May 5, 2011 (Washington, DC) — Could forgiveness lead to enough beneficial physiological change to improve immune function in people whose immune status is already compromised?

A new study conducted in people living with HIV shows individuals who truly forgave someone who had hurt them in the past showed positive changes in their immune status.

The study was presented here at the Society of Behavioral Medicine 32nd Annual Meeting and Scientific Sessions.

Amy Owen, PhD, Duke University Medical Center, Durham, North Carolina, found that greater forgiveness significantly correlated with higher CD4 cell percentages (P = .042). Unlike the CD4 cell count, which is a measure of how many functional CD4 T cells are circulating in the blood, the CD4 cell percentage represents the percentage of total lymphocytes that are CD4 cells.

In regression analyses, the relationship of forgiveness and CD4 cell percentages remained significant even when controlling for variables that could affect CD4 cell counts, including age, race, sex, level of education, years with HIV, adherence, substance use, and viral load (P = .034).

"We hypothesized that higher levels of forgiveness would be associated with higher CD4 cell percentages controlled for demographic and behavioral variables as well as viral load," Dr. Owen told Medscape Medical News. "And none of these variables accounted for the relationship between forgiveness and CD4 cell percentages. So there is something special going on between forgiveness and CD4 cell counts."

Beneficial Effect

The study involved 78 individuals living with HIV and receiving antiretroviral medications. Subjects had been taking anti-HIV medications for at least 1 year, and 67% of them had undetectable viral loads. Eighty-one percent were nonwhite. Medication adherence was assessed by calculating the mean number of missed doses during the past 4 days. Subjects were also asked about tobacco, alcohol, marijuana, and cocaine use.

Forgiveness was measured by the Enright Forgiveness Inventory, a tool that assesses positive and negative feelings, thoughts, behaviors, or imagined behaviors toward an individual who caused the subject hurt.

Dr. Owen also defined forgiveness strictly as being a freely made choice to move away from negative cognitive, emotional, and behavioral responses toward a person who caused a hurt and work towards developing positive cognitive emotional and behavioral responses toward that person.

"For my study, I compared the relationship of forgiveness of another person and CD4 cell percentages both without controlling for any other factors (using a bivariate correlation), and then I tested whether this relationship would hold up when I controlled for other possible factors linked to CD4 percentage levels that could account for an observed relationship between forgiveness and CD4 percentages (using a hierarchical linear regression)."

In bivariate correlations, results showed that greater forgiveness was significantly associated with higher CD4 percentages, whereas linear regression analyses found that this relationship remained significant after controlling for the potential influence of other factors.

"Results support our hypothesis and reflect previous findings on relationships of psychosocial factors with immune makers in people living with HIV/AIDS, and findings indicate that forgiveness of another person may be beneficial for their health," said Dr. Owen.

Understanding Forgiveness Key

She also noted that helping people who have been violated in the past come to a place of peace can be done, but it has to be done well.

"If psychiatrists want to counsel patients about forgiveness, they first need to understand very deeply what forgiveness is and what it is not," she said. "If there isn't a good therapeutic relationship between a physician and the patient, “what patients can hear from you when you are suggesting forgiveness is, 'I don't want to hear about it anymore and what's wrong with you that you are not just fine with it.' But that can be extremely violating and potentially retraumatize the person who has already been deeply hurt."

It's also very important to respect a patient's anger, she added, because sometimes that is all a person has.

"If you threaten that by suggesting that the patient shouldn't be so angry, it can be disrespectful, so if a psychiatrist wants to engage with a patient on the topic of forgiveness, it's essential they understand the definitions of forgiveness and be willing to journey with that person over time. Patients will struggle with it; it's not a linear process, but it is very transformative."

Emotional Pain Common

Reverend Michael Barry, PhD, Cancer Treatment Centers of America, Philadelphia, Pennsylvania, told Medscape Medical News that unforgiveness is a state where a person retains negative emotions, including anger and hatred, for a perpetrator of harm.

"This creates a state of chronic anxiety, and chronic anxiety has a predictable impact on a wide range of bodily functions, including the reproductive system, the digestive system, and the immune system," he said.

For example, stress hormones, including cortisol and adrenalin, have been shown to reduce the production of natural killer cells — the "foot soldiers" in the fight against cancer, he noted.

Dr. Barry's own research has shown that almost two-thirds of cancer patients identified forgiveness as a personal issue for them, and 1 in 3 of them indicated they had severe forgiveness issues, "so we are aware of the emotional pain that many of our patients are in.

"There is a direct correlation between unforgiveness and our immune system, which directly affects our healing processes. We teach people what we have learned about the process of forgiveness in a short-term forgiveness intervention program that works," he added.

Dr. Owen has disclosed no relevant financial relationships. Dr. Barry is the author of The Forgiveness Project. He also developed a forgiveness program, entitled Release! The Healing Power of Forgiveness.

Society of Behavioral Medicine (SBM) 32nd Annual Meeting and Scientific Sessions: Abstract 4010. Presented April 30, 2011.


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