation about the wrongdoing of abuse, assertiveness, and interpersonal skill building (AT). During an early period of separation from the abusive relationship (perhaps 1 to 2 years), anger validation likely helps emotionally abused women confirm the injustice of the abusive spouse’s behavior and thus provides support for the woman’s choice to escape the abusive relationship. Moreover, as validation of anger after such a deep, personal injustice can be an important step toward helping women uncover and mourn the pain (Mancoske et al., 1994) from this unjust injury, the uncovering phase of FT addresses this as well. However, we suggest that anger validation (even with the subsequent mourning) over time without the inclusion of work toward forgiveness may inadvertently promote the accusatory suffering described by Seagull and Seagull (1991) and thus contribute to the debilitating resentment that maintains and likely even increases the negative psychological outcomes of the abuse. FT does have an overall, targeted focus on decreasing this resentment toward the abusing former partner, which Seagull and Seagull (1991) suggested hinders optimal recovery. Moreover, the mourning work done in FT is for the specific purpose of aiding the recovering women to successfully relinquish resentment and revenge toward the former abuser and to develop goodwill. It is important, again, to reiterate that FT does not require nor encourage reconciliation (a critical concern that likely prevents recommendation of forgiveness in recovery strategies; Herman, 1997). FT, therefore, makes a safe and distinct contribution to postrelationship, postcrisis therapy for emotionally abused women by promoting the practice of a specific moral quality (choosing forgiveness, relinquishing resentment, developing goodwill) as a way of integrating the past traumatic experience of emotional abuse with current positive, empowering moral choices (Astin et al., 1993; Frankl, 1969; Reed, 1998). FT thus likely effectively ameliorates the negative psychological outcomes of emotional abuse because engagement in the forgiveness process does decrease resentment toward the former abuser (along with concomitant depression, anxiety, and low self-esteem, which are associated with emotional abuse; Sackett & Saunders, 1999) and validates the positive, moral decision to replace resentment with goodwill (thus addressing the learned helplessness associated with emotional abuse; Follingstad et al., 1990). We therefore hypothesized that individuals who participated in FT would demonstrate less depression, anxiety, and posttraumatic REED AND ENRIGHT 922 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. stress symptoms and more self-esteem, environmental mastery, and finding meaning in suffering than those who engaged in the more standard therapeutic procedure (AT), which does not directly target the amelioration of this resentment. To have as fair a comparison as possible between FT and AT, we addressed methodological problems in past AT studies for both treatment conditions by having a single presenting problem (psychological abuse), a single living arrangement (permanent separation from the abusive partner), postcrisis treatment (all women had been separated at least 2 years from the former abuser), and criterion ending (rather than brief therapy at 4 – 6 weeks). Method Participant Sample The participants were 20 psychologically abused women in a Midwest city who had been divorced or permanently separated for at least 2 years from their spouse or romantic partner. They ranged in age from 32 to 54 years (M ⫽ 44.95, SD ⫽ 7.01). Regarding ethnicity, 18 (90%) self-reported as European Americans, 1 (5%) was Hispanic American, and 1 (5%) was Native American. Educational levels included 4 (20%) with a high school diploma or general equivalency diploma, 6 (30%) with some college education or an associate’s degree, 4 (20%) who were college graduates, 3 (15%) who had some postgraduate education, and 3 (15%) who had postgraduate degrees. Three (15%) of the participants were unemployed, 5 (25%) had part-time employment, and 12 (60%) had full-time employment. One participant (5%) held a job in service, 7 (35%) worked in clerical jobs, 2 (10%) worked in business or sales, and 7 (35%) had professional careers. Six (30%) participants had no children living with them, whereas 14 (70%) had one to four resident children. Five (25%) of the participants had remarried, and 15 (75%) had not remarried or started a new relationship with a live-in partner. These participants were all self-selecting volunteers; 2 (10%) responded to recruitment flyers (posted in domestic abuse resource centers), and 18 (90%) responded to newspaper advertisements (for women between the ages of 25 and 55 who had experienced spousal psychological abuse but not physical abuse and who had been permanently separated for at least 2 years). The participants reported the following psychological abuse: Eighteen participants (90%) reported criticizing, 20 participants (100%) reported ridiculing, 15 participants (75%) reported jealous control, 20 participants (100%) reported purposeful ignoring, 5 participants (25%) reported threats of abandonment, 6 participants (30%) reported threats of personal harm, and 4 participants (20%) reported threats of harm to property or pets. Six (30%) participants also disclosed experiences of sexual abuse (5 described ridicule followed by demands for sexual favors, and 1 described threats of physical harm combined with demands for sexual favors). We set the criterion that women be 2 years postseparation to prevent promoting “false forgiveness” (e.g., “He won’t do it again”), which often occurs in the abuse cycle. Also, working on forgiveness too early in a separation might mistakenly encourage a woman to feel empathy and compassion for her abusive former partner in a way that would foster old patterns of reuniting, including inappropriate dependence on the part of the former partner and subsequent harm from further abuse. Actual time since separation ranged from 2 to 10 years (M ⫽ 5.00 years, SD ⫽ 2.61). Design A matched, yoked, and randomized experimental and control group design was used, with 10 pairs formed after screening interviews and pretest measures. Participants in each pair were matched as closely as possible on age, duration of the abusive relationship, and time since permanent separation or divorce. Correlations for matching variables within pairs were duration of abuse (r ⫽ .91, p ⬍ .0001), time since permanent separation (r ⫽ .72, p ⬍ .02), and age (r ⫽ .76, p ⬍ .01). Duration of the abusive relationship ranged from 1 to 31 years (M ⫽ 16.65 years, SD ⫽ 9.01). Contact with the former partner (regarding children) ranged from no contact to more than once per week, with a moderate correlation between matched pairs of .356. Following matching, 1 participant from each pair was randomly selected for FT, and the other was assigned to AT. Testing Procedure Screening. Screening measures included the Psychological Abuse Survey (Follingstad, 2000; Follingstad et al., 1990; Sackett & Saunders, 1999), a posttraumatic stress symptom checklist (PTSS; from the Diagnostic and Statistical Manual of Mental Disorders; 4th ed.; DSM–IV; American Psychiatric Association, 1994), and a psychological screening checklist. A participant was included in the study if she demonstrated psychological abuse in at least three categories with a score of at least four and demonstrated at least three symptoms on the PTSS checklist. A score of 41 or higher on the Psychological Abuse Survey was considered indicative of a present and serious pattern of emotional abuse. All participants reported scores of 41 or above. A participant was excluded from the study if she demonstrated current involvement in an abusive relationship, described a history of childhood physical abuse, or demonstrated evidence of significant ongoing psychiatric illness, such as suicidal ideation or psychosis. We excluded persons with a history of childhood abuse to fairly focus treatment (AT or FT) on only one major wrongdoing (i.e., the spousal emotional abuse). Exclusion for suicidal ideation and psychosis was done as such women would likely be better served with crisis care or counseling with the availability of psychiatric medical treatment. Appropriate referrals were offered. Dependent variables. Before administration of any pretest measure, all participants read and signed informed consent forms approved by the research program’s human subjects board and consistent with American Psychological Association standards. Then a brief description of the study was offered. The participants were told that the purpose of the study was to promote coping strategies for women who had experienced emotional abuse and that it included weekly 1-hr individualized therapy sessions. Each participant was then invited to fill out the nine pretest measures. Instruments All screening and dependent measures were presented to each participant in random order at pretest, posttest, and follow-up. All measures were given after signed informed consent. Psychological Abuse Survey. This questionnaire (an adaptation from Follingstad, 2000; Follingstad et al., 1990; Sackett and Saunders, 1999) asks, “How often did your partner ____?” with seven categories of abuse: (a) criticizing behavior (e.g., “You don’t do anything well enough”), (b) ridiculing of traits (e.g., “You are worthless”), (c) jealous control (e.g., “You can’t maintain any outside social support”), (d) purposeful ignoring (e.g., “You don’t exist”), (e) threats of abandonment, (f) threats of harm, and (g) threats to damage personal property. Frequency of each abuse category was scored on a Likert scale ranging from daily (8) to never (1). Total scores for participants ranged from 41 to 106 (M ⫽ 70.63, SD ⫽ 17.58). For the purposes of this study, a total score of 41 or above is considered a high level of abuse (Dutton & Painter, 1993; Sackett & Saunders, 1999). The Enright Forgiveness Inventory (EFI; Subkoviak et al., 1995). The EFI is a 60-item self-report measure of the degree of interpersonal forgiveness, equally divided in six components: Positive and Negative Affect (e.g., “I feel ____ toward him/her”), Positive and Negative Behavior (e.g., “Regarding the person who hurt me, I do or would ____”), and Positive and Negative Cognition (e.g., “I think she or he is ____”). Range is from 60 to This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. FORGIVENESS THERAPY AFTER SPOUSAL EMOTIONAL ABUSE 360, with high scores representing high levels of forgiveness. Subkoviak et al. (1995) reported an alpha coefficient of .98. Cronbach’s alpha for this study at pretest (N ⫽ 20) was .94. Coopersmith Self-Esteem Inventory (CSEI; Coopersmith, 1989). The adult form of the CSEI consists of 25 true–false statements (e.g., “This is like me or not like me”) evaluating attitudes toward the self in the following domains: general self, social self, self and peers, and self and parents. Range of scores is 0 (low score) to 100 (high score). Reliability and validity for this scale have been well documented (Coopersmith, 1989). The Cronbach’s alpha for pretest scores (N ⫽ 20) for this study was .84. State–Trait Anxiety Inventory (STAI; Spielberger, 1983). The STAI, a common instrument in clinical work, is composed of two self-report questionnaires (20 items each) that assess state (e.g., “Right now at this moment I feel ____”) and trait (e.g., “Generally I feel ____”) anxiety. The range of scores for each questionnaire is 20 (low anxiety) to 80 (high anxiety). Cronbach’s alphas for this study at pretest (N ⫽ 20) were .95 (state) and .92 (trait). Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996). The BDI-II is a self-report measure of 21 items in a multiple choice format (four choices, ranging from “I do feel ____” to “I do not feel ____”). Scores can range from 0 (no depression) to 63 (high depression). This instrument has been used extensively in clinical research and demonstrates construct validity and reliability. Freedman and Enright (1996) reported a reliability of .84 for incest survivors. The Cronbach’s alpha for pretest scores in this study (N ⫽ 20) was .90. Environmental Mastery Scale (Ryff & Singer, 1996). The Environmental Mastery Scale is one of six Scales of Psychological Well-Being (Ryff & Singer, 1996), which represent distinct concepts that are evaluated separately. It has 14 items rated from 1 (strongly disagree) to 6 (strongly agree)—for example, “I am the kind of person that ____” or “I am not the kind of person that ____.” The items contain questions about personal mastery in everyday decisions (high score indicates environmental mastery). The scale yields adequate reliability (Ryff & Singer, 1996). The Cronbach’s alpha at pretest for this study (N ⫽ 20) was .80. Reed (1998) Finding Meaning in Suffering. This instrument assesses the participant’s engagement in Viktor Frankl’s (1969) concept of finding meaning in suffering. Thus, items are questions about moral decisions in response to unjust suffering and questions about support (identifying with persons and values) for these moral decisions (Astin et al., 1993; Frankl, 1969; Reed, 1998) Each of 22 items is rated from 1 (not true) to 5 (very true)—for example, “I find this experience ____” or “I see this experience as ____”—producing scores of 22 to 110. Internal consistency is high (Reed, 1998). The Cronbach’s alpha at pretest for this study (N ⫽ 20) was .88. PTSS checklist. This checklist was derived directly from the DSM–IV criteria checklist. The lead question reads, “Are the events (of psychological abuse) re-experienced in one or more of these ways?” The categories include (a) recurring and intrusive memories, (b) distressing dreams, (c) intense distress on reminders of the abusive events, (d) the avoidance or denial of emotional responses to the abusive events, (e) anxious feelings and thoughts, (f) trouble sleeping, and (g) difficulty concentrating. Participants were to answer yes (1 point) or no (0 points) to each category if the symptom had occurred in the last month. This DSM–IV symptom checklist was used not only for screening and measurement purposes but also to clearly validate to participants in both treatment groups that the treatment focus was on the effects of a past traumatic relationship (rather than on what is wrong with women who enter and remain in abusive relationships). This was done to promote a sense of interpersonal safety (Herman, 1997) and rapport with the intervener. Story measure. This measure is a one-page narrative from the participant’s current perspective about the role that spousal psychological abuse has in her life story. Two raters who were blind as to the identity of the participant rated a score for both the old story (victim status) and the new 923 story (survivor status). One point was given for the following categories if they were present: for the old story, focuses on the power of abuser; describes self as victim of abuse; describes abuse events but no decisions; abuse memories are resentful, repetitive, or intrusive; for the new story, focuses on her power to choose, puts abuse in context of other life events, describes abuse review as impetus for new decisions, contrasts memories of abuse to ongoing personal growth. The interrater agreement on the story scores was 76.25%. Intervention Procedure Following pretesting, the experimental participants engaged in 1-hr, weekly FT sessions based on the Enright forgiveness process model (Enright & Fitzgibbons, 2000). AT participants engaged in 1-hr, weekly participant-initiated discussion of current life concerns (considering the impact of the past abuse) and in intervener-facilitated therapeutic discussions about the validity of anger regarding the injustice of the past abuse (and subsequent mourning of the associated pain), present strategies for healthy assertive choices, and interpersonal relationship skills. The intervener facilitated therapeutic intervener–participant interactions, with restating, paraphrasing, summarizing, and open-ended questions (Pulvino & Lee, 1995), for both treatment conditions (FT and AT). Participants in FT determined the time spent on each forgiveness topic, and participants in AT determined the time spent on each participant-initiated concern. Each matched pair was equal in time of treatment. The mean treatment time (one session per week) for the pairs was 7.95 months (SD ⫽ 2.61), with a minimum of 5 months and a maximum of 12 months. The FT treatment had a manualized protocol to promote uniformity in the treatment across participants. This protocol was a guide for the treatment sessions, which proceeded in a similar therapeutic manner as for the AT group (Pulvino & Lee, 1995). The protocol included (a) defining forgiveness (what it is and is not) and the distinction between forgiveness and reconciliation, (b) examining psychological defenses, (c) understanding anger, (d) examining abuser-inculcated shame and self-blame, (e) understanding cognitive rehearsal, (f) making a commitment to the work of forgiving, (g) grieving the pain and losses from the abuse, (h) reframing the former abusive partner (his personal history, fallibility, and culpability; the unfair, unequal power established by his abusive behavior; his inherent worth), (i) exploring empathy and compassion, (j) practicing goodwill (i.e., merciful restraint, or foregoing resentment or revenge; generosity; and moral love), (j) finding meaning in unjust suffering, and (k) considering a new purpose in life of helping others. FT was criterion-based, finishing when each participant reported that she had completed the work of forgiving her former partner. The AT was designed and delivered (with a written protocol) to match as closely as possible the basic elements of the therapy approach (anger validation with mourning, assertiveness strategies, and interpersonal skills) described and tested in the literature (Enns et al., 1997; Mancoske et al., 1994; Miller et al., 1997). Therefore, for comparison purposes, this was considered a treatment protocol intended to reflect real-world practice (Wampold & Serlin, 2000) and provided a therapeutic intervention (AT) for the control participants during the paired experimental participants’ FT. The current life concerns introduced by the control participants (which included the past abuse, child rearing, child placement interactions with the former partner, family, and work relationships) became part of a facilitated discussion within the parameters of the AT therapeutic approach. Research Design We compared FT and AT gain scores from pretest to posttest on all dependent variables with matched-pair t tests. We analyzed FT participants’ maintenance of gains by comparing each participant’s pretest to posttest gain scores with her gains scores from pretest to follow-up. REED AND ENRIGHT 924 Qualifications of the Intervener The intervener had extensive education in the forgiveness process model, experience in delivering FT workshops, training and practice as a psychiatric nurse, and previous experience working with women who had been psychologically abused. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Analysis We determined sample size by first examining the effect size for forgiveness gains in similar studies. Freedman and Enright (1996) demonstrated a 2.09 Cohen’s effect size for gain in forgiveness scores, which was associated with significant positive psychological outcomes in depression and anxiety (N ⫽ 12). Coyle and Enright (1997) reported a Cohen’s effect size of 1.20 for gains in forgiveness scores, which were associated with significant improvements in anger, anxiety, and grief (N ⫽ 10). Thus, a minimum projected effect size of 1.20 for forgiveness scores in combination with a sample size of 24 (12 pairs) would yield a power of .80, an acceptable possibility of Type II error. The recruited sample was 20 (10 pairs). The experimental group (FT) demonstrated a within-group Cohen’s effect size of 1.79 for gains in forgiveness scores. Each participant, treated individually in therapy, was independent of all others, which allowed for the individual rather than the group to be the level of analysis. On the basis of earlier studies (Coyle & Enright, 1997; Freedman & Enright, 1996; Lin et al., 2004), we used one-tailed matchedpairs t tests at an alpha level of .05 to compare the amount of change between the two treatment groups. Results Mean scores and standard deviations are reported in Table 1 for all measures at pretest, posttest, and follow-up for the FT group and at pretest and posttest for the AT group. The gains from pretest to posttest between FT and AT are presented in Table 2. The maintenance of gains at follow-up for FT are presented in Table 3. We performed one-tailed matched-pairs t tests to compare the amount of change between the two groups from pretest to posttest. Statistical significance was demonstrated on all the dependent variables, with the exception of state anxiety (see Table 2). FT participants demonstrated a statistically significantly greater increase in forgiving the former abusive partner, t(9) ⫽ 5.80, p ⬍ .001; in self-esteem, t(9) ⫽ 2.12, p ⬍ .05; in environmental mastery (everyday decisions), t(9) ⫽ 1.84, p ⬍ .05; in finding meaning in suffering (moral decisions), t(9) ⫽ 2.34, p ⬍ .05; and in new stories (survivor status), t(9) ⫽ 3.58, p ⬍ .01. The experimental group demonstrated a statistically significantly greater reduction in trait anxiety, t(9) ⫽ ⫺2.43, p ⬍ .05; in depression, t(9) ⫽ ⫺1.88, p ⬍ .05; in posttraumatic stress symptoms, t(9) ⫽ ⫺2.54, p ⬍ .05; and in old stories (victim status), t(9) ⫽ ⫺5.01, p ⬍ .001. There was within-group statistical significance (FT from pretest to posttest) for improvements in state anxiety scores, t(9) ⫽ ⫺2.22, p ⬍ .05. We note that if pretest means are compared in a randomized design, 5% of the time, the means will differ. Whether they differ significantly, or whether the difference in standard deviations is small or large, does not alter the fact that the participants were randomized to treatment group. The significance test on gain scores is based on a distribution that, as with all statistical tests, will yield significant differences 5% of the time. This distribution, under the null hypothesis, takes into account those times that yield pretest differences and those times that do not. Therefore, if one Table 1 Mean and Standard Deviations for Dependent Variables Pretest Variable M Posttest SD M Follow-up SD M SD 55.54 8.54 8.99 8.95 5.77 10.51 9.52 2.29 1.47 1.71 256.50 90.00 25.10 26.40 2.60 69.60 99.00 2.40 0.60 3.70 60.24 4.32 4.84 5.12 4.52 8.82 11.62 1.10 0.84 0.95 Experimental forgiveness therapy group Forgiveness Self-esteem State anxiety Trait anxiety Depression Environmental mastery Finding meaning PTSS Old story (victim) New story (survivor) 155.40 66.00 42.50 45.10 16.20 56.65 85.70 9.40 3.90 0.30 38.24 17.20 13.61 9.65 8.81 8.19 12.05 3.41 0.32 0.48 252.50 82.60 31.90 32.60 5.40 65.65 100.00 2.20 1.20 2.60 Alternative therapy group Forgiveness Self-esteem State anxiety Trait anxiety Depression Environmental mastery Finding meaning PTSS Old story (victim) New story (survivor) 171.00 43.20 48.70 53.40 23.40 47.40 74.80 11.00 3.70 0.30 48.59 21.23 14.63 11.54 10.62 11.99 16.11 2.87 0.67 0.67 172.90 49.60 44.80 52.40 21.70 48.80 76.50 8.50 3.70 0.40 Note. n ⫽ 10 per group. PTSS ⫽ posttraumatic stress symptoms. 42.47 24.31 16.09 12.63 13.68 8.68 12.61 3.06 0.48 0.69 FORGIVENESS THERAPY AFTER SPOUSAL EMOTIONAL ABUSE 925 Table 2 Comparison of Mean Change From Pretest to Posttest This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Forgiveness therapy group gain score (n ⫽ 10) Alternative therapy group gain score (n ⫽ 10) Variables M SD M SD t(9) Forgiveness Self-esteem State anxiety Trait anxiety Depression Environmental mastery Finding meaning PTSS Old story (victim) New story (survivor) 97.10 16.60 ⫺10.20 ⫺12.00 ⫺10.80 9.00 14.30 ⫺7.20 ⫺2.70 2.50 54.05 20.39 15.06 14.65 11.67 12.29 8.46 3.82 1.56 1.65 1.90 5.80 ⫺3.90 ⫺1.00 ⫺1.70 1.40 1.70 ⫺2.40 0.00 0.50 28.87 13.35 9.87 5.75 9.36 8.67 13.02 4.62 0.67 1.35 5.80*** 2.12* ⫺1.08 ⫺2.43* ⫺1.88* 1.84* 2.34* ⫺2.54* ⫺5.01*** 3.58** Note. PTSS ⫽ posttraumatic stress symptoms. * p ⬍ .05. ** p ⬍ .01. *** p ⬍ .001, one-tailed. had been permanently separated from her abusive spouse for 10 years. Marianne described the past psychological abuse as criticizing, ridiculing, jealous control (clothing, makeup, telephone use), purposeful ignoring, and threats of harm. In addition, at pretest, Marianne demonstrated negative outcomes of spousal emotional abuse, including anxiety, depression, low self-esteem, difficulty in decision making, and posttraumatic stress symptoms. Marianne actively engaged in all aspects of FT. She examined her past shame and self-blame and grieved the pain from the undeserved abuse. She moved from hate for her former partner to a genuine desire for his welfare (without excusing him or reuniting with him) as she enthusiastically relinquished resentment and thus cognitive rehearsal of the past abuse. She also found a remarkable increase in energy for her current life (new marriage, career, child rearing) and a surprising new sense of joy. At posttest, Marianne demonstrated considerable improvements: from above the published norms for trait anxiety scores (60) to below the norm (25), from moderate depression (25) to no depression (0), from below normative self-esteem to high self- has a difference in pretest scores between treatment groups (0.75 standard deviations for depression in this study, e.g.), one cannot conclude that in the population the difference is other than zero (Marascuilo & Serlin, 1988). A comparison of two sets of gains scores, pretest to posttest versus pretest to follow-up, in the FT group for the EFI, the BDI-II, the Ryff Environmental Mastery Scale, the Reed Finding Meaning in Suffering Measure, the PTSS checklist, and the story measure demonstrated no significant differences. This suggests maintenance of gains for the FT group to follow-up. The comparison of gain scores of the experimental group for the CSEI and the STAI State and Trait scales from pretest to posttest versus pretest to follow-up demonstrated significant further changes. This surpassed the expected outcomes, and these data suggest a continuation of gain for the FT group from postFT to follow-up. Case Study Marianne (name changed to protect confidentiality), age 38, a participant in the FT treatment group, was married for 6 years and Table 3 Comparison of Mean Changes: Treatment and Maintenance at Follow-Up Forgiveness therapy group Pretreatment to posttreatment gain score (n ⫽ 10) Pretreatment to follow-up gain score (n ⫽ 10) Variable M SD M SD t(9) Forgiveness Self-esteem State anxiety Trait anxiety Depression Environmental mastery Finding meaning PTSS Old story (victim) New story (survivor) 97.10 16.60 ⫺10.20 ⫺12.00 ⫺10.80 9.00 14.30 ⫺7.20 ⫺2.70 2.50 54.04 20.39 15.06 14.65 11.67 12.29 8.46 3.82 1.56 1.65 101.10 24.00 ⫺17.40 ⫺19.00 ⫺13.60 12.30 13.30 ⫺4.40 ⫺3.30 3.40 65.43 17.68 12.20 10.95 6.64 12.21 6.49 6.68 0.95 0.96 0.39 2.43* ⫺2.59* ⫺3.13* ⫺1.25 1.05 0.59 1.76 ⫺2.25 1.86 Note. PTSS ⫽ posttraumatic stress symptoms. * p ⬍ .05. REED AND ENRIGHT 926 esteem, from below normative scores on environmental mastery to above normal scores, from a low score on finding meaning in suffering to a score 1.85 standard deviations above the pretest mean, from frequent cognitive rehearsal of the past abuse (three times per week) to no cognitive rehearsal, and from nine posttraumatic stress symptoms to one. Marianne maintained these improvements at follow-up. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Discussion Studies such as Astin et al. (1993), Dutton and Painter (1993), Paul (2004), Sackett and Saunders (1999), and others have demonstrated the significant negative impact of spousal psychological abuse, including low self-esteem, anxiety, depression, learned helplessness, and posttraumatic stress symptoms. Seagull and Seagull (1991) suggested that in postrelationship, postcrisis emotionally abused women, these outcomes may be exacerbated by accusatory suffering, which includes a debilitating resentment and victim status. This is the first study to demonstrate that FT is efficacious as a therapeutic strategy for the amelioration of these long-term negative psychological outcomes of spousal psychological abuse. Moreover, this study demonstrates that FT promotes improvements in psychological health to a significantly greater extent than an AT recommended in the literature for emotionally abused women—that is, a focus on anger validation, assertive limit setting, and interpersonal skills (Enns et al., 1997; Miller et al., 1997; Paul, 2004). This study attempted to control a number of potential confounds, such as comparable treatment lengths for the two conditions, presentation of psychological abuse only (without reported physical abuse), and complete separation from the former spouse for at least 2 years at the time of the therapy. At pretest, all participants were low in forgiveness toward the abusive former spouse (see Table 1) and well below the published mean for nonclinical samples (Subkoviak et al., 1995). The mean for the FT group at posttest was comparable to the norms for nonabused adult populations reported in Subkoviak et al. (1995), whereas the control group was considerably below that. The gains of the FT group from pretest to posttest and from pretest to follow-up are similar to those reported in Coyle and Enright (1997). The Cohen’s effect size of 1.79 for this FT within-group change is a large effect size (Kirk, 1995) and represents a shift from below normative levels of forgiveness to normative levels that are frequently associated with gains in psychological health (Coyle & Enright, 1997; Lin et al., 2004). Both FT and AT participants presented at pretest with BDI-II mean scores in the mild to moderate range of depression (Beck et al., 1996). The FT group demonstrated clinically significant improvement at posttest by shifting into the minimal to nondepressed range (Beck et al., 1996). The within-group Cohen’s effect size of 0.93 is a large effect by Kirk’s (1995) criteria. In contrast, the AT group remained in the moderate range of depression. The FT group change to minimally nondepressed was sustained at follow-up. State and trait anxiety mean scores for both FT and AT participants at pretest were well above normative mean scores reported by Spielberger (1983) and approaching psychiatric levels. The reduction in trait anxiety for the FT group was significant (with a Cohen’s effect size of 0.88) and significantly greater than that for the AT group. This within-group change for the FT group represents a shift below published norms and a large effect size (Kirk, 1995). The FT group shifted from substantially above the published norms for state anxiety to below, whereas the AT group remained above the published average. The FT group maintained improvements in both state and trait anxiety and demonstrated further improvements at follow-up. The FT and AT participants both presented with high scores on the PTSS checklist at pretest. The FT group demonstrated significantly better improvement at posttest than the control group (AT). FT participants went from a mean of nine symptoms to a mean of two, whereas the mean for AT participants remained at approximately eight. In self-esteem, both FT and AT groups presented at pretest with mean CSEI scores lower than those reported by Coopersmith (1989) for adult women. The gains of the experimental group were not only maintained at follow-up; further improvement was demonstrated. A Cohen’s effect size of 0.81 (for within-group FT change, compared with a 0.45 effect size for the control group) represents a shift from below normative levels of self-esteem to above normative levels. This is a similar improvement to that in Freedman and Enright (1996) and Lin et al. (2004). FT and AT participants at pretest presented below normative (Ryff, 2002) mean scores for environmental mastery (everyday decision making). Those in the FT group moved to normative levels of environmental mastery (Ryff, 2002) and demonstrated statistically significant improvement at posttest, with a withingroup Cohen’s effect size of 0.73, and statistically greater improvement than AT. This improvement in decision making is uniquely important for women who have experienced spousal emotional abuse (Sackett & Saunders, 1999), as a partial amelioration of learned helplessness. Both FT and AT participants at pretest presented low scores for finding meaning in suffering that were similar to scores reported for untreated adults (Reed, 1998). FT participants improved statistically significantly (with a within-group Cohen’s effect size of 1.69) and in comparison with AT participants. The gains were maintained at follow-up testing. Finding meaning in unjust suffering (Frankl, 1969) entails moral decision making, which counteracts learned helplessness (Sackett & Saunders, 1999) and promotes recovery from trauma (Astin et al., 1993). FT and AT participants presented at pretest with high scores for their old story (resentful retelling and victim status) and low scores for their new story (survivor status). FT participants improved statistically significantly compared with AT participants. This demonstrates an important shift from accusatory suffering, as described by Seagull and Seagull (1991). The findings demonstrate the benefit of FT for women who have experienced spousal psychological abuse (and who have been permanently separated from the abusive partner for at least 2 years). The gains made by the FT group compared with the AT group suggest that FT was more efficacious in reducing anxiety, depression, and posttraumatic stress symptoms for these women. The effect sizes ( p ⬍ .05) in the between-treatments analysis were robust: 1.83 for forgiveness, 0.68 for self-esteem, 0.77 for trait anxiety, 0.58 for environmental mastery, 0.59 for depression, and 0.74 for finding meaning in suffering. In their meta-analysis with comparisons between psychotherapeutic treatments, Wampold et al. (1997) found effect sizes for dependent outcomes of 0.20 but, after adjusting for such problems as discontinuity between treatments in therapeutic intention, time span of treatment, and partic- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. FORGIVENESS THERAPY AFTER SPOUSAL EMOTIONAL ABUSE ipant’s presenting problem, concluded that true effect sizes for treatment comparisons across studies washed out to zero. The comparison in the present study between FT and AT was made with one presenting problem (spousal psychological abuse) in both treatment groups. Both treatments were designed to be therapeutic, were matched for time span of treatment, retained the same trained intervener, and used matched pairs. Thus, this study addresses concerns that led to a lowering of treatment comparison effect sizes in Wampold et al. (1997). We note that having the same intervener in both treatments in itself is a positive factor (Messer & Wampold, 2002), and all therapeutic gains should be considered to include both the treatment and the therapist’s relationship with the participants. Psychologically abused women may have difficulty recovering long after the termination of the abusive relationship because of continuing resentment about the unfair harm of the abuse. Therapies that support the expression of anger about the wrongdoing of abuse (and subsequent mourning of the pain), assertiveness, and reconnection with improved interpersonal skills may not be adequate to address this debilitating resentment. FT, by contrast, although it supports the client in appropriately expressing anger about the abusive relationship and grieving the pain from the abuse, specifically targets the debilitating resentment toward the former abusive partner. The FT client is encouraged to tell her own unique story of the abuse experience, with the purpose of working through this story to a healthy resolution that includes forgiveness. During the forgiveness process, the client does the hard work of uncovering anger and shame, grieving the undeserved pain from the abuse, and reframing the former partner (personal history, fallibility, and culpability, yet inherent human worth), with the purpose of relinquishing debilitating resentment. Most important, FT can then take the paradoxical route of focusing the client’s thoughts, feelings, and behavior on a benevolent response to that former spouse rather than retaining the debilitating resentment. Thus, FT ameliorates the negative outcomes of psychological abuse. Another therapeutic factor in FT may be the acknowledgement that the client herself is a person of worth. In the process of therapy, the client makes the effort to integrate the reality of the abusive spouse’s wrongdoing and his inherent human worth. This does not negate the reality of the wrongdoing of the abuse itself but rather establishes that what the abuser did, however hurtful and unfair, does not change his worth as a human being (see Table 3 of Enright & the Human Development Study Group, 1994, for an explication of unconditional human worth undiminished by wrongdoing). As the client sees her abuser’s inherent worth, she then may be able to understand that she is also a person of inherent worth. The abuser’s mistaken view of her (as a worthless person who can be mistreated at will) does not have to be her view. This rediscovery of inherent human worth can be enhanced in that the client recognizes that she is a person of courage because she is choosing to relinquish resentment and develop goodwill for the former abusive spouse (in contradistinction to his abusive choices). It seems to us that clients benefit psychologically because of the interaction between understanding inherent human worth in others and in the self and relinquishing resentment (which, if left untreated, can prolong depression, anxiety, learned helplessness, shame, victim status, and low self-esteem). At this point, the client may see that her courageous response to unfair suffering (i.e., 927 forgiveness) is making her emotionally and ethically stronger. Thus, finding meaning in unjust suffering (Frankl, 1969) may strengthen the resolve to continue practicing forgiveness and thus also experiencing further psychological improvement. Another therapeutic aspect of FT that follows from finding meaning in unjust suffering is finding new purpose in helping others who are in pain or experiencing injustice (Enns et al., 1997; Seagull & Seagull, 1991). FT has a distinct advantage in this aspect of recovery because, after forgiveness, engagement in personal and social causes can proceed with a positive energy that is no longer confused by lingering, debilitating resentment. Moreover, this engagement can be more clearly focused on relevant social justice issues, untainted by any subtle motivation for revenge. FT participants at the end of this study planned to work toward change in conditions for other women in divorce law, social services, and disability benefits. Further study could be done after FT to ascertain progress in and psychological benefits from these pursuits. The robust findings of this study suggest that forgiveness can have a general effect on emotional regulation, reducing anxiety and depression while also increasing self-esteem and healthy (practical and moral) decision making. Previous studies have suggested that such variables are difficult to ameliorate (Sackett & Saunders, 1999; Seagull & Seagull, 1991). Perhaps unsuccessful emotional regulation after spousal emotional abuse is a set of symptoms for what is at the heart of the matter, deep and continuing resentment that has no apparent resolution. FT provides such a resolution in a safe environment that allows the abused client to move at her own pace in confronting the injustice. Moreover, FT encourages goodwill toward the former abuser with careful discretion. It is important to note that FT distinguishes carefully between the goodwill of forgiveness and reconciliation. For example, a woman may have goodwill for her former abusive partner (positive thoughts and feelings) but tell the truth about the situation (the former partner still has a problem); she may be benevolent (e.g., “I hope he obtains effective professional treatment”) yet maintain safety (no direct engagement with the former partner). Thus, FT promotes recovery benefits for the woman while avoiding the risk of further harm (therefore, it can also be appropriate for women with a past history of spousal physical or sexual abuse; Freedman & Enright, 1996). Finally, FT is appropriate as a postrelationship, postcrisis recovery treatment for emotionally abused women. FT is best offered after safety issues have been addressed (safety from the former partner and by reconnecting with social support), after some initial time for uncovering of the trauma (Herman, 1997), and as an aspect of long-term recovery, which entails empowering moral choices and integration of these healthy choices with memories of the past abuse. The research design includes strengths such as individualized therapy, moving at the client’s own pace and terminating therapy at the discretion of the participant, the use of an alternative treatment advocated in the published literature, manualized treatment, and careful screening for psychological abuse. Limitations include the sample size and some salient aspects of the participant sample. First, an all-volunteer, self-selecting participant sample may contribute particular characteristics (greater ongoing problems after the abuse, e.g.). Second, the ethnic mix of the sample was quite homogeneous (90% European Americans). Replication REED AND ENRIGHT This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 928 is, therefore, recommended to ascertain generalizability. In addition, because of the exclusion of potential participants who exhibited evidence of significant psychiatric illness, this study does not provide information on the benefits of FT for these particular women. Moreover, the study design of one intervener for all participants (although a strength of the study regarding continuity across treatment groups) contributes a limitation in that the outcomes of the study (for both treatment groups) may be due in part to an intervener effect (Messer & Wampold, 2002). A dismantled study design that compares FT and AT delivered with an intervener and FT and AT delivered with manuals only (Wampold et al., 1997) might further clarify the contributions of the treatments and the intervener relationship. Finally, a replication with only one or two salient dependent measures, with participants matched on these measures before being randomized to treatment groups and with an analysis of covariance, might lower the possibility of pretest mean differences between groups and thus further elucidate the relative benefits of FT and AT. This study is the first empirical investigation of the benefits of FT for women who have experienced spousal emotional abuse. As the benefits of FT were tested against one therapy currently specifically recommended for emotionally abused women (AT: anger validation with subsequent mourning, assertiveness, and interpersonal relationship skills), it would now be helpful to test the efficacy of FT with respect to other recovery strategies for traumatic relationships, such as Herman’s (1997) three phases of safety, mourning, and reconnection. What would be the relative efficacy of FT, Herman’s (1997) three phases, and the integration of these two approaches? The FT research should also deepen its focus by further study on the contributions of specific aspects of FT to the subsequent psychological improvements for emotionally abused women and other populations who have experienced unjust, traumatic relationships. What are the specific contributions of reframing, practicing goodwill, or finding meaning in unjust suffering? Future FT research could follow up participants who benefited from FT for one traumatic relationship (spousal abuse) to determine whether the practice and benefits transferred to another such relationship (e.g., an alcoholic parent). FT research should also explore how the benefits of FT transfer from the forgiver through emotional regulation and goodwill to a larger circle of personal relationships beyond the wrongdoer. FT holds promise as a postrelationship, postcrisis therapeutic approach for women who have experienced spousal emotional abuse, as it provides relief from negative psychological outcomes and fosters the positive characteristics of courage, competence, and altruism. These women have been given the message in the abuse context that they are worthless and that they cannot make good choices. FT corrects that message. References Aguilar, R. J., & Nightingale, N. N. (1994). The impact of specific battering experiences on the self-esteem of abused women. 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