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1 This article was downloaded by: [Iowa State University], [Nathaniel G. Wade] On: 13 June 2012, At: 14:44 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Psychotherapy Research Publication details, including instructions for authors and subscription information: Comparison of forgiveness and anger-reduction group treatments: A randomized controlled trial Daniel B. Goldman a & Nathaniel G. Wade a a Department of Psychology, Iowa State University, Ames, IA, USA Available online: 12 Jun 2012 To cite this article: Daniel B. Goldman & Nathaniel G. Wade (2012): Comparison of forgiveness and anger-reduction group treatments: A randomized controlled trial, Psychotherapy Research, DOI: / To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 Psychotherapy Research, 2012, 117, ifirst article Comparison of forgiveness and anger-reduction group treatments: A randomized controlled trial DANIEL B. GOLDMAN & NATHANIEL G. WADE* Department of Psychology, Iowa State University, Ames, IA, USA (Received 26 October 2011; revised 4 May 2012; accepted 8 May 2012) Downloaded by [Iowa State University], [Nathaniel G. Wade] at 14:44 13 June 2012 Abstract Interventions to promote forgiveness are effective. However, in what ways and in comparison to what other treatments is still unresolved. College students (n112) who had been hurt in the past and struggled to overcome their negative experiences of it participated in this study. They were randomly assigned to one of two treatments, one focused on promoting forgiveness and one focused on reducing anger for past hurts, or a waiting list control. Treatment consisted of six 90-minute sessions held in small groups led by one facilitator over the course of 3 weeks. Results of three-level (time within participants within groups) hierarchical linear modeling indicated that the forgiveness treatment (n41) resulted in greater reductions in hostility and psychological symptoms and more empathy for the offender than the alternative treatment (n39) and the waitlist (n32). Participants in both treatment conditions reported greater reductions in desires for revenge than those in the waitlist condition. All participants reported a significant reduction in rumination about the offense. Clinical significance testing mirrored these results. These findings support forgiveness-promoting treatments as effective for reducing psychological symptoms and achieving forgiveness, and suggest that they may be more effective than other types of treatments. Keywords: forgiveness intervention; anger reduction; rumination; group counseling The physical and mental health risks of harbored anger, chronic frustration, and unresolved bitterness are well known. Those who cannot cope with and resolve their anger are at greater risk of heart disease, earlier mortality, depression, anxiety, and troubled relationships (Chida & Steptoe, 2009; Miller, Smith, Turner, Guijarro, & Hallet, 1996; Williams, 2010). In addition, greater anger and hostility have been linked to greater violence. For example, across a number of studies, men who report more anger and hostility are more likely to be perpetrators of intimate violence (Norlander & Eckhardt, 2005). In women, greater hostility is associated with markers for cardiovascular heart disease (Elovainio et al., 2011). Anger, hostility, desires for revenge, and the violence that can accompany these feelings create a host of negative consequences for individuals, communities, and societies. One potentially effective method for resolving anger, hostility, and vengefulness, particularly in response to interpersonal offenses, is forgiveness, a concept receiving growing attention in the psychological literature (Worthington, 2005). Forgiveness is the process of replacing harbored anger toward an offending person with more positive, prosocial feelings such as compassion. It is not simply the reduction of angry feelings or the elimination of desires for revenge, although that is certainly a part of the forgiveness process (Enright, Eastin, & Goldin, 1992; Worthington & Wade, 1999). Instead, forgiveness includes an important additional component. In addition to a reduction in the negative emotional and cognitive experiences following a hurt (such as feelings of rage or thoughts of hurting the offending person), forgiveness includes the development of positive feelings and thoughts (Wade & Worthington, 2003). This positive element might include a return to feelings of compassion or love for the offending person, or even simply a sense of pity (Wade, Bailey, & Shaffer, 2005). Furthermore, forgiveness is distinct from forgetting, condoning, or reconciling with the offending person (Enright et al., 1992; Freedman & Enright, 1996). It is possible to experience the development of positive thoughts and feelings for an offender and still decide to end a relationship Correspondence concerning this article should be addressed to Nathaniel G. Wade, Department of Psychology, Iowa State University, w112 Lagomarcino, Ames, IA, USA. nwade@iastate.edu ISSN print/issn online # 2012 Society for Psychotherapy Research

3 2 D. B. Goldman and N. G. Wade (or not be able to restore one if the person is unwilling or deceased). Forgiveness as a means of responding to or coping with interpersonal transgressions seems to be a beneficial strategy. A forgiving response has been linked to greater emotional well-being, greater empathy for others, less physiological reactance (e.g., lower blood pressure), and, for the elderly, fewer physical health problems (Toussaint, Williams, Musick, & Everson, 2001; Witvliet, Ludwig, & Vander Laan, 2001; Worthington & Scherer, 2004). In addition, those who are more vengeful have shown greater physical complaints over an 8-week period (McCullough, Bellah, Kilpatrick, & Johnson, 2001). However, forgiveness might not cause well-being, but instead might be the result of increases in wellbeing (Orth, Berking, Walker, Meier, & Znoj, 2008). Although the direct causal relationship between forgiveness and well-being is still debated, findings in this area suggest that the ability to forgive may be a skill that serves a protective function against both mental and physical illness. Thus, understanding the most effective ways to help people achieve forgiveness could have a direct impact on interventions designed to help people overcome anger and bitterness and thereby indirectly improve their long-term mental and physical health. In fact, interventions designed specifically to help people achieve forgiveness have been shown to be effective (Wade, Worthington, & Meyer, 2005). Past studies have found that these interventions help people resolve anger and bitterness, reduce depression and anxiety, and increase hope and self-esteem (Baskin & Enright, 2004; Wade, Worthington et al., 2005). Interventions to promote forgiveness have been effectively applied to a broad range of hurts and offenses, including incest (Freedman & Enright, 1996), parental neglect (Al-Mabuk, Enright, & Cardis, 1995), and divorce (Rye et al., 2005), as well as with groups of people experiencing diverse hurts, from romantic betrayal to familial abuse (e.g., McCullough, Worthington, & Rachal, 1997; Wade & Meyer, 2009; Wade, Worthington, & Haake, 2009). The research is promising: interventions to promote forgiveness can help those who want to overcome the effects of an interpersonal offense, cope with the past by achieving some degree of forgiveness, and move on with their lives. However, the research in this area is also limited in several ways. First, although interventions designed to promote forgiveness have been shown to be effective in general there is little compelling evidence that these specific interventions are any more effective than factors that might be common across all forms of bona fide therapy. For example, only a handful of studies have been conducted to compare a forgiveness-promoting intervention with an alternative therapy that is truly intended to be therapeutic. The large majority of the existing outcome studies have either compared the treatment to no treatment (e.g., waiting list controls; Freedman & Enright, 1996) or to a placebo treatment (e.g., discussion group; Hebl & Enright, 1993). Studies that have compared the forgiveness treatment to alternative forms of therapy have shown mixed results. For example, four studies using a legitimate comparison therapy have found the explicit forgiveness treatment under investigation to be superior on measures of forgiveness. The first found that a full-forgiveness intervention was more effective for promoting affective empathy and forgiveness toward an offender than a similar treatment that did not include theoretically relevant components (McCullough et al., 1997). In this study, the researchers removed a central component of the treatment, the interventions designed to help participants develop empathy for their offenders. The treatment with the empathy-promoting component was more effective than the treatment without that component and the waiting list condition. Another study comparing a forgiveness treatment to a treatment-as-usual for patients suffering with chemical dependency found that the forgiveness treatment was superior not only in promoting forgiveness but also in preventing relapse (Lin, Mack, Enright, Krahn, & Baskin, 2004). A third study showed that women in the forgiveness treatment were more likely to forgive past partners who were emotionally abusive than those in a treatment-asusual condition (Reed & Enright, 2006). The fourth compared Emotion-Focused individual therapy with group psychoeducation and found that the former was more effective at promoting forgiveness than the latter (Greenberg, Warwar, & Malcolm, 2008). These studies suggest that explicit forgiveness treatments might be more effective than typical treatments in promoting forgiveness and even in addressing other concerns (such as chemical dependency). However, there are other factors that might account for the results, such as therapist/researcher allegiance to the treatment. Although allegiance to a particular treatment can be an effective component of counseling (Wampold, 2001), a significant problem emerges when allegiance is confounded with treatment type. In all of the studies above, the researchers allegiance to the forgiveness treatment was clear and some evidence suggests that the therapists themselves may have had allegiances to the forgiveness treatment. In contrast, some studies have found no significant differences between an explicit forgiveness treatment and alternative treatments. Two examples come

4 from Wade and his colleagues. In one study, participants in a forgiveness treatment devoid of the theoretically relevant component (i.e., empathy building) and in a relaxation training condition forgave their offenders to the same degree as participants in the explicit forgiveness treatment (Wade et al., 2009). Similarly, participants in a short-term, process-oriented group treatment condition achieved degrees of forgiveness similar to those in the forgiveness treatment condition (Wade & Meyer, 2009). Although these studies indicate that there may be no important differences between explicit forgiveness treatments and other legitimate treatments, there are some limitations with these studies as well. First, Wade and Meyer (2009) had a small sample size, such that the study may have been underpowered to find significant differences between the treatment conditions. Second, Wade et al. (2009) used a small group treatment modality and did not account for the nested structure of the data. Thus group-level effects may have masked true differences that occurred between the different treatments. Finally, forgiveness intervention research has focused on important but limited outcomes. Most of the studies conducted on forgiveness interventions have used forgiveness, empathy, and some psychological symptom variables (e.g., depression, anxiety) as outcomes (Baskin & Enright, 2004; Wade, Worthington et al., 2005). Others have included measures of hope and well-being (e.g., Freedman & Enright, 1996; Rye & Pargament, 2002). However, few studies have directly examined participants anger or hostility toward the offenders or the degree to which the participants still ruminate about the offenses. These are both important and common responses to being hurt. The degree to which an intervention might reduce or eliminate these responses would be a strong indicator of the treatment s effectiveness. Hostility and Rumination Although researchers do not all agree (see Eckhardt, Norlander, & Deffenbacher, 2004, for a review), hostility can be defined as an affective and attitudinal complex marked by angry emotions, as well as cynical and mistrusting thoughts about others that motivates the denigration of and aggression toward others (e.g., Barefoot & Lipkus, 2004). Psychological research has implicated hostility in the development of physical and psychological problems. Perhaps the best-known correlate of hostility is cardiovascular disease (Chida & Steptoe, 2009). However, other correlates include greater negative affect and sleep disturbance following conflict (Brissette & Cohen, 2002) and depression and Forgiveness interventions 3 physical aggression (e.g., Sadeh, Javdani, Finy, & Verona, 2011). In college students, hostility has been related to less social support, more frequent and excessive experiences of anger, and more alcohol consumption (Houston & Vavak, 1991). Although most of these relationships are correlational and not causal, there is evidence to suggest that hostility is the driving force behind most of these negative outcomes. Thus, understanding how hostility changes over the course of treatment would provide valuable information about the role of forgivenesspromoting interventions to reduce or eliminate hostility toward a specific offender. Likewise, rumination is a common response to being hurt. Rumination is repetitive, recursive thoughts in response to negative mood states or life experiences that can be targeted toward a specific hurtful event (Wade, Vogel, Liao, & Goldman, 2008). Researchers have argued that rumination might be one of the primary pathways from a perceived hurt or injustice to the establishment of the bitterness and resentment of unforgiveness (Worthington & Wade, 1999). Thus, reductions in rumination might be a good indicator of reductions in unforgiveness and perhaps the achievement of forgiveness. Covariates Two important variables that are related to forgiveness are trait forgivingness (i.e., the disposition to forgive across time and situations) and biological sex. Past research has consistently shown that the general tendency to forgive is related to forgiveness for a specific offense (e.g., Berry, Worthington, O Connor, Parrott, & Wade, 2005; Wade, Meyer, Goldman, & Post, 2009; Wade & Worthington, 2003). Therefore, controlling for the potential variations in trait forgivingness across groups and conditions is important. Likewise, biological sex has been related to forgiveness, both the general tendency to forgive as well as forgiveness for a specific offense (Miller, Worthington, & McDaniel, 2008; Toussaint, Williams, Musick, & Everson-Rose, 2008). In addition, there is some evidence to suggest that men and women might respond differently to forgiveness-promoting treatments (Wade & Goldman, 2006). Therefore, biological sex might be an important covariate to control as well. The Current Study To address the limitations in this research, the present study was designed to compare two active treatments (and a waitlist control) that would treat an adequate number of participants and were

5 4 D. B. Goldman and N. G. Wade conducted by facilitators who were trained with equal emphasis in both treatments and were not a part of the research team (thus limiting unequal therapeutic allegiance; see Group Facilitators below). In addition, multi-level modeling was used to account for the nested design, so that individual- and group-level effects could be separated. Finally, additional outcome variables have been addressed, including state hostility and state rumination. In designing this study, the researchers expected that the two active treatments would show no statistical or clinically meaningful differences in the outcome variables, but would both be superior to the waiting list condition. This expectation was based on forgiveness research that has shown that bona fide therapeutic treatments are equally effective for promoting forgiveness when administered by individuals with little to no allegiance to the treatments (e.g., Wade et al., 2009). In addition, research on common factors in psychotherapy treatment has indicated that what treatments share (e.g., therapeutic alliance, hope for change) is often more powerful for producing change than factors specific to different treatments (Wampold, 2001). Method Participants Group members. A total of 113 students from a large Midwestern university participated in the study. Females constituted 61.9% of the participants (n 70; 38.1% males, n 43). Participants ages ranged from 18 to 46, with a median age of 20 years (M 21.1, SD4.3). The majority (n 99, 87.6%) were unmarried, whereas 7.1% (n 8) were engaged and 5.3% (n6) were married. In regard to religious affiliation, 29.2% (n 33) indicated that they were Protestant, 25.7% (n 29) indicated Catholic, 21.2% (n 24) indicated Other (which included 14 people who indicated an alternate form of Christianity, such as nondenominational), 18.6% (n 21) indicated None, 1.8% (n 2) Hindu, and 0.9% (n 1) Jewish (2.7% did not indicate religious affiliation). The majority of participants were European-American (n 102, 90.3%), with others identifying as Asian-American (n 5, 4.4%), Hispanic/Latino (n 3, 2.7%), or African-American (n 2, 1.8%). One participant (0.9%) did not indicate race/ethnicity. The racial/ethnic composition of the sample was approximately proportional to that of the student population of the university. At the start of the study, 9.0% (n 10) participants reported that they were currently receiving counseling outside the intervention study. Group facilitators. Facilitators (n 5) were one male and four female doctoral students in an APAaccredited counseling psychology program. The facilitators ranged in age from 25 to 29 and were all European-American. Two of the facilitators were primarily interpersonal process in therapeutic orientation, one was primarily Cognitive Behavioral (CB), and two indicated that they favored both a CB and interpersonal process approach equally. All facilitators had completed a course in group counseling (focused on interpersonal process but covering structured groups as well), a minimum of two semesters of practicum in individual counseling (one semester focused on CB treatments and one on interpersonal process), and had either co-led or observed a minimum of one counseling group. Facilitators also received 3 hours of specialized training for each treatment and instruction from a licensed counseling psychologist to conduct the interventions from the manuals. The trainer emphasized the benefit of the two treatments equally, by providing empirical support for each treatment, discussing the treatments as being potentially helpful for people in different ways, and explicitly avoiding any discussion of the research design or hypotheses. Furthermore, none of the group facilitators was involved with any aspects of the research. They did not participate in developing the study design or materials, were not involved with IRB approval, did not collect data from participants, and were not involved in the analysis or write-up of this study. They were basically contract therapists who were trained to conduct treatments with clients, much as would be conducted in a community mental health agency, private practice, or university counseling center. The same licensed psychologist who trained the facilitators provided weekly supervision. 1 In order to help control for potential facilitator effects, each facilitator led at least one six-session group for each experimental intervention. Measures Transgression Related Interpersonal Motivations-Revenge Subscale. One measure utilized to assess forgiveness-related dimensions was the Revenge subscale of the Transgression Related Interpersonal Motivation Scale (TRIM; McCullough et al., 1998). The TRIM measures motivations to seek revenge against and avoid a specific offender. We only used the revenge subscale because the interventions were not necessarily intended to help participants reduce avoidance (i.e., increase reconciliation), because this may be unwise or even unsafe in some situations. The Revenge subscale is composed of five statements

6 (e.g., I want him/her to get what he/she deserves ) that participants rate on a 5-point Likert-type scale (1 strongly disagree, 5 strongly agree). McCullough and his colleagues have reported both subscales to have adequate internal consistency (alphas ].85), 9-week test-retest reliability (rs.64 and.65 for avoidance and revenge, respectively), and adequate convergent and discriminant validity (McCullough et al., 1998; McCullough et al., 2001). In the present study the Cronbach s alphas ranged across time periods from.87 to.94. Batson s Empathy Adjectives. Emotional empathy for one s offender was assessed using Batson s Empathy Adjectives (BEA; Batson, 1987, 1991). The scale is composed of eight affective terms, such as softhearted and compassionate. Participants are instructed to rate their attitudes toward the offender...right now as you think about this event using a 6-point Likert-type scale (1 not at all, 6 extremely). Reliability estimates for this scale have generally been high, with Batson (1991) reporting estimates ranging from.79 to.95. Researchers have found the scale to have high internal reliability (a s.94,.95) in previous forgiveness intervention studies (Wade & Goldman, 2006). Extensive research on this instrument has demonstrated the construct validity (Batson, 1991) and convergent validity with other measures of empathy (Batson, 1987) and perspective-taking (Batson, Bolen, Cross, & Neuringer-Benefiel, 1986). In the current study, Cronbach s alphas ranged across time periods from.92 to.97. Rumination about an Interpersonal Offense Scale. The Rumination about an Interpersonal Offense Scale (RIO; Wade et al., 2008), a six-item scale, was used to measure rumination about the specific interpersonal offense being reported by participants. Participants are instructed to indicate the degree to which you agree or disagree with the following statements about your current experience with the person who hurt you. Sample items include I find myself replaying the events over and over in my mind and Memories about this person s wrongful actions have limited my enjoyment of life. Items are rated on a 5-point Likert-type scale (1 strongly disagree, 5 strongly agree). Exploratory and confirmatory factor analyses have established a single-factor structure for the RIO. Construct validity was established by Wade et al. (2008) by comparing responses on the RIO with those of inventories measuring related constructs, including angry rumination, and state and trait forgiveness. While the RIO measures situationspecific rumination, it is moderately correlated Forgiveness interventions 5 (r.51) with measures of dispositional rumination (Wade et al., 2008). In Wade et al. s study, the internal consistency was estimated to be.90. In the current study Cronbach s alphas ranged across time periods from.88 to.91. State Hostility Scale. The State Hostility Scale (SHS; Anderson, Deuser, & DeNeve, 1995) is a 32- item measure of situation-specific hostility. The scale is composed of short sentences all starting with the stem, I feel... followed with descriptors that are related to hostility (e.g., I feel outraged, I feel furious ). Participants rate the degree to which they agree or disagree with the statements on a 5-point Likert scale (from 1 strongly disagree to 5 strongly agree). Cronbach s alphas range from.81 to.96 (Anderson et al., 1995; Anderson, Anderson, & Deuser, 1996). In the current study Cronbach s alphas ranged across time periods from.92 to.95. Brief Symptom Inventory. The Brief Symptom Inventory (BSI; Derogatis, 1993) is a 53-item inventory used to assess a variety of psychological symptoms. The BSI evaluates nine core dimensions of symptoms (e.g., depression, anxiety), and offers more comprehensive indices of distress (e.g., Global Severity Index). Participants respond to statements about symptoms that all followed the stem, In the past 7 days, how much were you distressed by... All items are rated using a 5-point Likert-type scale (0 not at all, 4 extremely). For the present study we used the Global Severity Index (GSI), which has been shown to have a high internal consistency (.77.90) and 1-week test-retest reliability (.80.90) with a diverse population (Derogatis, Rickels, & Rock, 1976). Convergent validity of the GSI has been demonstrated with the clinical, Wiggins, and Tryon scales of the MMPI, while predictive validity has been indicated in the adjustment of cancer patients, bereaved adults, and drug-dependent clients (Derogatis, 1993). In the current study Cronbach s alphas ranged across time periods from.95 to.97. Covariate Trait forgivingness. The Trait Forgiveness Scale (TFS; Berry et al., 2005) is a 10-item self-report measure of proneness to forgive interpersonal transgressions across time and situations. Sample items include I can forgive a friend for almost anything and I feel bitter about many of my relationships. Participants are instructed to indicate the degree to which you agree or disagree with each statement using a 5-point Likert-type scale (1 strongly disagree, 5 strongly agree). Berry and his colleagues

7 6 D. B. Goldman and N. G. Wade reported Cronbach s alpha coefficients between.74 and.80, as well as an 8-week test-retest reliability of.78. The scale s validity was further corroborated through correlations with other measures of dispositional forgiveness and a variety of other personality traits in expected directions (Berry et al., 2005). In the present study, the Cronbach s alpha was.84. Procedures Prior to recruitment of participants, the following procedures were approved by the Institutional Review Board at Iowa State University. All participants entered the study via one of two recruitment avenues. First, undergraduate students in psychology courses were invited to participate to fulfill the research experience option of their classes. Second, fliers were posted in campus buildings and advertisements were placed in the campus newspaper seeking participants. Admission to the study was based on responses to an initial screening questionnaire. In order to meet the criteria to take part in the study, potential participants must have responded affirmatively to a single item assessing forgiveness ( Can you think of a time when someone hurt or offended you in a significant way? [Yes or No]. Those who answered Yes were then directed to complete the Revenge subscale of the TRIM (McCullough et al., 1998). Individuals scoring at or above a 10 on the scale were deemed eligible for the study. This score reflected an average item response of 2 (for which item responses can range from 1 to 5), suggesting that a respondent who responded in this manner would still have a legitimate hurt to overcome. Individuals who did not meet these cutoff criteria for eligibility were given referral information about local mental health service providers where they could address any concerns they might have. All groups were primarily psychoeducational in nature, involving a mix of didactic materials, interactive exercises, and personal sharing. Each treatment intervention followed a specific treatment manual (for more detail on the specific treatments, see below). The treatments involved six, twiceweekly, 90-minute group sessions that took place over three consecutive weeks. Participants were randomly assigned to one of three conditions: an intervention designed to help manage and reduce anger (Anger Reduction), an established intervention designed to promote interpersonal forgiveness (REACH; Worthington, 2001), and a waitlist control condition. We randomized the assignments by using a random-number generator ( which provided a number 13 (corresponding to the conditions Anger Reduction, REACH, and Waitlist, respectively) for each participant. The number assignments were limited in such a way that each condition would receive an equal number of participants. Data were collected at four time points: immediately prior to participation in the first treatment session (pre-treatment), right after the third session, which was the group treatment halfway point (mid-treatment), immediately following the sixth and final treatment session (post-treatment), and at 3 weeks following the treatment (follow-up). Participants in the treatment and waitlist conditions received $15 US each time they completed a questionnaire packet. In addition, most participants were enrolled in psychology classes in which they were awarded partial credit toward research participation options in their courses. Treatment Interventions REACH. The experimental treatment was based on Worthington s (2001) Pyramid Model to REACH Forgiveness. REACH is an acronym that stands for the five main components of the treatment: Recall the hurt, Empathize with the offender, [giving an] Altruistic gift, Commit to forgiveness, and Hold onto forgiveness. The six-session REACH program for this study was based on a program that has been used in previous research (e.g., Wade et al., 2009) and is described in Worthington s (2001) book, Five Steps to Forgiveness: The Art and Science of Forgiving. In the first session, participants explored what is and is not meant by forgiveness, with special emphasis given to the notion that forgiveness does not require reconciliation. In the second session, participants recalled the hurtful experiences and shared them with the group. The third session provided additional time to disclose the offense and attend to emotions that surfaced as a result. The fourth session introduced empathy. Included in this session was a video clip from a popular film that illustrates how empathy could be reached even in a hurtful situation. Participants also completed exercises intended to help them develop empathy, such as writing a letter as if they were the offending person, explaining some of the reasons why they, as the offenders, committed the offense. The fifth session provided more opportunity to develop empathy for the offending person. In addition, participants recalled times when they had hurt others and had wished to be forgiven. This forgiveness, which participants envisioned themselves receiving and giving, is framed as an altruistic gift. In the sixth and final session, participants who feel they are ready to forgive their offenders developed personal ways to commit to their decisions to forgive. Various strategies were discussed (e.g., Write out a list of all the

8 hurts and then burn, bury, or shred the paper and Tell a trusted friend that you have forgiven the offender ). Participants then wrote a letter of forgiveness to their offenders (not actually to be sent). Finally, participants shared with one another their experiences over the six sessions and the treatment was concluded. Anger reduction intervention. The alternative intervention was focused on reducing anger and hostility. Interventions were developed from effective anger management techniques, such as relaxation, cognitive restructuring, and social skills building (for a review see, Deffenbacher, Oetting, & DiGiuseppe, 2002) with one significant alteration. Participants in our study were not necessarily dealing with problem anger as are many clients who participate in anger management treatment. Therefore, all interventions were tailored for people dealing with past offenses who were still angry about them and wanted to resolve that anger. In addition, the treatment did not address forgiveness as a target outcome and use of the word forgive and its derivatives was expressly avoided. The first session in this intervention was similar to the first session in the REACH intervention; participants discussed letting go of grudges, the drawbacks and benefits of this, and how that might be similar to and different from reconciling with the offender. The second session was devoted to developing insight into one s anger and style of experiencing and expressing anger. In addition, time was spent focusing on understanding anger in general, its defining features, uses, benefits, and drawbacks. In the third session, participants identified and challenged negative beliefs about anger (e.g., Good people don t feel angry and Holding onto my anger is the only way to get what I want ). They noted how they experienced anger as they recalled the hurtful event and practiced relaxation exercises (both deep muscle relaxation and guided imagery about the offense). Session four explored alternatives to retaliation, revenge fantasies, and angry rumination. Instead, participants were provided both the rationale and skills to cope with hurts and personal boundary violations without harboring grudges. They worked to develop strategies for staying safe and protecting themselves, for example by setting limits through assertive communication. In the fifth session, participants explored how harboring a grudge, and thereby continuing to feed their anger, was ultimately hurtful to them. They practiced the relaxation skills again and worked on cognitively reframing the hurtful event. To do this, participants explored the possible side benefits of the offense, despite all the pain and difficulty it had created. The Forgiveness interventions 7 sixth and final session mirrored the final session of the REACH intervention in that the primary emphasis was placed on committing to release the grudge. Various strategies were discussed and participants were encouraged to complete a contract to release the grudge. Waitlist condition. Data were collected from participants assigned to the waitlist control condition at the same times they were collected from those assigned to the experimental interventions. Once data collection had been completed, all waitlist participants were offered the opportunity to participate in a 1-day intensive group experience that covered the materials in the REACH treatment. The REACH treatment was chosen because there was more research on that approach toward helping people with a past hurt than the alternative treatment. Results Preliminary Analyses Comparability of drop-outs and completers. Approximately 28% of those starting the treatment dropped out of the study. Although we were not able to contact all those who dropped out, those who did respond to our inquires reported several different reasons for dropping out, including change in schedule, no longer needing/wanting the research credits, and disinterest/discomfort with the group setting. The most frequent reason for dropping out was a schedule change or difficulty. As a result of the participant drop-out, it was important to determine if any differences existed between those who completed the study and those who did not on relevant variables. 2 Therefore, we conducted a series of independent samples t-tests to determine whether important differences existed in any of the outcome variables and the covariate (trait forgivingness) at pre-treatment between completers and those who dropped out. No significant differences (p B.05) were found. We also examined whether there were differences between these groups in sex and treatment condition through chi-square analyses. Neither of these analyses revealed any significant differences. Therefore, the completers and drop-outs were similar on all study variables. 3 For the group of completers, the mean number of sessions attended out of six was 4.28 (SD1.56) with a median of five sessions attended. Categorization of offenses. Classification of interpersonal offenses was performed by trained research assistants in accordance with guidelines

9 8 D. B. Goldman and N. G. Wade Completed informed consent and were screened: 130 Participants randomized: 112 Not eligible for study: 17 Dropped out after screening: 1 Assigned to REACH treatment: 41 Assigned to Anger Reduction treatment: 39 Assigned to the waitlist control group: 32 Downloaded by [Iowa State University], [Nathaniel G. Wade] at 14:44 13 June 2012 Received REACH treatment Completed post-tx assessment: 29 (71% retention) Completed 3 week follow-up: 15 (37% retention) Figure 1. Flow of participants through the study. developed by Leary, Springer, Negel, Ansell, & Evans (1998). The majority (57.6%) of offenses described by participants were classified as interpersonal betrayals, with 29.7% of reported offenses being betrayals by a romantic partner (mostly infidelity). Other hurts were being mocked or teased (9.9%), being left by other people (9.9%), being criticized (4.5%), and being taken for granted (1.8%). The rest were either unclassifiable (13.5%), such as being robbed or missing (2.7%). Treatment fidelity. Preliminary analyses of treatment fidelity revealed that both treatment interventions were administered in accordance with the treatment manuals. In order to measure adherence to the manuals, two research assistants who were blind to the hypotheses of the investigation were trained to analyze video recordings of the group sessions to see if the interventions matched the prescribed foci of the treatment manuals. For each session of each treatment conducted, a computer Received Anger Reduction treatment Completed post-tx assessment: 28 (72% retention) Completed 3 week follow-up: 20 (51% retention) Waiting for treatment Completed post-tx assessment: 24 (75% retention) Completed 3 week follow-up: 9 (28% retention) Received REACH treatment program randomly generated three numbers between 0 and 89. These numbers represented the minutes of each 90-minute group session. Research assistants cued the video of each session to the time markers (i.e., number of minutes into the session) corresponding to the generated numbers and then watched a 3-minute clip starting from that time point. As such, for each six-session treatment, 18 time points were generated (three times for each of six group sessions). A total of 13 six-session treatments were carried out, for a total of 234 time points assessed. A total of 44 time points (19%) were not assessed due to technical problems, such as no sound or no video. Two time points did not match the manual because the sessions started late and three time points did not match because the sessions finished earlier than anticipated. This left 185 (79%) time points that raters were able to assess, of which 183 (99%) were rated as adhering to the manual.

10 Facilitator effects. In order to examine potential facilitator effects, five 35 (facilitator) mixed ANO- VAs were conducted with facilitator as the independent variable and each of the outcomes as dependent variables. In all cases, the timefacilitator interaction effect was not significant, suggesting that there were no differences in the degree of change based on the facilitators. However, the small number of participants per facilitator might mask smaller effects (i.e., inadequate power to detect small or moderate effects on the interaction term). Therefore, we analyzed a graph of average change for each outcome over the three time points for each facilitator. The pattern was similar for each facilitator across the outcome variables. Main Analyses A correlation matrix of study variables is reported in Table I and means, standard deviations, and effect sizes for all outcome variables are reported in Table II. Due to the nested structure of the data, we conducted multi-level regression analyses for each of the five outcome variables (i.e., revenge, rumination, hostility, empathy, and psychological symptoms) to account for time (level 1) being nested within person (level 2) and person nested within group (level 3) (Table III). Following the recommendations of Tasca, Illing, Joyce, and Ogrodniczuk (2009), we built a three-level multi-level regression model accounting for individual and group pre-treatment scores on the outcomes that included our variables of interest (time and treatment condition) and the covariates (trait forgiveness and sex). With three conditions (i.e., REACH, Anger Reduction, and Waitlist), treatment condition was dummy coded into two variables such that the main experimental condition, REACH, was compared against the alternative treatment in the first variable and against the waiting list condition in the second variable. These variables were entered into the equation as group level (level-three) variables. To control for the effects of sex and trait forgivingness, these variables were entered into the model as individual-level (level-two) variables. As a continuous variable, trait forgivingness was group mean centered before being entered. These variables were included in the model such that they predicted both the intercept and the slope of the outcome variable, indicating (a) the value of the outcome when all predictors are zero and (b) change in outcome, respectively. However, we were interested only in the change in outcome (i.e., slope predictors) and so only those are reported. Time was entered as the level-one variable, such that data from the Forgiveness interventions 9 outcome variables were included as pre, mid and post treatment. We then conducted five multi-level regression analyses, one for each of the five outcome variables. Although we conducted five separate analyses, we still used a significance cut-off of.05. We used this more liberal cut off to investigate any possible differences because (a) this is a relatively new area of investigation that could lead to more powerful and specific future research; (b) group counseling research puts a heavy burden on participant and group numbers and we wanted to maximize the data we were able to collect; and (c) we also conducted clinical significance tests (see below) to determine the relative importance of our findings beyond the simple statistical significance. Revenge. The results of the multi-level regression predicting desires for revenge indicated that over the course of treatment, those in the REACH treatment condition reduced desires for revenge more than those in the waiting list condition, B.56, SE.18, p.01. However, there was no significant difference between the REACH treatment and the Anger Reduction treatment. In addition, the time main effect was significant, B 1.20, SE.18, p B.001. Rumination. The results for rumination about the offense indicated that treatment condition did not predict change. However, there was a significant main effect for time, B2.15, SE.35, p B.001. This indicates that all participants, regardless of treatment condition, sex, or trait forgivingness, reduced their rumination about the offense to a similar degree. This can also be seen in Table II, where participants in each condition reported a reduction in rumination from pre- to post-treatment of about one half of a standard deviation (Cohen s d s of.47,.47, and.51). Hostility. Changes in hostility toward the offender indicated that the REACH condition was more effective at reducing hostility than the alternative condition, B5.99, SE2.04, p.01, and the waiting list condition, B8.56, SE2.43, p.005. This indicates that those in the REACH condition reduced hostility toward their offenders more than participants in the other two conditions. Empathy. The results for empathy indicated that the REACH treatment was more effective at promoting empathy for the offender than the alternative treatment, B2.02, SE.53, p.003, and the waiting list condition, B 2.21, SE.43, p B.001. Unlike the other outcomes where all

11 Table I. Correlations among study variables Rev_pre 2. Rev_mid.77* 3. Rev_post.69*.79* 4. Rum_pre.35*.26.29* 5. Rum_mid.11.28*.34*.69* 6. Rum_post.25.31*.38*.71*.80* 7. Host_pre.57*.50*.40*.57*.49*.46* 8. Host_mid.30*.53*.40*.31*.56*.40*.60* 9. Host_post.40*.50*.53*.38*.49*.52*.62*.83* 10. Emp_pre.26*.33* Emp_mid.29*.34* * 12. Emp_post.20.31* *.34*.32*.63*.76* 13. GSI_pre.34*.20.35*.43* * GSI_mid *.27*.33*.30*.26*.23.29* * 15. GSI_post.30*.35*.36* * * *.81* 16. TFS.41*.34*.34*.47*.24.29*.50*.23.33* *.38* Sex Note. Rev_pre, mid, post desires for revenge at pre-, mid-, and post-treatment; Rum_pre, mid, post rumination about the offense at pre-, mid-, and post-treatment; Host_pre, mid, post hostility toward the offender at pre-, mid-, and post-treatment; Emp_pre, mid, post empathy for the offender at pre-, mid-, and post-treatment; GSI_pre, mid, post Global Severity Index of the Brief Symptom Inventory (BSI) at pre-, mid-, and post-treatment; TFS trait forgivingness; Sex biological sex with female 0 and male 1. Sample sizes for the correlations range from 80 to 111. *pb D. B. Goldman and N. G. Wade

12 Table II. Means and standard deviations for outcome variables Revenge Rumination Hostility Empathy Psych symptoms Condition pre mid post pre mid post pre mid post pre mid post pre mid Post Downloaded by [Iowa State University], [Nathaniel G. Wade] at 14:44 13 June 2012 REACH Tx (4.5) (3.9) (3.7) (6.6) (5.2) (5.5) (22.7) (19.7) (22.0) (7.0) (7.1) (9.0) (.65) (.67) (.55) n a Effect size b.49 (.28, 1.25).51 (.48, 1.50).81 (3.48, 5.09).21 (.94, 1.36).51 (.23,.83) Anger Tx (4.0) (4.0) (3.6) (5.8) (4.9) (5.9) (18.5) (21.5) (20.4) (8.9) (9.0) (8.4) (.55) (.41) (.53) n Effect size.24 (.47,.95).47 (.52, 1.45).57 (2.25, 3.39).37 (1.54,.72).17 (.04,.38) Waiting list (5.2) (4.9) (3.8) (6.5) (6.0) (5.8) (17.9) (20.6) (22.2) (10.1) (8.9) (7.5) (.61) (.65) (.55) n Effect size.29 (.42,.99).47 (.53, 1.48).35 (1.93, 2.62).37 (1.50,.85).17 (.01,.35) a Data provided only for those who completed questionnaires at all three time points. b Effect size is the Cohen s d pre-to-post treatment effect size as calculated by M post M pre SD pooled, where rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ðn SD pooled ¼ 1 1ÞSD 2 1 þ...þðn j 1ÞSD2 j with one alteration: negative signs were used to indicate change in a negative direction, or indications of deterioration rather than improvement in the outcome ðn 1 1Þþ...þðn j 1Þ variable. Also, 95% confidence intervals follow each of the effect sizes in parentheses. Note. Psych symptoms refers to psychological symptoms as assessed with the Global Severity Index of the Brief Symptom Inventory (BSI). Forgiveness interventions 11

13 12 D. B. Goldman and N. G. Wade Table III. Results of multi-level regression analyses for each outcome variable Predictors Time Sex Trait forgivingness REACH vs. ANGER REACH vs. WL Outcomes B SE p B SE p B SE p B SE p B SE p Revenge Rumination Hostility Empathy Symptoms Note. These data include the outcomes assessed at pre-, mid-, and post-treatment. WL is the waiting list condition. All p values are exact, except for.000. In these cases, the p value was below.001. Symptoms refers to psychological symptoms as assessed with the Global Severity Index of the Brief Symptom Inventory (BSI). Downloaded by [Iowa State University], [Nathaniel G. Wade] at 14:44 13 June 2012 change was in a positive direction and the REACH treatment (when significantly different) simply led to more change, for empathy the REACH treatment was the only treatment that led to a positive change. Participants in the other two conditions on average decreased empathy over the course of time. Therefore, although the pre-to-post effect size for the REACH treatment was not that large (.21, see Table II), when compared with effect sizes of.37 and.37 indicating change in the opposite direction for the alternative treatment and waiting list conditions, respectively, the differential effect was considerable. Psychological symptoms. The results for psychological symptoms indicated that the REACH treatment was more effective for reducing symptoms than the alternative treatment, B.11, SE.05, p.03, and the waiting list condition, B.14, SE.05, p.02. Clinically Significant Change Although statistical significance is an important measure of change following treatment, there are a number of ways to assess change that may be more reliable and clinically meaningful (Bauer, Lambert, & Neilsen, 2004). Jacobson and Truax (1991) outlined one method for assessing reliably and clinically significant change that we have adopted for our data. All clinically significant change analyses were conducted on the data at post-test. Reliably significant change was assessed with the Reliable Change Index (RCI), which is estimated by dividing the difference between pre- and posttreatment scores by a variant of the standard error of measurement. As suggested by Bauer et al. (2004), we used previously established internal consistency reliabilities of the outcome measures when available (which was the case for all the variables except GSI, where we used the test-retest reliability published in the manual). This assessment provided an estimate of whether participants changed reliably in a positive direction (improvement), in a negative direction (deterioration), or did not change. Then, to measure clinically meaningful change, we calculated a cut-off score for each outcome that would represent an estimated difference between a distressed and normal level of the variable. In all but one case we used Jacobson and Truax s third method (cut-off C), which is the weighted average between a clinical sample and a comparable sample which was not distressed. Because we did not have adequate samples from previous research for the hostility measure, we used cut-off A, which is two standard deviations below the mean of the current sample. For the other four variables we accessed published reports and previous data to determine the clinical and non-clinical norms for each measure. With the reliably and clinically significant change criteria combined, four categories of outcomes emerge: Recovered (reliable change below the cutoff), Improved (reliable change not below the cutoff), No Change (no reliable change), and Deteriorated (reliable change in a negative direction). Categorization of the participants across treatment condition appears in Table IV. Several themes emerged from these results. First, mirroring the results above, several outcomes showed the superiority of the REACH condition (e.g., 31% improved or recovered on empathy, whereas in the Anger and Waitlist conditions only 4% did). Second, there was a minority of participants who deteriorated on the outcomes, the largest numbers being on empathy (1429%). Third, the majority of participants did not show change beyond what might be expected as a result of measurement error on the outcome variables (range from 41% to 75%). This might be expected given the nature of the offenses and the short duration of the treatment.