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This paper was presented to a convention of the Association for the Advancement
of Behavior Therapy (AABT), Special Interest Group Exposition, Reno, Nevada, November
14-17 2002. Dr Hart kindly made the findings available to ForgivenessNet.
Therapy (AABT), Special Interest Group Exposition, Reno, Nevada, November 14-17 2002. Dr Hart kindly made the findings available to ForgivenessNet.
Facilitating Stage Two Recovery Among Sober Members of Alcoholics Anonymous Who Harbor Grudges: A Randomized Clinical Trial Testing Two Forgiveness Interventions
by Dr. Kenneth E. Hart (Department of Psychology, University of Windsor, Windsor ON Canada), David A. Shapiro (School of Psychology, University of Leeds, UK), Niki Gervais, Heather Wilkie & Tobi Wilson (Department of Psychology, University of Windsor, Windsor ON Canada)
Using a two-group pre-test, post-test and follow-up design with a focus on client-by-treatment interactions, we examined the impact of two types of forgiveness-promoting interventions upon emotional well-being and spiritual outcomes, using members of Alcoholics Anonymous (AA) who were sober but distressed due to unresolved grudges. In regards aptitude-by-treatment (ATI) interactions, we examined whether pre-treatment levels of client empathy and value-placed-on-spirituality have a moderating effect on forgiveness-related outcomes in the context of our manual-driven psychoeducational interventions. Our first intervention was spiritual in orientation and our second was psychologically focused (secular).
In a British cultural context, we recruited a clinical sample of 84 sober members of AA who were seeking greater levels of emotional sobriety (serenity). Using these clients, we conducted a treatment outcome study to examine the impact of two types of forgiveness interventions upon measures of forgiveness, repentance, and spiritual growth.
Two pre-treatment client characteristics (value-placed-on-spirituality and empathy) served as blocking variables, and Urn randomization (Stout et al., 1994) was used to ensure balanced distribution of these two client prognostic variables. Clients were assigned to one of two psychoeducational interventions: (1) secular forgiveness (SEC-F) intervention or spiritual forgiveness and repentance (SPIRIT-FR) intervention. Using treatment manuals in a group workshop format, both programs were delivered over the course of a five-month period of time by experienced addictions counselors who received 10 hours of training in the use of their respective manual.
The Treatment Programs
The SEC-F treatment manual consisted of a British adaptation of a psychoeducational treatment manual developed in the USA by Enright and his graduate-student colleagues. Previous treatment research (see Enright & Fitzgibbons, 2000 for a review) suggests the SEC-F intervention developed for use in the present study should facilitate the growth of 20 therapeutic processes (e.g., empathy) believed to be instrumental in assisting angry victims of harm to let go of their grievances, forgive their transgressors, and view them with mercy and compassion. The SEC-F program was completely silent on the issue of spirituality/religiosity.
The Spiritual Forgiveness and Repentance (SPIRIT-FR) treatment manual consists of a 12-Step facilitation that engaged clients in the first nine steps of the 12-Step program of spiritual growth described in AA literature. Special emphasis was placed on amplifying components of the steps which emphasized forgiveness of perpetrators and making amends for victimizing others (i.e., repentance). Consistent with AA theology, the SPIRIT-FR intervention was sanctified. Steps 2 through 9, for example, were presented as a spiritual solution to the problem of personal powerlessness over anger. It was suggested that faith in a Higher Power and reliance on the omnipotence of a benevolent Supreme Being (i.e., spiritual surrender) was required to experience release from the bondage of anger directed outward (resentment/unforgiveness of others) and inward (shame/unforgiveness of self).
Experienced addictions counselors, who were themselves 12-Step members, served as group leaders/counselors. There were eight counselors in total, four per condition. Six junior counselors were randomly assigned to treatment conditions. Senior counselors (who had developed the respective treatment manual) supervised the junior counselors.
Process & Outcome Data
Of the 84 clients who were randomized, 76 attended the first treatment session, and 61 clients completed the treatment program. Thirty-one clients completed the SEC-F program and 30 completed the SPIRIT-FR program. Of those who completed, mean attendance across the 10 sessions was 73% for the SEC-F condition and 82% for the SPIR-FR condition. Results of counselor adherence process data derived from Workshops 4 10 indicate the two treatments had high levels of discriminant validity and that counselors showed high levels of fidelity to their respective treatment manuals. For instance, clients consistently rated that spiritual content was emphasized more in the SPIRIT-FR condition. At pre-treatment, post-treatment and four-month follow-up, clients completed a questionnaire battery, which yielded (among other things) four reliable and valid outcome measures: two for forgiveness and two for repentance.
Treatment Effects on Forgiveness & Repentance
Four-month follow-up results examining change scores showed completer clients in both the SEC-F group and SPIRIT-FR showed significant improvements in terms of:
Between-groups ANOVAs for change scores of completers at the follow-up period showed clients in the SPIRIT-FR group (n = 30) showed a greater ability to forgive their worst offender than did clients in the SEC-F group (n = 23) (F = 4.67, df = 1,53, p < .05). 2x2 ANOVAs (high & low empathy by condition and high & low spirituality by condition) showed individual differences in client empathy or spirituality did not differentially moderate the impact of treatments on outcomes. Regression analyses, however, revealed both client attributes had moderating effects on treatment outcome.
Treatment Effects on Spirituality
During our pre-treatment, post-treatment and follow-up assessments, we included a host of subscales from spiritual scales such as the Fetzer/NIA multidimensional measure of spirituality/religiosity. Selected findings are reported here, and can be seen in Figures 1-3 (to be attached shortly).
Separate subgroup analyses for clients in the two treatment conditions showed a wide variation of statistically significant beneficial/therapeutic effects. These statistical effects, however, varied as a function of the nature of the dependent variable, the time period of the assessments, and group membership status. The amount of improvement on the God and coping variables was no different for clients in the SPIRIT-FR condition relative to the SEC-F condition.
In regards to the variable spiritual transformation (ST), results obtained at follow-up showed 13 of the 52 completers (24.5%) indicated they had had a ST since entering the research study (we asked: since entering this program, have you had a religious or spiritual experience that changed your life?). At posttreatment and follow-up, ST was significantly and positively correlated with daily spiritual experiences (rs ranged from .287 to .521). The number of clients reporting ST at post-treatment was 12. Chi-square analysis revealed the two treatment conditions did not differ on this variable at either point in time. At both post-treatment and follow-up, ST was unrelated to forgiveness or repentance. However, other spiritual indicators showed statistically significant associations to these outcomes. Aggregate cross-sectional results at follow-up, for example, showed private prayer/meditation was positively correlated to the generalized disposition to forgive (GDF: r(52)=.28, p<.05). Daily spiritual experience was related to GDF (r(53)=.446, p=.001), forgiveness of ones worst offender (r(53)= .279, p<.05) & anxiety (r(49)= -.314, p<.05). Finally, positive spiritual coping was related to GDF (r(53)=.311, p<.05).
Findings pertaining to treatment impact on forgiveness-related outcomes are consistent with results of previous treatment outcome research (see Worthington, Sandage & Berry, 2000 for a review) suggesting that forgiveness-based interventions are effective in helping angry individuals to let go of specific interpersonal grudges. Extending previous research, results also suggest both secular and spiritual forgiveness protocols may motivate clients to become willing to express contrition when appropriate. Other unique findings include evidence favoring the superiority of a spiritually-integrated forgiveness and repentance approach, and results showing degree of forgiveness varies as a function of the interaction between treatment characteristics and levels of client empathy and value placed on spirituality.
The present results also suggest that forgiveness interventions that involve recovering 12-step members can inculcate a measure of spiritual growth, and spiritual transformation. This finding is consistent with other treatment research showing forgiveness interventions can lead to improvements in spiritual well-being (Rye & Pargament, 2002). It is noteworthy that forgiveness interventions need not be explicitly spiritual/religious in orientation to impact improvement at the spiritual level.
In this regard, results of the present study mirror those reported by Rye & Pargament (2002) who studied a sample of Christian women who harbored grudges against a romantic partner. Collectively, these studies show that interventions designed to be psychological or secular in content have the same beneficial impact on spiritual growth as interventions designed to be spiritual (this study) or religious (Rye & Pargament, 2002). Lack of differential treatment effects supports the contention that forgiveness is tied intricately to religion/spirituality (Rye & Pargament, 2002, p. 439). Consistent with Rye & Pargament (2002), we speculate the explanatory mechanism is spontaneous sanctification of forgiveness interventions. Considering that 95% of the clients in the present study identified themselves at pre-treatment as spiritual seekers, this explanation seems apt.
In conclusion, results of the present study provide empirical evidence to show mental-health interventions designed to inculcate forgiveness can facilitate Stage Two recovery among AA members who have previously quit drinking and who are now seeking to improve their quality of life. The present findings suggest these Stage Two interventions are not only effective in lessening resentments and grudges, they can also facilitate greater levels of contrition and spiritual growth. While these benefits might play a salutogenic role in the maintenance of abstinence from alcohol (relapse prevention), they also represent valuable benefits in their own right. n
For further details and for access to a detailed
PowerPoint presentation about this research, given at the 2002 convention of the American