Forgiveness Is An Emotion-Focused Coping Strategy That Can Reduce Health Risks and Promote Health Resilience - Theory, Review, and Hypotheses

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Forgiveness is an emotion-focused
coping strategy that can reduce health
risks and promote health resilience:
theory, review, and hypotheses
a a
Everett L. Worthington Jr. & Michael Scherer
a
Virginia Commonwealth University
Version of record first published: 01 Feb 2007.
To cite this article: Everett L. Worthington Jr. & Michael Scherer (2004): Forgiveness is an emotion-
focused coping strategy that can reduce health risks and promote health resilience: theory, review,
and hypotheses, Psychology & Health, 19:3, 385-405
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Psychology and Health
June 2004, Vol. 19, No. 3, pp. 385–405
FORGIVENESS IS AN EMOTION-FOCUSED
COPING STRATEGY THAT CAN REDUCE HEALTH
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RISKS AND PROMOTE HEALTH RESILIENCE:

THEORY, REVIEW, AND HYPOTHESES
EVERETT L. WORTHINGTON, JR.* and MICHAEL SCHERER
Virginia Commonwealth University
(Received 26 September 2002; Revised 9 June 2003)
Experimental evidence suggests that when people are transgressed against interpersonally, they often react by
experiencing unforgiveness. Unforgiveness is conceptualized as a stress reaction. Forgiveness is one (of many)
ways people reduce unforgiveness. Forgiveness is conceptualized as an emotional juxtaposition of positive
emotions (i.e., empathy, sympathy, compassion, or love) against the negative emotions of unforgiveness.
Forgiveness can thus be used as an emotion-focused coping strategy to reduce a stressful reaction to a trans-
gression. Direct empirical research suggests that forgiveness is related to health outcomes and to mediating
physiological processes in such a way as to support the conceptualization that forgiveness is an emotion-
focused coping strategy. Indirect mechanisms might also affect the forgiveness-health relationship. Namely,
forgiveness might affect health by working through social support, relationship quality, and religion.
Keywords: Forgiveness; Coping strategy; Health risks
In 1997, research on forgiveness consisted of only 58 empirical studies (McCullough

et al., 1998). Since then, that number of studies has more than quadrupled.
We define two types of forgiveness – decisional and emotional. We closely examine
the emotional forgiveness as being rooted within the individual and involving emotional
experiences (though transgressions usually occur in interpersonal contexts). We use a
stress-and-coping framework and show that emotional forgiveness might be one of
many coping strategies people use to deal with transgressions, perceived injustices,
and the emotion of unforgiveness. We hypothesize that unforgiveness produces ill
health and emotional forgiveness might lessen health risks. We submit this conceptuali-
zation in terms of four theoretical propositions and adduce initial evidence bearing on
them. Finally, if the propositions are (at least partially) supported, physical mechanisms
must underlie the relationship between forgiveness and physical health. We suggest
possible physical mechanisms – direct and indirect – based on research in the neuro-
science of anger (Pietrini et al., 2000), the study of anger and health (Williams
and Williams, 1993), and the emerging field of positive psychology and its health
*Corresponding author. E-mail: eworth@vcu.edu
ISSN 0887-0446 print: ISSN 1476-8321 online ß 2004 Taylor & Francis Ltd
DOI: 10.1080/0887044042000196674
386 E.L. WORTHINGTON AND M. SCHERER
implications (Salovey et al., 2000; Fredrickson, 2001). Finally, we sketch out a research
agenda based on our theorizing and review.
DEFINITIONS AND THEORETICAL CONTEXT
Researchers who study forgiveness have used many theoretical understandings of the
construct. Most agree that forgiveness is complex (Enright and Fitzgibbons, 2000).
It involves cognitive (Flanigan, 1992), affective (Malcolm and Greenberg, 2000), behav-
ioral (Gordon et al., 2000), motivational (McCullough et al., 1997), decisional (DiBlasio,
1998), and interpersonal (e.g., Baumeister et al., 1998) aspects. Researchers do not agree
about which aspects are most important.
Worthington (2003) has proposed that two types of forgiveness exist – decisional and
emotional forgiveness. Decisional forgiveness is a behavioral intention statement that
one will seek to behave toward the transgressor like one did prior to a transgression.
One decides to release the transgressor from the debt (Baumeister et al., 1998; DiBlasio,
1998). One might grant decisional forgiveness and still be emotionally upset, cognitively
oriented toward angry, anxious, or depressive rumination, and motivationally oriented
toward revenge or avoidance. However, in some cases, decisional forgiveness could
trigger emotional forgiveness.
The second type of forgiveness is called emotional forgiveness. Worthington and his
colleagues have defined forgiveness as rooted in emotions (Worthington and Wade,
1999; Worthington, 2000; Worthington et al., 2001), which affect motivations. They
theorize that people who are offended or hurt experience an injustice gap, which is
described as the difference between the way one would prefer a transgression to be
fully resolved and the way they perceive the situation currently (Exline et al., 2003).
The injustice gap widens as subsequent events aggravate the person or narrows as
subsequent events mitigate the injustice. Magnitude of the injustice gap is hypothesized
to be inversely proportional to ease of forgiving and directly proportional to unforgive-
ness. They define unforgiveness as a complex combination of delayed negative emotions
toward a person who has transgressed personal boundaries. Immediate negative
emotions include anger, fear, or both. Anger is typically thought to be an emotional
state that arises due to a threat, frustration, or perceived transgression (Spielberger
and Moscoso, 1999). Unforgiveness is more a limited, nuanced, and delayed response
to a perceived transgression. Unforgiveness is not thought to arise from threat or
frustration. Anger can also become a trait (Spielberger and Moscoso, 1999) generalized
across situations and time. Numerous researchers have studied anger and its effects on
health (e.g., Williams and Williams, 1993; Gallo and Matthews, 2003). Mostly, anger
affects cardiovascular health (Gallo and Matthews, 2003). Reviewing the literature
on anger and health would be beyond the scope of the present article. Delayed negative
emotions – resentment, bitterness, hostility, hatred, anger, and fear (the combination
of which is unforgiveness – may derive from rumination. Worthington and Wade
(1999) have differentiated anger and unforgiveness. Not everyone will develop unfor-
giveness when transgressed against. Only people who ruminate angrily (and perhaps
anxiously and depressively) will likely develop unforgiveness. People try to reduce
negatively experienced unforgiveness by dealing with the transgression to rectify it
(thereby leading to a narrowed injustice gap and less unforgiveness) or by dealing
with the emotion directly.
FORGIVENESS AS EMOTION-FOCUSED COPING 387
Worthington (2001) identified over 25 ways by which people attempt to reduce unfor-
giveness. They can try restore justice through seeking retaliation or revenge, pursuing
legal or political justice, seeking restitution, demanding an apology, or appealing to
divine justice. People also might try to create a new narrative about the transgression
(i.e., perhaps excusing or justifying it). People might try to reduce their unforgiveness
directly by accepting the misfortune and moving on with their life (i.e., Jacobson and
Christensen, 1996). They might employ defenses such as denial and avoidance. They
might also forgive.
Worthington and Wade (1999) defined forgiveness as the emotional juxtaposition
of positive other-oriented emotions against negative unforgiveness, which eventually
results in neutralization or replacement of all or part of those negative emotions with

positive emotions. The positive emotions that lead to forgiveness have been identified
as empathy, sympathy, compassion, romantic love, and altruistic love (Worthington
et al., 2001; Wade and Worthington, 2002). Whereas the experience of some positive
emotions is necessary to neutralize unforgiveness, the person may or may not have
a net final positive emotion toward the transgressor. The forgiveness might be partial
(reduced unforgiveness) or complete (resulting in a net neutral or even net positive
emotion toward the transgressor).
Berry et al. (2001) have conceptualized unforgiveness as a stress reaction to apprais-
als of interpersonal stressors that include transgressions, betrayals, offenses, and
wrongs. Using Lazarus and Folkman’s (1984) schema, the transgression is considered
a stressor. A perception of the interpersonal stressor as a hurt or offense is considered
to be the result of primary and secondary appraisals. The appraisals create physiolog-
ical, cognitive, motivational, behavioral, and emotional stress reactions. Unforgiveness
is one emotional part of the stress reaction. People’s attempts to reduce the injustice
gap (Exline et al., 2003) and unforgiveness (Worthington, 2001) are seen as coping
strategies. Some are problem-focused coping strategies such as seeking to bring
about justice in the situation. Others are meaning-focused coping strategies such as
renarrating the event through excusing or justifying the transgression. Still others are
emotion-focused coping strategies, such as seeking to regulate the person’s emotional
experience (see Thayer and Lane, 2000). This might occur through self-soothing or
avoidance. Worthington’s definition of forgiveness as being an emotional juxtaposition
of positive emotion against the negative emotions comprising unforgiveness places it
within Lazarus and Folkman’s model as an emotion-focused coping strategy (see
Park and Folkman, 1997; Folkman and Moskowitz, 2000; McCullough, 2001).
Research on coping has shown that neither problem-focused nor emotion-focused
coping strategies per se are superior for dealing with stress (Park et al., 2001). When
direct action is possible, problem-focused coping has often been found to be superior
(Lazarus, 1999). When direct action to remove stressors is hampered, emotion-focused
coping has often been found to be superior (Lazarus, 1999). By extension, this suggests
that unforgiveness might be reduced most effectively by using different strategies (such
as seeking redress for injustice) sometimes and by forgiving at other times. Both might
be simultaneously or sequentially employed at still other times. In addition, in meaning-
focused coping (Park and Folkman, 1997), people try to modify the appraised meaning
of situations to be more consistent with their goals. Forgiving, in some cases, could
affect one’s appraisal of the meaning of the situation and could be a meaning-focused
coping strategy. In other cases, forgiving could be a problem-focused coping strategy
if it contributed to solving an interpersonal problem. Generally, though, we believe
it is usually an emotion-focused coping effort. Within this stress-and-emotion-focused-

coping framework, we suggest four principal theoretical propositions that relate
unforgiveness, emotional forgiveness, and health.
1. Unforgiveness is stressful.
2. Coping mechanisms besides forgiveness can reduce unforgiveness.
3. Forgiveness reduces the stress of unforgiveness.
4. Forgiveness as a coping strategy is related to health.
In the following section, we adduce evidence that addresses these four propositions.
DIRECT EVIDENCE PERTAINING TO THE FOUR PROPOSITIONS
Proposition 1: Unforgiveness is Stressful

To declare support for this proposition, we would have to establish that unforgiveness
could lead to physical changes similar to those produced in other stress reactions. Stress
involves decreases in prefrontal activity and associated increases in limbic-system activ-
ity and later changes in cortisol-mediated areas of the hippocampus and amygdala.
In addition, stress involves (a) stimulation of the direct pathway from hypothalamus
to adrenals with subsequent release of epinephrine, (b) stimulation of the hormonally
mediated HPA axis, (c) release of the Vagal ‘‘brake,’’ and (d) activation of the sympa-
thetic nervous system (SNS) and engagement of the visceral afferent system. Each of
these (and all in conjunction) lead to allostasis (McEwen, 2002), characterized by
increases in respiration, blood pressure, heart rate, and energy release and by decreases
in digestion, growth hormone, and sexual hormones.
There are four lines of evidence suggesting that unforgiveness is stressful and arouses
corresponding negative emotions. First, activity in the brain during unforgiveness is
consistent with activity in brain structures involved in stress and other negative emo-
tions. Pietrini et al. (2000) have examined anger using positron emission tomography
(PET) scanning with 15 participants who imagined neutral and angry scenarios.
Pietrini et al. showed that, when people become angry, cognitive activity in the ventro-
medial prefrontal cortex diminishes and limbic-system activity increases.
Unforgiveness, which has been shown to correlate highly with anger (Berry and
Worthington, 2001; Berry et al., 2001; McCullough et al., 2001), might thus have
a neuro-physical basis that identifies it as an emotion. Farrow et al. (2001) showed,
using functional MRI technology, that judgments of the fairness of a transgression
versus whether to forgive it are processed differently. Ten individuals made judgments
of social scenarios. Both empathic and forgiveness judgments activated the left superior
frontal gyrus, orbitofrontal gyrus, and precuneus. Empathy judgments also activated
the left anterior middle temporal gyrus and the left inferior frontal gyrus. Forgiveness
judgments also activated the posterior cingulated gyrus. Empathy and forgiveness
resulted in similar neural structure and function, and yet they were differentiated
from each other. McCullough et al. (1998) have demonstrated that forgiving and
empathy are often related but not overlapping.
Second, hormonal patterns – notably glucocorticoid secretion – in unforgiveness
are consistent with hormonal patterns from negative emotions associated with stress.
Berry and Worthington (2001) assessed self-reports and measured salivary cortisol
for 39 people involved in romantic relationships. They selected people who had
(a) happy ongoing versus (b) either unhappy ongoing or recently ended romantic
relationships. Baseline levels of cortisol were moderately negatively correlated with
trait forgivingness. Also, a modest change in salivary cortisol level, when thinking
about a typical interaction with the relationship partner, was related to both relation-
ship satisfaction and self-reported unforgiveness toward the partner.
Third, sympathetic nervous system (SNS) activity and EMG tension in facial muscles
are similar to patterns obtained with stress and negative emotion. Witvliet et al. (2001)
assessed 64 undergraduates using questionnaires and measures of physical responses.
Undergraduates imagined a transgressor (a) of whom they were unforgiving, (b) against
whom they held a grudge, (c) toward whom they felt empathic, or (d) whom they
had forgiven. Witvliet et al. measured self-reported (via questionnaires) unforgiveness

and forgiveness. They also used immediate joystick ratings of the person’s sense of
control, empathy, and gratitude. Participants’ heart rate and mean arterial pressure
during periods of imagination as well as skin conductance were measured. EMG
in three facial locations was recorded during participants’ imagery. Mean arterial
pressure, heart rate, and skin conductance all showed a pattern of SNS arousal when
imagining the transgression or the person against whom one held a grudge. Facial
muscle EMG was consistent with the expression of anger and fear and subtle second-
ary emotions that include both. These findings are consonant with research by other
emotion researchers (Ekman et al., 1983) and are consistent with Worthington and
Wade’s (1999) emotional juxtaposition hypothesis.
Witvliet, Worthington and Wade (2002) presented three studies that examined
students’ reactions to an imaginal crime. The three studies will be discussed below.
For now, in Witvliet, Worthington and Wade Study 3, participants were assessed physio-
logically using the same measures as in Witvliet et al. (2001). People who imagined that
they were robbery victims responded similarly to people in Witvliet et al. (2001) who had
imagined being unforgiving or holding a grudge. Thus, Witvliet et al. (2001) was repli-
cated. Lawler et al. (in press) also replicated these findings using different methods.
Fourth, measures of blood chemistry reveal a similarity between unforgiveness
and both stress and negative emotion. Seybold et al. (2001) conducted a correlational
study of forgivingness disposition and physical markers in 68 patients at a Veteran’s
Administration Medical Center. They measured corrugator EMG, blood pressure,
heart rate, plasma protein, cholesterol (LDL and HDL), non-estisfied fatty acids, trigli-
cerides, total lymphocytes, neurophils, T-cells, and T-activated cells. People who
were unforgiving chronically had blood chemistry assays that were similar to those
of people under stress. The evidence was weak: only 3 of 16 correlations were signifi-
cant. Dispositional forgivingness was correlated negatively with blood viscosity and
positively with toxicity-preventive activity. Forgiving the self was positively correlated
with the T-helper-to-T-cytotoxic ratio.
In general, research evidence to date supports the proposition that unforgiveness is
stressful. Numerous experiments using a variety of methods converge to support this
proposition.
Proposition 2: Many Coping Mechanisms Besides Forgiveness

Can Reduce Unforgiveness
Worthington (2001) hypothesized many ways to reduce unforgiveness. To support this
proposition, it would be necessary to show that, at some time after a transgression,
people could (a) report reduced unforgiveness but simultaneously report zero forgive-
ness had occurred presumably because they had gotten revenge, received an apology,
or experienced some other non-forgiving event and (b) report complete forgiveness
and not have residual unforgiveness.
Evidence that people use a variety of coping mechanisms to deal with unforgiveness
comes from two sources. First, Wade and Worthington (2002) assessed 96 psychology
student volunteers on both unforgiveness for a particular transgression and the degree
to which they had forgiven the offender for that transgression. Wade and Worthington
graphed the range of scores in unforgiveness against the degree of forgiveness. The
Transgression Related Inventory of Motivations (TRIM; McCullough et al., 1998)
was used to assess unforgiveness. The TRIM has a possible range between 12 and 60.
Students rated the degree to which they had forgiven the transgressor on a five-point
scale from 0 ¼ no forgiveness to 4 ¼ complete forgiveness. At 0 forgiveness, the range
of scores on the TRIM was from 15 to 59, reflecting the full range of unforgiveness.
Some people virtually eliminated unforgiveness without forgiving. They must have
done so by using some alternatives to forgiving. With each subsequent unit of increase
in forgiveness, the range of scores on unforgiveness narrowed. People who said they
had completely forgiven the perpetrator had a range on the TRIM that extended
only from 12 to 31. When people forgave completely, they eliminated almost all their
unforgiveness.
Second, as we alluded to above, Witvliet, Worthington and Wade (2002) examined
the relationship between offender apology, restitution, both, and neither (using a
2 2, apology restitution design) and victim responses to an imaginary robbery sce-
nario. Participants completed questionnaires, were instructed to imagine that they had
been robbed, and were assessed again. They then were told that the next day the offen-
der (a) apologized, (b) sent back the stolen money plus an additional money (i.e., res-
titution), (c) both, or (d) neither. People were assessed on a third time. In Study 3,
besides completing questionnaires, participants were assessed on SNS markers and
facial EMG at baseline and while imagining responding to scenarios.
In Study 1, participants were told that the offender’s note merely said that he or she
was sorry for taking the stolen items (i.e., a weak apology). In Study 2, the offender
made a strong apology – several expressions of regret, contrition, and remorse along
with the statement of being sorry. In Studies 1 and 2, Witvliet, Worthington and
Wade (2002) used a between-subjects design. In Study 3, which included the physiolo-
gical measures, Witvliet et al. used a within-subject design. People imagined each of the
four conditions counterbalanced for order. In all studies, participants self-reported the
degree of unforgiveness they still felt toward the offender and the amount to which they
had forgiven the offender.
In Study 1, restitution reduced self-reported unforgiveness. However, the weak
apology reduced unforgiveness minimally. In Study 2, the strong apology produced
as much reduction in unforgiveness as did making restitution. Furthermore, the two
effects added together when the perpetrator both strongly apologized and offered res-
titution. In Study 3, Witvliet, Worthington and Wade (2002) replicated the self-report
findings of Study 2. They also found some physiological differences among the con-
ditions (e.g., heart rate, corrugator [brow muscle] EMG, and obicularis oculi [eye
muscle] EMG). They did not find differences for mean arterial pressure, skin
conductance, or zygomatic (smile muscle) EMG. It is instructive to compare the phy-
siological responses from Witvliet, Worthington and Wade (2002), who attempted to
promote victims’ judgments of repaired injustice through receiving an offender apology,

restitution, or both, with Witvliet et al. (2001), who had people imagine having empathy
for offenders or forgiving them. The measures of mean arterial pressure, heart rate, skin
conductance, and facial EMG at three sites were the same in both studies for (a) no
offender apology or restitution (Witvliet et al., 2002) and (b) imagining someone
against whom held a grudge or was unforgiving (Witvliet et al., 2001). However,
when people imagined forgiving or having empathy for an offender (Witvliet et al.,
2001), they experienced reduced heart rate, mean arterial pressure, skin conductance,
and facial EMG at three locations. In Witvliet et al. (2002), though, participants in
‘‘justice’’ conditions (i.e., offender apology, restitution, or both) had reduced heart
rate (but not blood pressure or skin conductance) and lower facial EMG on two of
the three facial muscles. Apparently, perceiving justice to have been done does not
have quite as much physiological effect as does forgiving. This is consistent with
Worthington’s theorizing about apologies and restitution (Worthington, 2000; see
also Exline et al., 2003). He hypothesized that ease of forgiving was inversely
proportional to the magnitude at the injustice gap. Thus, apology and restitution are
each thought to have reduced the injustice gap, stimulating some forgiveness in addition
to the reduced unforgiveness that directly attends receipt of apology or restitution or
both. Witvliet, Worthington and Wade (2002) found that more forgiveness indeed
occurred with both a strong apology and restitution than with only an apology, only
restitution, or neither.
Witvliet et al. (2003) assessed the psychophysiological effects of justice and forgive-
ness. Participants (27 male and 30 female college students) imagined a scenario in
which they were victim of a home burglary. There were six justice-forgiveness outcomes.
A 3 Justice (Punitive, Restorative, No Justice) by 2 Forgiveness (Granted, Not Granted)
repeated-measures design was used. Each participant imagined all six conditions twice
with order of conditions counterbalanced. For justice, main effects indicated increasingly
positive and decreasingly negative self-reports across the no-justice to punitive justice to
restorative justice conditions. For forgiveness, granting forgiveness to the perpetrator
yielded self-reports of more positive feelings, perceived control, gratitude, and empathy,
and less fear, anger, and arousal than did not granting forgiveness. Granting forgiveness
also was associated with significantly lower heart rate and corrugator EMG level.
Physical reactions were generally less responsive to differences in justice conditions
than to forgiveness relative to none. Witvliet et al. (2003) concluded that for victims,
restorative justice and granting forgiveness may yield the strongest emotional benefits.
A methodological note is in order, Green and his colleagues (Green et al., 1999) have
observed that when positive and negative emotions are measured simultaneously, the
results often do not suggest strong effects of both positive and negative emotions
even though effects are strong if either is measured separately. Multivariate analyses
tend to capture the variable with the strongest effect and remove common variance,
leaving only one significant effect. Researchers, thus, often measure only one variable.
Researchers who study forgiveness often measure only unforgiveness or forgiveness.
They infer that if unforgiveness decreased, then forgiveness must have occurred. Or
they infer that if forgiveness took place, then unforgiveness must have been reduced.
These are probably good assumptions for intervention studies that try to produce
forgiveness. But this may not be a good strategy when studying justice, such as in
the Witvliet, Worthington and Wade (2002) study of apology and restitution. In studies
such as that, it is necessary to measure both unforgiveness and forgiveness.
In summary, there is initial support for this proposition. Clearer demonstrations

are needed that hypothesized alternatives to forgiving actually reduce unforgiveness.
Only hearing an apology, receiving restitution, and being informed of criminal convic-
tion have been investigated thus far. All three resulted in less unforgiveness accompa-
nied by a little forgiveness. Future research needs to consider revenge, which would be
expected to reduce unforgiveness but produce virtually no forgiveness. Also, future
research should investigate other alternatives. Measures that clearly distinguish reduced
unforgiveness and the experience of emotional forgiveness must be developed.
Proposition 3: Forgiveness Reduces the Stress of Unforgiveness

Theoretical difficulties to overcome

Emotional forgiveness is thought to reduce the stress of unforgiveness. Evaluating this
proposition requires more measurement precision than has thus far been evident.
Granting decisional forgiveness might change negative motivations but not change
negative emotions. Some people grant forgiveness and sincerely never intend to seek
revenge or avoid the offender, yet they remain bitter, resentful, hostile, hateful,
angry, and fearful toward the offender. Measures that reliably distinguish of decisional
forgiveness from emotional forgiveness are needed. None now exist. Furthermore, the
emotional juxtaposition hypothesis suggests that measuring emotional forgiveness
might not be as straightforward as has been assumed. Emotions differ in both degree
of arousal and valence (Russell and Carroll, 1999). Low doses of positive emotions
(say love, for instance) experienced after a transgression might neutralize some unfor-
giveness, which would reduce the arousal of the negatively valenced unforgiveness. But
a high dose of love might change the arousal and also the valence. Researchers have
until now used linear measures of forgiveness and unforgiveness.
Evidence bearing on the proposition

Witvliet et al. (2001) investigated people physiologically. When they directed students
to take an empathic mindset toward the transgressor or to recall and imagine a
person they had forgiven, students showed a marked reduction in mean arterial pres-
sure, heart rate, and skin conductance relative to people toward whom they felt unfor-
giving. This suggests that forgiving reduces the sympathetic nervous system responses
to the transgression. Similar findings come from Lawler et al. (2003). They replicated
Witvliet et al. (2001) using a between-subjects design with 108 college students, while
Witvliet used a within-subjects design. Lawler et al. found that state forgiveness was
associated with lower blood pressure and product of heart rate and blood pressure
while participants described transgressions by both (a) friend or partner and (b) parent.
Huang and Enright (2000) used blood pressure to determine the degree to which
44 children or adolescents might have forgiven a transgressor. They found a relation-
ship between stage-of-development thinking about forgiveness and blood pressure
at the end of one minute of recounting a transgression. Huang and Enright differen-
tiated two types of forgiveness. One they called ‘‘anger-related forgiveness’’ – forgiving
motivated by obligation – which is similar to decisional forgiveness, using our distinc-
tion. They compared this to forgiveness due to ‘‘unconditional love’’ – which is like
emotional forgiveness. People who forgave due to ‘‘unconditional love’’ had lower
blood pressure (both systolic and diastolic) when recalling the transgression. Other
unobtrusive behavioral measures – such as masking smiles and lowering the eyes –
showed parallel findings.
These three studies suggest that emotional forgiveness indeed reduces the stress of
unforgiveness. Much research is still needed to support this proposition.
Proposition 4: Forgiveness as a Coping Strategy is Related to Health

Forgiveness is hypothesized to be a coping strategy that reduces acute unpleasant stress
and thus affects more positive health. However, negative health effects would likely
be measurable only if people were chronically unforgiving. If people were frequently
unforgiving for years yet they experienced no negative health symptoms, it could be
because they consistently employed alternative ways of reducing unforgiveness (e.g.,
renarrating events, giving judgment to God, accepting misfortune philosophically).
Or they could be persistently forgiving. Therefore to establish that forgiveness was
at least partially responsible for absence of stress-related disorders as one aged, one
would have to show that a person was forgiving at a trait level and that trait forgiving-
ness was related to health. The strength of the correlation would be expected to increase
with age. (Note that Kiecolt-Glaser et al., 2002, have shown that even acute stress can
produce negative physical effects. These are expected to accumulate with age.)
Several investigators have studied trait forgivingness and health at different ages.
Toussaint et al. (2001) conducted a national telephone survey of randomly selected
people throughout the United States. They sampled people in young adulthood
(18–44 years), middle age (45–64), and older adults (65 and older). Toussaint et al.
had people rate the degree to which they felt generally forgiving against those who
had transgressed against them. They also rated degree of forgiveness of self, forgiveness
of God, and forgiveness by God. They estimated proactive forgiveness, and they
completed health measures. Toussaint et al. found that middle-aged people forgave
others more than did young adults and also felt more forgiven by God. Older adults
were more proactively forgiving than were younger adults. There was a relationship
between forgiving and health symptoms in the elderly but not in other age cohorts.
Krause and Ingersoll-Dayton (2001) surveyed 129 older adults in Michigan. They
found that some people were automatic forgivers; others were reluctant forgivers;
others treated forgiveness as something that must be earned. Religion was often
implicated in decisions about forgiving. Forgiveness seemed related to health, but
evidence was qualitative.
Findings from both surveys above are consistent with research that has investigated
other positive emotional states and health, such as optimism. When people chronically
experience negative emotions, it typically takes years of negative emotional experience
before ill health results. This has also been demonstrated frequently with the literature
on stress (for reviews, see Sapolsky, 1994; McEwen, 2002).
McCullough et al. (2001) has studied the personality disposition, vengefulness. They
had people complete a measure of dispositional vengefulness. Students returned eight
weeks later for a subsequent testing, which assessed physical complaints. More physical
complaints were noted among the dispositionally vengeful people than among those
who were not vengeful. Small physical impairments can occur from being disposition-
ally unforgiving – especially vengeful – over a period as short as eight weeks.
While we can tentatively say that emotional forgiveness is related to health, research
is needed to test the emotional juxtaposition hypothesis. Forgiveness is hypothesized
in the emotional juxtaposition hypothesis to involve experiences of positive emo-

tions such as empathy, sympathy, compassion, or love that systematically neutralize
the stressfulness of unforgiveness and promote forgiveness. In naturally occurring
situations, testing this hypothesis would require making ambulatory measures of phys-
iological events. In the laboratory, events could be arranged to produce positive
other-oriented emotions and measure physical responses. In psycho-educational set-
tings, creating positive other-oriented experiences in people who feel unforgiving
is precisely the goal. Many studies have placed volunteers in psychoeducational
groups that undergo an intervention to promote forgiveness. In almost every group,
the effect sizes for forgiving and for reducing unforgiveness are positive. In fact,
Worthington et al. (2000), besides reporting the results of three brief interventions,
examined data from interventions drawn from four independent laboratories. They
found that a linear relationship existed between the amount of time people attempted
to forgive, and the amount of forgiveness people actually experienced.
Findings in support of these four propositions are consistently supportive. Yet find-
ings are weak on several fronts. (1) Alternative explanations have not been ruled out.
(2) Methods of measuring forgiveness and unforgiveness have not been precise.
(3) Longitudinal research has been short-term (on the order of weeks). (4) An insuffi-
cient number and variety of health measures have been employed. (5) No prospective
studies have been done. At the present, research is promising but only suggestive at best.
THEORIZING AND EVIDENCE ABOUT THE DIRECT MECHANISMS

BY WHICH UNFORGIVENESS AND FORGIVENESS MIGHT AFFECT
PHYSICAL HEALTH
Given that evidence is suggestive that emotional forgiveness might reduce the stressful-
ness of unforgiveness and prevent stress-related disorders, the question of physical
mechanisms arises. Obviously, forgiveness affects mental and relational health. For
example, frequent forgivers might have better mental health (and thus fewer suicides).
Also, frequent forgivers might affect relationships and thus provoke fewer homicides,
incidents of road rage, or accidents. However, we draw from the literature on stress
and coping to suggest direct mechanisms whereby forgiveness might affect physical
health (this section) and indirect mechanisms (the following section). We suggest poten-
tial mechanisms and review existing research specifically on forgiveness that is relevant
to each.
There are several of direct mechanisms by which (1) unforgiveness might lead to
ill health and (2) forgiveness might act as a coping strategy affecting better health.
Some were alluded to as we discussed four propositions.
Direct Mechanism 1: Forgiveness Might Reduce Hostility

Hostility is a central part of unforgiveness (Worthington and Wade, 1999; Thoresen
et al., 2000). Hostility also has been found to be the part of Type A behavior that
seems to have the most pernicious health effects (Smith, 1992; Miller et al., 1996).
Thus, the first hypothesized mechanism is that unforgiveness instigates hostility,
which heightens risk of cardiovascular disease. Thoresen et al. (2000) have described
hostility as a core component of unforgiveness. Hostility has been directly related
to numerous health problems. Hostility has its most deleterious effects on the cardio-
vascular system (Kaplan, 1992; Williams and Williams, 1993). Measures of heart
rate variability and cardiac impedance might be used to assess the degree to which
unforgiveness might affect the cardiovascular system (Brosschot and Thayer, 1998).
At present, neither of these measures has been used to assess unforgiveness, its effects,
or possible moderating effects of forgiveness. Forgiveness has been found to be inversely
related to hostility. Berry and Worthington (2001) have found that unforgiving
romantic relationships were characterized by hostility. Berry et al. (2001) have shown
dispositional forgivingness is negatively correlated with trait hostility (see also
Mauger et al., 1992; McCullough et al., 2001).
Forgiveness has been hypothesized to be an emotion-focused coping strategy. It has

been found to reduce anger and hostility (Al-Mabuk et al., 1995). Williams and
Williams (1993) have described numerous ways by which reducing anger and hostility
can affect physical health. For example, stress transients can damage the inner lining
of arteries providing sites for subsequent collection of arterial plaque and perhaps
eventual arteriosclerosis. Arterial inflexibility can lead to increased risks for cardiac
infarction, hypertension, and stroke. Williams and Williams (1993) suggested ways to
modulate hostility, including forgiving. Their suggestions need to be tested using
more measures of cardiovascular health.
Direct Mechanism 2: Forgiveness Could Affect the Immune System

at the Cellular Level
Another possible mechanism for affecting health outcomes is that the stressfulness of
unforgiveness might affect the immune system. A sizable literature has developed
about how negative emotions (of which unforgiveness is one) is related to and can
cause dysregulation in the immune system. Kiecolt-Glaser et al. (2002) have thoroughly
reviewed the literature on how stress and negative emotion can affect cytokines.
Cytokines are protein-like materials that are secreted when an infection or injury is
sustained or when stress is experienced. They primarily help fight infection and provide
an early response to injury. They attract immune cells to the site of damage and activate
them. They also affect metabolism, and help regulate body temperature. When a person
is under constant stress, pro-inflammatory cytokines are elevated. This can dysregulate
the intercellular immune system. No researcher who is studying forgiveness has yet
examined cytokine production as a measure of responsiveness to unforgiveness or to
forgiveness, though such research is underway by Temoshok and Wald (2002).
Direct Mechanism 3: Forgiveness Could Affect the Immune System at

the Neuro-endocrine Level
Forgiveness could affect health by boosting the immune system. Specifically, forgive-
ness could reduce HPA reactivity and reduce secreted cortisol. Over-production of
cortisol has been shown to have deleterious health effects on the cardiovascular and
immune systems and on cognitive and brain functioning (for reviews, see Sapolsky,
1994; McEwen, 2002).
Only one study has addressed cortisol and unforgiveness. Berry and Worthington
(2001) found base-rate production of salivary cortisol to be slightly elevated in
people who were high in trait unforgiveness. They also found cortisol reactivity in
people who think about unforgiving events in their relationship to be slightly greater in
troubled relative to happy relationships. The findings suggested the need for additional
study.
The neuro-endocrine system is affected by stress, which affects the immune system.
Extension to the study of unforgiveness has little support.
Direct Mechanism 4: Forgiveness Could Affect the Immune System

through Release of Antibodies
The study of stress suggests that anti-bodies are suppressed during chronic stress. Given
that forgiveness is hypothesized to juxtapose positive emotions against unforgiveness,

we suggest that findings from the study of positive emotions can provide hypotheses
about forgiveness.
Salovey et al. (2000) reviewed the literature on the relationship between negative
and positive emotions and physical health. They focused primarily on the relationship
between negative emotions and suppression of secretatory Immunoglobulin-A (sIg-A)
inhibition. Levels of sIg-A have been found to affect immune system functioning.
At the present, sIg-A suppression has not been investigated in relation to the unfor-
giveness. It is hypothesized that when people use forgiveness as a coping strategy to
reduce unforgiveness, then sIg-A levels would return to baseline. This has not been
investigated.
Direct Mechanism 5: Forgiveness Might Affect Central Nervous System Processes

At the level of the central nervous system (CNS), three processes might be affected.
(a) Gray’s (and others’) identification of two motivational systems suggests CNS pro-
cesses and structures that might pertain to unforgiveness and forgiveness. (b) Likewise,
structure and function of the hypothalamus and amygdala might be implicated in
unforgiveness and forgiveness. (c) Finally, vagal tonality might affect forgiving or
unforgiving responses.
Motivational Systems
Gray (1994) has identified two motivational systems. The Behavioral Inhibition System
(BIS) is primarily associated with anxiety. The BIS responds to conditioned stimuli
associated with aversive and novel events. It typically increases arousal and interrupts
ongoing behavior, preparing the organism for focusing attention on aversive or novel
stimuli. The BIS involves the septohippocampal system, the prefrontal cortex, and
monoaminergic pathways that innervate the hippocampus based on limbic stimulation.
The Behavioral Activation System (BAS) is associated with both positive and negative
emotions. Both types of emotions can stimulate the BAS because both arouse and moti-
vate the organism to engage with the environment. The BAS has been shown to be
involved both with extreme happiness, aggression, anger (Harmon-Jones et al., 2001)
and trait anger (Harmon-Jones and Allen, 1998). The neural structures associated
with BAS arousal include the basal ganglia (dorsal and ventral striatum and dorsal
and ventral pallidum), dopaminergic pathways from limbic system to basal ganglia,
thalamic nuclei that are linked to the basal ganglia, prefrontal cortex, and motor and
sensori-motor cortical areas.
Harmon-Jones et al. (2002) have examined 67 people’s responses to an anger-evoking

event. They found a relative increase in left frontal activity using EEGs. Individuals
who showed more tendency to actively cope with their anger showed more BAS activa-
tion, and individuals who showed more tendency toward depression and inhibited
coping showed less BAS activation. The research by Harmon-Jones et al. (2002) suggest
that unforgiveness–which involves anger–and forgiveness, which is theorized to involve
(a) active emotion-focused coping and (b) use of positive emotions to regulate the nega-
tive emotions, might be associated with people who have an active BAS. People whose
BIS is more active might be more likely to be mired in unforgiveness and be anxious
about being hurt in subsequent interpersonal interactions (see Worthington, 1998).
Structure of the Hypothalamus and Amygdala

One speculative relationship concerns the relative production of testosterone and sera-
tonin in the hypothalamus (Bell and Hobson, 1994). Aggressive youth tend to be high
in testosterone. They might be unable to inhibit testosterone production after a provo-
cation. Seratonin seems to decrease aggression. The hypothalamus is rich in receptor
sites for both testosterone and seratonin, and the hypothalamus has been implicated
in motivational processes. Newberg et al. (2000) suggests that it makes sense evolutio-
narily to have motivational processes of aggression and its regulation controlled by the
same central nervous system area. Animals often must act aggressively to defend eating,
drinking, and mating rights, motivations which have been found to be associated with
the hypothalamus. Thus, seratonin may counteract testosterone in the hypothalamus.
Forgiveness, as an emotion-focused coping strategy might inhibit testosterone by
stimulating seratonin release. This potential connection would support hypothesizing
by McCullough (2001) and his colleagues (McCullough et al., 1998) who have suggested
that the regulation of vengeance (McCullough et al., 2001) by forgiving is a fundamen-
tally motivational process (McCullough et al., 2002; McCullough et al., 2003).
Vagal Nerve Tonality

Vagal tonality might be another mechanism by which forgiveness and health are
connected (Brosschot and Thayer, 1998). The vagus nerve is the hub of the parasym-
pathetic nervous system (PSNS), which regulates the SNS by inhibiting SNS
activation. Vagal tonality inhibits arousal. When a stressor is encountered, vagal tonal-
ity decreases, almost instantaneously removing SNS inhibition–releasing the ‘‘vagal
brake.’’ This allows rapid arousal (McEwen, 2002). Vagal tonality has been found to
be related to cardiovascular disease, emotional expression, and emotion regulation
(Porges et al., 1994).
Forgiving people might be hypothesized to have high vagal tonality. Unforgiving
people might be hypothesized to react quickly to an interpersonal threat by rapidly
decreasing vagal tonality. These very speculative hypotheses have not been investigated.
Direct Mechanisms and Physical Health

Based on an analogy of unforgiveness-and-forgiveness to the stress-and-coping litera-
tures, many direct physical pathways might be investigated between unforgiveness
and ill health, forgiveness and good health, and unforgiveness-reducing alternatives
to forgiveness and good health. For the most part, researchers have only scratched the
surface in studying these.
Other analogies might also provide heuristic hypotheses. For example, we have
argued that the emotional juxtaposition hypothesis suggests that positive emotions
are experienced when one forgives. A literature is emerging that relates positive emo-
tions to health outcomes and mechanisms (Salovey et al., 2000). Theories such as
Fredrickson’s (2001) broaden-and-build theory might be used to generate hypotheses
about forgiveness and health.
In the present article, we have focused mostly on hypotheses that link unforgiveness
with ill health and forgiveness with good health. This, of course, does not fully explain
all cases. For example, cortisol has short-term health benefits as do most aspects of
allostasis. However, chronic exposure to, overproduction, or underproduction of corti-
sol have mostly damaging effects. By analogy, we might suggest that unforgiveness
could have some health benefits. Unforgiveness could mobilize a betrayed person to
protect himself or herself from further damage. It could boost short-term immune
responses. It could focus cognition toward escaping danger. Perhaps only in the
long-term is chronic unforgiveness physically harmful.
Some people have argued that some alternatives to forgiving – such as denying that
one was harmed – are ‘‘pseudoforgiveness’’ (Enright and Fitzgibbons, 2000, p. 268),
and could be harmful. ‘‘Pseudoforgiveness’’ might be thought to occur if, misunder-
standing forgiveness, a person believed he or she had forgiven when he or she had in
fact denied or condoned, and thus continued to experience emotional stress until it
caused physical damage. We prefer to treat these as merely alternatives to forgiving.
Each alternative might reduce the injustice gap and unforgiveness variably. Future
research could untangle which alternatives work best for which people in which situa-
tions to bring about which physical outcomes.
INDIRECT MECHANISMS BY WHICH FORGIVENESS MIGHT

CONTRIBUTE TO BETTER PHYSICAL HEALTH
Forgiveness can possibly affect physical health in a variety of indirect ways as

well. For example, forgiveness might increase social support or improve marital
quality. Forgiveness might be part of a constellation of personality attributes.
Forgiveness might be a good relationship skill. Each indirect mechanism might affect
the forgiveness-health connection. We reviewed relevant research in the present section.
Indirect Mechanism 1: Forgiving People Might Have More Social Support

More forgiving people might have larger or more emotionally supportive networks.
Forgiveness can promote reconciliation (Worthington and Drinkard, 2000), which
suggests that highly forgiving people might repair relationships more than less forgiving
people. Quality and quantity of social support networks have been related to physical
health (Brownley et al., 1996).
One physical mechanism through which better quality social support might affect
health involves release of ‘‘bonding’’ neuropeptides such as oxytocin and prolactin.
In animal models, injected oxytocin has lowered blood pressure, heart rate, and cortisol
levels in rats (Petersson et al., 1996). In humans, contact and warmth stimulate oxytocin
(Uvnas-Moberg, 1998). Prolactin might also produce physiological effects of positive

human interaction (Curtis and Wang, 2003). No researchers have studied the ‘‘bonding’’
peptides in conjunction with forgiveness.
Obviously, the direction of causality – if such a connection exists – is uncertain. We
have suggested above that forgiving might contribute to more social support through
relational repair. However, people with more robust social networks might just as rea-
sonably be more confident and less easily threatened, and thus they might be less likely
to develop unforgiveness or, if it develops, more willing to forgive. Both the empirical
connection and relative contribution of each causal pathway need to be studied.
Indirect Mechanism 2: Forgiving People Might Have Less Stressful Marriages

Marriage has been related to physical health (Friedman et al., 1995). Forgiving people
have been hypothesized to be less likely to develop marital conflict and are expected to
resolve conflict more thoroughly than are people who are more unforgiving (Fincham,
2000). Some evidence exists that supports the stabilizing power of forgiveness in
marriage (McCullough et al., 1998; Fincham et al., 2002); however, much research is
needed. Witvliet, Ludwig and Bauer (2002) have shown that seeking forgiveness can
produce physiological changes that suggest less stress response. When coupled with
Witvliet et al. (2001), this research supports other physical effects in good marriages.
Indirect Mechanism 3: Forgiveness Might Be Related to Personality Traits

That Are In Turn Related to Health
Forgiveness, especially as a personality disposition, is likely to co-vary with numerous
other (often-related) dispositional variables that have been found to be connected to
physical health. These include more committed religion (Gorsuch and Hao, 1993),
higher trait empathy (Berry and Worthington, 2001), lower rumination (Caprara,
1986), lower levels of neuroticism (Berry et al., 2001; McCullough and Hoyt, 2003;
Symington et al., 2002), and higher levels of agreeableness (McCullough et al., 2001;
Symington et al., 2002). McCullough et al. (2001) have shown vengefulness to be associ-
ated with most of these (see also Mauger et al., 1992; Mullet and Girard, 2000; Berry
et al., 2001; McCullough et al., 2003). Dispositional forgivingness has been related
to health indicators (Berry and Worthington, 2001; McCullough et al., 2001). For
instance, Lawler et al. (2003) found trait forgivingness to be related to lower levels of
baseline blood pressure and to faster recovery to baseline blood pressure and to
faster recovery to baseline blood pressure after recalling and discussing a transgression.
Indirect Mechanism 4: Forgiveness Might Be Related to Relationship Skills

Furthermore, forgiveness might be hypothesized to be related to some relationship skills.
For instance, people who forgive more readily might have (a) a greater number of gen-
eral coping repertoires for dealing with the stress of negative emotions, (b) more robust
emotion-regulation strategies (Gross, 1998), (c) less likelihood of offending a partner,
which could lead to lower guilt and shame (Enright and the Human Development
Study Group, 1996), (d) less capacity to commit to a relationship (Finkel et al.,
2002), and (e) less willingness to sacrifice for a relationship (Van Lange et al., 1997).
There is only a little evidence at present to support such theoretical speculation in

studies that measure forgiveness directly (i.e., see Finkel et al., 2002).
Indirect Mechanisms and Physical Health

In each of these indirect mechanisms, the relationships of forgiving people are likely to
be better overall with emotional steadiness being more characteristic of the relationship.
Thus less time is expected to be spent in negative emotional arousal. In all of these
indirect mechanisms, we hypothesize a connection between forgiveness-as-a-coping-
strategy and physical health.
RESEARCH AGENDA
There is a proliferation of definitions of unforgiveness and forgiveness. In many ways,

they are complementary rather than competing. However, we believe that there are
advantages to investigating the emotional juxtaposition hypothesis (Worthington and
Wade, 1999). Viewing forgiveness as an emotion-focused coping strategy can lead to
promising research directions. Namely, such an approach links forgiveness research
to the field of stress and coping. It suggests potential studies that forgiveness research-
ers could pursue in health psychology as it intersects with other sub-fields (e.g., social,
developmental, or clinical) of psychology. We suggest a brief research agenda that
derives from the foregoing review.
1. The role of positive emotions in stress, coping and health research has gained atten-
tion recently (Folkman and Moskowitz, 2000; Fredrickson, 2001). Forgiveness can
be conceptualized as a replacement of negative with positive emotions, suggesting
a link between these fields as we have argued throughout the article.
2. Forgiveness is hypothesized to be relevant at the social and political levels as well as
at the intra-personal and inter-personal dyadic levels. More research should investi-
gate whether forgiveness can affect relationships in the friendship-dyad, co-worker
(Bradfield and Aquino, 1999), romantic partner, and family levels. Forgiveness can
also be relevant to interactions in the judicial and criminal processes (Worthington,
2000), national and international political levels (Helmick and Petersen, 2001), and
health and health-care issues (Worthington and Berry, in press).
3. New research is needed to describe the interactions among the many coping-
strategies people employ to reduce the stress of interpersonal transgressions: Who
uses which coping strategy, under what circumstances, and with what effects on
physical health?
4. Can forgiveness be used as proactive coping (Aspinwall and Taylor, 1997)?
5. Little has been done to determine the physical mechanisms by which forgiveness
might produce better health. In the present article, we have summarized relevant
empirical research. It is scant, though most existing research supports the theorized
mechanism. We have also reviewed research that suggests hypotheses about forgive-
ness and health. Those need to be examined.
6. Researchers need to find who best uses forgiveness as an emotion-focused coping
strategy, and to whom forgiveness can best be taught as an active coping strategy.
People who seem at first blush to be excellent candidates for the forgiveness inter-
ventions are those who are high in trait forgivingness. However, it may turn out
that such people will likely forgive naturally. Better candidates for interventions
might be those who are moderate or low in trait forgivingness. This question
deserves an empirical answer.
7. The role of forgiveness in coping with disease is uncertain at this point. Forgiveness
might play a palliative role in coping with gastrointestinal, cardiovascular, and
stress-related disorders. Research is needed to identify the roles that forgiveness
plays in what disorders.
8. In diseases such as cancer, forgiveness might or might not play a role in the etiol-
ogy, physical manifestation, or healing. Forgiving might affect cancer risk directly
by affecting glutamate and thus the N-methyl-D-asparate receptor, which affects
free radical concentration, which in turn might affect cancer risk (McEwen,
2002). Forgiveness might contribute to the healing of cancer only by indirect
mechanisms through improving relationships with people’s support network, help-
ing people be at more peace with their ailments, or contributing to fewer and less
negative mental health consequences and more positive mental health conse-
quences. On the other hand, forgiving might even have a negative impact on
one’s will to battle the disease; thus, the impact of forgiving might be negative.
Research is needed to determine the physical, psychological, and relational
mechanisms involved in dealing with diseases.
9. We have argued that emotional forgiveness acts primarily as an emotion-
focused coping strategy. It might be, however, that emotional forgiveness might
be an instance of meaning-focused coping (Park and Folkman, 1997). Forgive-
ness might also, in some cases, be instrumental as a problem-focused coping
strategy. Research is necessary about how different people use forgiveness to
cope.
10. Decisional and emotional forgiveness can be independent or related to each
other. Investigations are needed to describe the conditions for independence or
interdependence.
11. More attention is needed to identify negative physical effects of forgiving.
Forgiveness can be detrimental if it results in forgivers endangering themselves
by forgiving when instrumental behavior is needed to rectify a problem. But are
there negative health effects that directly follow forgiving? Can forgiving short-
circuit one of the alternative means of reducing unforgiveness that would have
been better? Under what circumstances?
SUMMARY
In the present article, we have presented a theoretical model that describes unforgive-
ness as being stressful, and we have argued that forgiveness can be viewed as emo-
tion-focused coping. The evidence is reasonably strong supporting that unforgiveness
is stressful. Evidence is suggestive that unforgiveness can lead to negative health out-
comes. However, longitudinal studies showing that unforgiveness is related to ill-
health have not yet been done. Empirical evidence that forgiveness is an emotion-
focused coping strategy that actually promotes positive health is intriguing and sugges-
tive but largely inferential. The hypotheses need to be tested directly.
Forgiveness is used by many people to deal with transgressions. Yet, until recently, it
has largely been overlooked by scientists studying the relationships between stress,
coping, and health. In this article, we provided a theoretical framework and derive
hypotheses that we hope will stimulate additional research and understanding.
Acknowledgements
We wish to express our gratitude to and acknowledge support from Virginia
Commonwealth University’s General Clinical Research Center, which is supported
by NIHS M01 RR000065, and from the John Templeton Foundation (grant #239).
Portions of this chapter were supported by each. In addition, we acknowledge the
support of the John Templeton Foundation and the Atlantic Philanthropic Society
for administering A Campaign for Forgiveness Research. The authors compiled this
research on forgiveness partially in their work as Executive Director and Executive
Assistant, respectively, for the Campaign.
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Forgiveness Is An Emotion-Focused Coping Strategy That Can Reduce Health Risks and Promote Health Resilience - Theory, Review, and Hypotheses

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RISKS AND PROMOTE HEALTH RESILIENCE:

Virginia Commonwealth University

(Received 26 September 2002; Revised 9 June 2003)

Keywords: Forgiveness; Coping strategy; Health risks

In 1997, research on forgiveness consisted of only 58 empirical studies (McCullough

*Corresponding author. E-mail: eworth@vcu.edu

DEFINITIONS AND THEORETICAL CONTEXT

results in neutralization or replacement of all or part of those negative emotions with

it is usually an emotion-focused coping effort. Within this stress-and-emotion-focused-

DIRECT EVIDENCE PERTAINING TO THE FOUR PROPOSITIONS

Proposition 1: Unforgiveness is Stressful

had forgiven. Witvliet et al. measured self-reported (via questionnaires) unforgiveness

Proposition 2: Many Coping Mechanisms Besides Forgiveness

promote victims’ judgments of repaired injustice through receiving an offender apology,

In summary, there is initial support for this proposition. Clearer demonstrations

Proposition 3: Forgiveness Reduces the Stress of Unforgiveness

Theoretical difficulties to overcome

Evidence bearing on the proposition

Proposition 4: Forgiveness as a Coping Strategy is Related to Health

in the emotional juxtaposition hypothesis to involve experiences of positive emo-

THEORIZING AND EVIDENCE ABOUT THE DIRECT MECHANISMS

Direct Mechanism 1: Forgiveness Might Reduce Hostility

Forgiveness has been hypothesized to be an emotion-focused coping strategy. It has

Direct Mechanism 2: Forgiveness Could Affect the Immune System

Direct Mechanism 3: Forgiveness Could Affect the Immune System at

Direct Mechanism 4: Forgiveness Could Affect the Immune System

that forgiveness is hypothesized to juxtapose positive emotions against unforgiveness,

Direct Mechanism 5: Forgiveness Might Affect Central Nervous System Processes

Harmon-Jones et al. (2002) have examined 67 people’s responses to an anger-evoking

Structure of the Hypothalamus and Amygdala

Vagal Nerve Tonality

Direct Mechanisms and Physical Health

INDIRECT MECHANISMS BY WHICH FORGIVENESS MIGHT

Forgiveness can possibly affect physical health in a variety of indirect ways as

Indirect Mechanism 1: Forgiving People Might Have More Social Support

(Uvnas-Moberg, 1998). Prolactin might also produce physiological effects of positive

Indirect Mechanism 2: Forgiving People Might Have Less Stressful Marriages

Indirect Mechanism 3: Forgiveness Might Be Related to Personality Traits

Indirect Mechanism 4: Forgiveness Might Be Related to Relationship Skills

There is only a little evidence at present to support such theoretical speculation in

Indirect Mechanisms and Physical Health

strategy and physical health.

There is a proliferation of definitions of unforgiveness and forgiveness. In many ways,

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