FORGIVENESS AND HIV

1. Center for Psychosocial Health FORGIVENESS AND HIV Presentation by Will Hua and Luci Martin

2. Who We Are • The Center for Psychosocial Health • Focus on research on psychological phenomena involved in healthy living • Multidisciplinary group • Provide psychoeducational services to communities throughout DFW • www.unt.edu/cph

3. Overview • Our Research and Relevance to HIV+ Mothers • Effects of Stress on HIV+ Mothers • Definition of Forgiveness • Current Research in Forgiveness • Rationale for Project Forgive • Project Forgive • A Case Example • Implications for Future Studies • Q and A

4. Relevance to HIV+ Mothers • What are some issues that HIV+ mothers face on a daily basis? • How does the added stress of being HIV+ affect their parenting skills and styles? • How can “forgiveness” help with these parenting issues?

5. How Stress Can Affect the HIV+ Mother • Stress  Depression  Decreased medical adherence (Kalichman et al., 1999) • Stress  Post-partum  Subsequent depression (Bernazzani et al., 1997) • Stress  Adverse birth outcomes • Earlier delivery • Lower birth weight • Stress, social isolation, and behavioral disengagement  greater depression (Blaney, 2004)

6. Effects of Unforgiveness • Worthington et al. (2004) suggests four lines of evidence that support unforgiveness as a stressful event • Brain activity patterns • Hormonal patterns • Patterns of SNS activity • Blood chemistry

7. So…What is Forgiveness? • What does it mean to you? • Forgiveness is… • Forgiveness is not… • Forgiveness as a construct • Forgive for Good (Luskin, 2002)

8. Forgiveness is… • Two textbook answers- • Dr. Luskin describes forgiveness as a trainable skill that teaches individuals to create a feeling of peace in the present moment. Further, it’s a process that helps individuals gain control over their feelings in order to take power back from the individuals who hurt them. • Dr. Lydia Temoshok conceives forgiveness to be ‘a multi-dimensional concept that extends beyond spiritual and existential meanings to have significant consequences for self-perceptions, coping, interpersonal relationships, as well as health and medical outcomes in the context of HIV/AIDS.’

9. Forgiveness is… • Conceptual answers- • Forgiveness… • is the feeling of peace that emerges when a person learns how to take hurt less personally. • is taking responsibility for one’s feelings. • takes place by undoing each of the steps of the grievance process. • is choosing to hurt and suffer less even when feeling wounded. • is a complex experience that changes an offended person’s feelings, emotions, thoughts, actions, and self-confidence level. (Luskin, 2002)

10. Forgiveness is not… Forgiveness, within the context of this intervention, differs from conventional definitions. Specifically, forgiveness is not… about reconciling with the offender forgetting something painful denying or minimizing hurt condoning unkindness excusing poor behavior It doesn’t parallel any religious definition, but the concept is compatible with all religious beliefs. (Luskin, 2002)

11. Forgiveness as a Construct • Forgiveness is a complex construct! Involves many aspects: • Cognitive (Flanigan, 1992) • Affective (Flanigan, 1992) • Behavioral (Gordon et al., 2000) • Motivational (McCullough et al., 1997) • Decisional (DiBlasio, 1998) • Interpersonal (Baumeister et al., 1998)

12. Current Research in Forgiveness • The Forgiveness Intervention was pioneered by Dr. Fred Luskin • ‘Forgive for Good’ • Intervention has shown success with other populations, but, to date, it has not been used in HIV+ populations • Survivors of the Protestant/Catholic conflicts in Ireland • Patients suffering from a range of chronic illnesses (Luskin, 2002)

13. Research on Forgiveness • In multiple studies, the Forgiveness Intervention has shown success in: • Improving the mental and physical health of people with chronic illness • Reducing the physical symptoms of stress (e.g. anxiety and panic attacks) • Improving the functioning of the cardiovascular, muscular, and nervous systems in people who practice forgiveness. (Luskin, 2002)

14. Research in Forgiveness (cont.) Forgiveness has been linked to • Decreased depression (Brown & Phillips, 2005) • Reduced levels of stress hormones • Increased hope (Maltby et al., 2001) • Increased self-esteem (McCullough, 2001) • Greater life satisfaction (Brown & Phillips, 2005) • Reduced hostility, anger • Increased social support (Worthington & Drinkard, 2000) Overall: direct psychological benefits and indirect physical health benefits!

15. Project Forgive

16. Study Design • Randomized clinical trial of a Forgiveness Intervention designed for HIV+ women • Based on the methods used by Dr. Luskin • Consists of 6 group sessions using cognitive-behavioral group therapy that targets the concept of forgiveness • The control group receives 6 group sessions of an educational intervention • Each group consists of 7 diverse, HIV+ women • Facilitated by two upper level graduate students

17. Study Design continued… • Four group design: 2 treatment, 2 control with 7 participants per group • Participants complete three computerized surveys: • Baseline • Post-Intervention • 3-month follow-up • Group sessions and surveys conducted at the Resource Center of Dallas • Participants paid for their participation

18. Psychosocial Changes • Depression • (CES-D; Radloff, 1977) • Coping • (COPE; Carver et al. 1989) • Perceived Stress • (PSS; Cohen et al., 1983) • Quality of Life • (MOS-HIV; Wu et al., 1999) • UCLA Social Support Inventory • (UCLA-SSI; Dunkel-Schetter et al., 1986)

19. Common Characteristics Among Sessions • Handouts and In-session Activities • Relaxation Exercises • Homework • Review of Previous Session • Agenda • Summary Practice Practice Practice Practice

20. Three Key Ingredients • Stress management through RELAXATION • Changing negative emotions to POSITIVE emotions • Learning to THINK clearly

21. What is forgiveness? • Forgiveness is GOOD for you! • Forgiveness is about YOU! • You have CONTROL over Forgiveness! Not… - Condoning poor behavior - Giving up feelings - Reconciling with offender - Forgetting

22. The Grievance Process • The exaggerated taking of personal offense • The blaming of the offender for how you feel • The creation of a grievance story Taking up space in the mind rent free!

23. The Grievance Story (Yes or No) • Have you told your story more than twice to the same person? • Do you find yourself speaking to the person who hurt you even when they are not there? • Does your story focus primarily on your pain and what you have lost?

24. Positive Emotion Refocusing Technique (P.E.R.T) • Utilizes breathing techniques, positive emotions, and the recognition of unresolved grievances. • Helps the griever to stay calm and remain in control of his/her emotions. • Helps to decrease the perceived threat of the situation. • The power of the person who hurt the griever is decreased and replaced with self-confidence and feelings of peace and calm. • Can be discretely employed anytime and anywhere for a variety of situations.

25. P.E.R.T. Demonstration • Take two deep breaths, gently pushing your belly out as you inhale and consciously relaxing your belly (making it feel soft) as you exhale • Take a third deep inhalation • While continuing to breathe, bring to your mind an image of a loved one or a beautiful scene from nature that brings you a sense of peace • Imagine these positive feelings centered in the area around the heart • Continue to breath, making sure that your belly continues to rise and fall • Ask the relaxed and peaceful part of you what you can do to resolve your difficulty

26. Negative habits, thoughts and grievances compete with positive experiences Places us in the victim/martyr role Gives away personal power and choices Lowers our resistance to disease Robs us of joy Gratitude Channel Beauty Channel Forgiveness Channel Love Channel Changing the Channel

27. Unenforceable Rules • Think about the situation: • What did you want to happen? • What happened? • Did you have control over the situation? • What unenforceable rule was involved? RULES

28. From Unenforceable Rules to Wishes and Hopes • We have limited power to control the behavior of another person. • We can only hope that other people treat us well. • We can not accurately label our own or another’s entire life. • No one is truly a creep ALL of the time. • To stay peaceful and be able to think straight, we can acknowledge that their rules are different from ours, and they have the right to choose not to follow ours.

29. The HEAL Method • Mnemonic device that helps a person grasp the concepts and essentials of forgiveness • Reinforces the goals of forgiveness and addresses specific hurtful experiences • The first two stages focus on past events that caused grievances and ways to put them into a healing perspective, in order to move forward in life • The latter two stages focus on the present and future state of forgiveness • The method aims to reduce the influence that a grievance can have on a life and incorporates positive direction into one’s actions

30. HEAL: Hope, Educate, Affirm, Long-Term Commitment • Hope: a statement that represents a positive outcome desired in a hurtful situation • Educate: your control over a situation or a person is limited and uncertain - Awareness that an outcome is not guaranteed • Affirm: affirms a positive intention or long-term goal that was desired for a specific situation • Long-term commitment: emphasizes the importance of practice and committing to one’s well-being over time, by no longer dwelling on the grievance

31. Case Example: Jan • Arrived 30 minutes late to 2nd session • Kept head down, hunched over • Limited eye contact • Would not participate in group activities • Distrustful of others • Not involved in Resource services • Tearful • Not aware of health terms

32. Jan continued… • Posture • Initiated conversations • Had attended lunch/social groups and planned to continue • Arrived on time • Participated in Relaxation exercises • Knowledgeable and helpful to other participants

33. Overview of Educational Intervention • Sessions were designed to mirror the length and execution of the treatment intervention sessions • A relaxation component was not included

34. Educational Intervention • Session I: Challenges of being an HIV+ woman in today’s society • Session II: Nutrition and exercise specific to HIV+ women • Session III: Cultural implications of HIV on Latina/Asian/African-Americans

35. Educational Intervention • Session IV: HIV and pregnancy, childcare, parenthood, and adoption • Session V: HIV and medical adherence, women’s health, drug use, and alcohol consumption • Session VI: HIV and dating, relationships, and disclosure

36. Challenges • Recruitment • History of Sexual Abuse • Adherence • Diversity within the group • Diversity among Facilitators • Imaging a positive or loving experience • Language (i.e. Positive) • Illiteracy

37. Implications for Future Studies • Include physiological measures (CD4, cortisol, blood pressure) • More diverse sample (men, Latino/a, Caucasian, SES) • More diverse facilitators • Variation in length of intervention • Comparison to other cognitive-behavioral interventions

38. Conclusion • What forgiveness is and is not • Current research in Forgiveness and Health and Well-being • Implications for research with forgiveness and HIV • Project Forgive • Future research and challenges

39. Questions and Answers

40. Contact Information • Mark Vosvick, Ph.D. vosvick@unt.edu • Luci A. Martin lam0246@unt.edu • Will Hua willhua@unt.edu

41. References • Baumeister, R.F., Exline, J.J. and Sommer, K.L. (1998). The victim role, grudge theory, and two dimensions of forgiveness. In: Worthington, E.L. Jr. (Ed.), Dimensions of Forgiveness: Psychological Research and Theological Perspectives, pp. 79-104. Templeton Foundation Press, Philadelphia. • Bernazzani, O., Saucier, J-F., David, H., Borgeat, F. (1997). Psychosocial predictors of depressive symptomatology level in postpartum women. Journal of Affect Disorders, 46, 39-49. • Blaney, N.T., Fernandez, M.I., Ethier, K.A., Wilson, T.E., Walter, E., Koenig, L.J. (2004). Psychosocial and Behavioral Correlates of Depression Among HIV-Infected Pregnant Women, AIDS Patient Care and STDs, 18, No. 7. • Brown, R.P. & Phillips, A. (2005). Letting bygones be bygones: Further evidence for the validity of the Tendency to Forgive Scale. Personality and Individual Differences, 38, 627-638. • Carver, C. S., Scheier, M. F., & Weintraub, J. K.  (1989).  Assessing coping strategies:  A theoretically based approach. Journal of Personality and Social Psychology, 56, 267-283. • Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A Global Measure of Perceived Stress. Journal of Health and Social Behavior, 24, 385-396. • DiBlasio, F.A. (1998). The use of decision-based forgiveness intervention within intergenerational family therapy. Journal of Family Therapy, 20, 77-94.

42. References continued… • Flanigan, B. (1992). Forgiving the unforgivable. Macmillan, New York. • Gordon, K.C., Baucom, D.H. and Snyder, D.K. (2000). The use of forgiveness in martial therapy. In: McCullough, M.E., Pargament, K.I. and Thoresen, C.E. (Eds.)., Forgiveness: Theory, Research, and Practice, pp. 203-227. Guilford Press, New York. • Kalichman, S.C., Ramachandran, B., Catz S. (1999). Adherence to combination antiretroviral therapies in HIV patients of low health literacy. Journal of General Intern Medicine, 14, 267-273. • Maltby, J., Macaskill, A., & Day, L. (2001). Failure to forgive self and others: A replication and extension of the relationship between forgiveness, personality, social desirability and general health. Personality and Individual Differences, 30, 881-885. • McCullough, M.E. (2001). Forgiveness: Who does it and how do they do it? Current Directions in Psychological Science, 10, 194-197. • Worthington, E.L., Jr. and Drinkard, D.T. (2000). Promoting reconciliation through psychoeducational and therapeutic interventions. Journal of Marital and Family Therapy, 26, 93-101. • Worthington, E.L., Scherer, M. (2004). Forgiveness is an Emotion-Focused Coping Strategy that can Reduce Health Risks and Promote Health Resilience: : Theory, Review, and Hypotheses. Psychology and Health, 19, 385-405.