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Implications of Forgiveness Enhancement in Patients with Fibromyalgiaand Chronic Fatigue SyndromeLoren Toussainta; Mary Overvold-Ronningenb; Ann Vincentc; Connie Luedtkec; Mary Whipplec; TinaSchrieverc; Frederic Luskind

a Department of Psychology, Luther College, Decorah, Iowa, USA b Department of Nursing, LutherCollege, Decorah, Iowa, USA c Mayo Clinic, Rochester, Minnesota, USA d Stanford University, PaloAlto, California

Online publication date: 22 July 2010

To cite this Article Toussaint, Loren , Overvold-Ronningen, Mary , Vincent, Ann , Luedtke, Connie , Whipple, Mary ,Schriever, Tina and Luskin, Frederic(2010) 'Implications of Forgiveness Enhancement in Patients with Fibromyalgia andChronic Fatigue Syndrome', Journal of Health Care Chaplaincy, 16: 3, 123 — 139To link to this Article: DOI: 10.1080/08854726.2010.492713URL: http://dx.doi.org/10.1080/08854726.2010.492713

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Implications of Forgiveness Enhancementin Patients with Fibromyalgia and

Chronic Fatigue Syndrome

LOREN TOUSSAINTDepartment of Psychology, Luther College, Decorah, Iowa, USA

MARY OVERVOLD-RONNINGENDepartment of Nursing, Luther College, Decorah, Iowa, USA

ANN VINCENT, CONNIE LUEDTKE, MARY WHIPPLE, andTINA SCHRIEVER

Mayo Clinic, Rochester, Minnesota, USA

FREDERIC LUSKINStanford University, Palo Alto, California

The purpose of this review is to examine forgiveness as a means toenhance coping with the emotional sequelae of two disorders,fibromyalgia and chronic fatigue. As with many chronic illnesses,fibromyalgia and chronic fatigue often result in a host of negativeemotions including, anger, stress, fear, and depression. We con-tend that learning to become more forgiving may be a complemen-tary treatment to cope with the ongoing stress, frustration, andnegative emotions that result from these two conditions. Our reviewincludes descriptive information on fibromyalgia and chronic fati-gue, a brief review of the literature on anger and its influence onhealth, a review of the connections between forgiveness and well-being, and methods to enhance forgiveness in patients’ lives. Weconclude with a conceptual model that we hope will be useful todesign and=or evaluate work on forgiveness in these patients.

KEYWORDS chronic fatigue syndrome, fibromyalgia, forgiveness

Address correspondence to Loren Toussaint, Department of Psychology, Luther College,700 College Dr., Decorah, Iowa 52101. E-mail: touslo01@luther.edu

Journal of Health Care Chaplaincy, 16:123–139, 2010Copyright # Taylor & Francis Group, LLCISSN: 0885-4726 print=1528-6916 onlineDOI: 10.1080/08854726.2010.492713

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Fibromyalgia and chronic fatigue syndrome are debilitating disorders thatresult in a number of challenges for both patient and physician. Patientsare often faced with significant loss of function and decreased quality of life(Arnold, Crofford et al., 2008; Hellstrom, Bullington, Karlsson, Lindqvist, &Mattsson, 1999; Van Heck & De Vries, 2002), while physicians are challengedwhen attempting to make efficient and accurate diagnoses and effectivelymanage these disorders (Friedberg & Jason, 1998; Wolfe, 1993). Neitherdisorder has any established cure. As a result, individuals with fibromyalgiaand chronic fatigue commonly struggle with anger and stress due to: 1)the negative effects of the disorders themselves, and 2) perceptions of limitedsuccess in treatment (Friedberg & Jason; Hellstrom et al., 1999; Raymond &Brown, 2000). Fibromyalgia and chronic fatigue have both been connectedto dysregulation of the nervous system (Bennett, 2005; Demitrack & Abbey,1996), whereas, anger, stress, and negative emotions have all been linked tochanges in autonomic activity (Buss, 1961; Levenson, Ekman, Campos,Davidson, & de Waal, 2003; B. S. McEwen, 2007; Okuneva, Zhvania,Japaridze, Gelazonia, & Lordkipanidze, 2009).

Consequently, the frustration, anger, stress, fear, and other negativeemotional reactions experienced by individuals with fibromyalgia andchronic fatigue often exacerbate their symptoms. Forgiveness is one copingmechanism that may mitigate the exacerbating role of negative emotionalreactions, especially anger, in fibromyalgia and chronic fatigue. The purposeof this paper is to outline the conceptual connections and offer theoreticalreasons for the utility of forgiveness as a psychosocial intervention in thepalliative care of patients with fibromyalgia and chronic fatigue syndrome.

We begin by reviewing diagnostic and epidemiological data relevant toeach syndrome. We then consider the role of anger in the progression ofthese diseases. Finally, we discuss the definition of forgiveness, provideevidence of the connection between forgiveness and health, and describeempirically proven psycho-educational forgiveness interventions.

Fibromyalgia and Chronic Fatigue Syndrome: Diagnosis

According to the American College of Rheumatology (Wolfe et al., 1990),fibromyalgia is a syndrome of chronic widespread pain. The classification cri-teria for fibromyalgia require that the patient has had pain for at least threemonths involving three or more quadrants of the body. In addition to meetingthese criteria, a diagnosis also requires finding 11 or more out of 18 standardtender points. In almost 20 years since the publication of these criteria therehas been a dramatic increase in fibromyalgia related research (Bennett,2005; Goldenberg, 1988). As a result of this research, it is now generallyagreed that patients fulfilling the 1990 American College of Rheumatology cri-teria have a dysregulation of sensory processing often referred to as ‘‘centralsensitization’’ (Bennett). However, fibromyalgia is more than just a chronic

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pain syndrome, as numerous studies have documented a high prevalence ofmood disorders, non-restorative sleep, autonomic dysregulation, subtle neuro-endocrine dysfunction, impaired work performance, and association withother syndromes such as irritable bowel, restless legs, chronic fatigue, over-active bladder, and multiple chemical sensitivities (Adler, Manfredsdottir, &Creskoff, 2002; Cassisi et al., 2008; Clauw, 2001; Zoppi & Maresca, 2008).

Chronic fatigue syndrome is a multi-faceted and complex illness whosehallmark symptom is unrelenting and debilitating fatigue that lasts six monthsor more. Fatigue is unexplained, does not improve with rest, and may beworsened though physical or mental exertion. Since the earliest attemptsto define and diagnose chronic fatigue syndrome (Holmes et al., 1988)problems have persisted in understanding what represents the key clinicalfeatures of this illness. Attempts have been made to improve diagnosticprecision and additional diagnostic symptoms have been identified includingthe presence of: 1) impaired memory or concentration, 2) sore throat, 3)tender lymph nodes, 4) muscle pain, 5) joint pain, 6) headaches, 7) unre-freshing sleep, and 8) post-exertional malaise (Fukuda et al., 1994). Attemptsto refine the diagnostic criteria and assessments for chronic fatigue syndromeare ongoing (Reeves et al., 2003; Reeves et al., 2005), and the current criteriainclude six months of chronic fatigue and four or more of the aforemen-tioned symptoms that last for 24 hours or more (CDC, 2006).

Fibromyalgia and Chronic Fatigue Syndrome: Prevalenceand Impact

According to the National Institute of Arthritis and Musculoskeletal and SkinDiseases (NIAMS, 2009) fibromyalgia affects an estimated 5 million people inthe U.S. This estimate varies from .5% to 5% across several countries(Neumann & Buskila, 2003). It occurs mostly in women (75–90%), but alsoaffects men and children of all ethnic groups. Severe cases can be extremelydebilitating. There is no known cure and current treatment focuses onimproving function and relieving symptoms. The financial burden of fibro-myalgia is also quite significant (Spaeth, 2009). Investigations of fibromyal-gia, employment, and disability have shown that almost half of patientslose their jobs and approximately 25% have received disability payments(Al-Allaf, 2007; Wolfe & Potter, 1996). Failure to diagnose a true case of fibro-myalgia has its own costs, largely with excess general practitioner visits andprescriptions (NIAMS, 2009).

The Centers for Disease Control and Prevention (CDC) reported thatapproximately 1–4 million Americans have chronic fatigue syndrome whichaffects more Americans than lupus, lung cancer, and multiple sclerosis(CDC, 2006). Other estimates range from less than .01% to almost 3% incommunity and primary care settings (Ranjith, 2005). The debilitating natureof the illness renders patients functionally impaired. Depending on the level

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of impairment, chronic fatigue patients can lose their jobs, economic security,and homes. Consequently, the annual economic impact of chronic fatiguesyndrome in the United States is $9.1 billion in lost productivity (Reynolds,Vernon, Bouchery, & Reeves, 2004).

Fibromyalgia and Chronic Fatigue Syndrome: Treatment

Although fibromyalgia and chronic fatigue syndrome have been the subjectsof thousands of studies, most of those have focused on epidemiology andetiology (Mease, 2005). At present, there is no cure for either fibromyalgiaor chronic fatigue syndrome. Symptoms have been managed in a widevariety of ways including medication (e.g., serotonin- and norepinephrine-reuptake inhibitors), self-management (e.g., exercise), and alternativetherapies (e.g., acupuncture) (Rooks, 2007). Unfortunately, only limitedoutcome research has been conducted on these two disorders, includingboth pharmacologic and nonpharmacologic treatment interventions (Rooks).

The multifaceted nature of fibromyalgia and chronic fatigue syndromesuggests that multimodal and multidisciplinary treatment programs may benecessary to achieve positive outcomes in patients diagnosed with these syn-dromes (Arnold, Bradley, Clauw, Glass, & Goldenberg, 2008; Goldenberg,2008). A range of pharmacological treatments, including antidepressants,opioids, nonsteroidal anti-inflammatory drugs, sedatives, muscle relaxants,and antiepileptics, have been used to treat fibromyalgia with varying levelsof success (Sarzi-Puttini et al., 2008). Nonpharmaceutical treatment modal-ities, including exercise, physical therapy, massage, acupuncture, andcognitive behavioral therapy have been demonstrated to be helpful, as well(Sim & Adams, 1999). Research findings suggest that fibromyalgia and chronicfatigue syndrome are best treated with a combination of symptom-basedpharmacological therapies and nonpharmacological therapies such asexercise and cognitive behavioral therapy (Burckhardt, 2006; Goldenberg,2008; Sim & Adams). Further investigations are warranted as more effectivetreatments are developed and our ability to accurately measure the effective-ness of these treatments improves (Rooks, 2007; Sim & Adams).

Of the treatments studied to date, two nonpharmacological treatmentshave demonstrated the most promise. The first is activity management=graded exercise which is targeted at physical symptoms such as fatigueand pain (Hauser et al., 2009; Rooks, 2007). A second treatment thataddresses the emotional and psychological experience of the patient is cog-nitive behavioral therapy (CBT) (Hauser et al.). The use of CBT has beenshown to be effective in small, short-term trials. Cognitive behavioral therapyhelps some patients cope with the impact of a chronic illness, and it helpswith symptom management as well. Cognitive behavioral therapy may workby helping patients develop constructive coping strategies, better managetheir symptoms, improve their level of function, and enhance their ability

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to perform activities of daily life (CDC, 2009). There exist few othertreatments for fibromyalgia and chronic fatigue syndrome that target theemotional and psychological issues related to the two syndromes.

Chronic Illness and Anger

Anger is a common reaction for individuals who receive a diagnosis of chronicillness such as fibromyalgia or chronic fatigue syndrome (Topf, 1995).Feelings of ‘‘Why me?’’ and denial often occur (Kubler-Ross, 1967). Havinga condition with debilitating symptoms that will not go away is frustratingand often seems unfair (Hanson, 2000). Anger is also a common reactionfor individuals whose symptoms are dismissed as being ‘‘all in their head’’(McManis, 2009). Like many other chronic illnesses, fibromyalgia and chronicfatigue are considered to be ‘‘invisible illnesses,’’ in that patients who havebeen diagnosed often do not look sick. Patients not only have to cope withthe symptoms related to their disorders, they also must cope with public skep-ticism. This skepticism leaves many patients feeling misunderstood, isolated,and angry. Many persons with chronic pain and disability believe that theyhave been treated unfairly and unjustly by other people, as well as by themedical and disability systems (Hanson). As a result, many individuals withchronic illness experience anger at themselves and=or others, includingdoctors, for perceived injustices or losses (Falvo, 2005). Losses may include:identity, relationships, social status, financial security, and the loss of hopesand dreams. Anger can be a response to frustration or the realization of theseriousness of one’s condition. Unfortunately, even though anger is normaland can sometimes temporarily distract individuals from various symptomssuch as pain, it is, ultimately, unhealthy and self-defeating.

Detrimental Effects of Anger

The harmful effects of anger on physical and mental health have beenwell-documented. Individuals who are chronically angry are more likely todevelop hypertension, heart disease, digestive disorders including ulcers,headaches, skin rashes, and increased susceptibility to infection (Everson,Goldberg, Kaplan, Julkunen, & Salonen, 1998; H. S. Friedman, Booth-Kewley, Salovey, & Rothman, 2003; Gouin, Kiecolt-Glaser, Malarkey, &Glaser, 2008; Iqbal, Ahmad, & Khan, 2003; Player, King, Mainous, & Geesey,2007). Anger also increases muscle tension that can cause additional pain(Burns, 2006). In addition, unacknowledged or unexpressed anger can pre-vent learning how to effectively manage emotions related to chronic illness(Hanson, 2000). Recent literature suggests that the spiritual well-being ofindividuals with fibromyalgia is often diminished as a result of harboringfeelings of anger and resentment toward a higher power, significant others,and=or the health care system (Kautz, 2008).

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The Role of Forgiveness in Fibromyalgia and Chronic Fatigue

Forgiveness training has been shown to reduce anger and resentment andenhance emotional and spiritual functioning, though no research has beenconducted specifically with fibromyalgia or CF patients. Research indicatesthat forgiveness training is an effective strategy for helping individuals withchronic physical conditions (e.g., hypertension) decrease their anger andresentment toward others (Carson et al., 2005). Consequently, physical andpsychological symptoms decrease leading to improvement in overall func-tioning and quality of life (Kautz, 2008). Recently researchers have arguedthat forgiveness is an emotion-focused coping process that promotes health(Worthington, 2006), reduces anger, and, especially when undertaken foraltruistic motives, affects both physical and mental health (Witvliet andMcCullough, 2007; Worthington, Witvliet, Lerner, & Scherer, 2005). Modestdata suggest that forgiveness interventions are helpful for both mind andbody, but are infrequently used in medical settings (Harris and Thoresen,2006).

Forgiveness and Health

Evidence for the link between forgiveness and health has been provided inrecent years (for reviews, see Worthington et al., 2005; Worthington, Witvliet,Pietrini, & Miller, 2007; Toussaint and Webb, 2005). However, the idea thatforgiveness could be protective of health is reflected in the thinking ofKaplan (1992) a consultant to Friedman’s Recurrent Coronary PreventionProject (M. Friedman et al., 1986). Kaplan observed that compared to TypeA (a.k.a., coronary prone personality), Type B patients possessed a forgivingnature that appeared to protect them from poor health. In the 1980s and1990s, there was little known about the association between forgivenessand health. This is made clear in Kaplan’s words, ‘‘I consider the social psy-chology of the forgiving heart in everyday relationships to be an amazinglyneglected topic, a fundamental coping issue’’ (Kaplan, p. 8). Just one yearlater Kaplan (1993) again reiterated this sentiment underscoring the impor-tance of understanding the role of forgiveness in chronic illness.

In response to Kaplan’s (1992; 1993) and others’ more recent (Thoresen,Harris, & Luskin, 2000) calls for more attention to the potentially importantrole of forgiveness in chronic health conditions, in the last decade a researchbase has developed. The role of forgiveness in multiple aspects of health,illness, disease, and disability has been studied including global health andwell-being and several chronic conditions such as cardiovascular disease(Toussaint & Cheadle, in press), pain (Carson et al., 2005) and spinal cordinjury (Webb, Toussaint, Kalpakjian, & Tate, 2010).

With the expansion of this research have come a number of theoreticaland empirical attempts to describe and explain why forgiveness is associated

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with improved health. One of the first attempts focused on multiplepathways through which hurts and injustices could be resolved (Worthington& Wade, 1999). This theory held that forgiveness was connected to healthstatus through the reduction of a variety of negative emotions such as anger,hate, vengeance, fear. About the same time Thoresen et al. (2000) proposedthat forgiveness was connected to health through the reduction of any one ofan already established set of psychosocial factors known to impact healthsuch as anger, hostility, hopelessness, and self-efficacy.

More recently Toussaint and Webb (2005), elaborating on a modeldeveloped by Worthington, Berry, and Parrott (2001), suggested that someof the same psychosocial mechanisms are determinants in forgiveness’ con-nection to mental health. Finally, Worthington (2006) developed a stress andcoping model of forgiveness which suggests that interpersonal transgressionsact as stressors that, when forgiven, reduce stress and, thereby, have an over-all impact on health and well being. Both Thoresen et al. (2000) andWorthington (2006) included discussion of the primary physiologicalmechanisms through which forgiveness has its effects on health. ‘‘Over arou-sal of the autonomic nervous system and allostatic load are two suggestedmechanisms implicated in the experience of fibromyalgia and chronic fatigue(B. McEwen, 1998). To the extent that these patients can be educated inforgiveness for offenses done to them or for their illness, then we can hopethat improved health outcomes may result.

Forgiveness Training and Improved Health

Research has demonstrated that forgiveness has beneficial effects for the for-giver’s health (Worthington et al., 2005; Worthington et al., 2007). Forgive-ness interventions using both clinical and psycho-educational approacheshave shown health benefits (see Baskin & Enright, 2004; Burchard et al.,2003; Lampton, Oliver, Worthington, & Berry, 2006; Ripley & Worthington,2002; Wade & Worthington, 2003). In short, a rapidly growing body of workshows positive changes in health and well-being as a result of forgivenesseducation or clinical training. Two studies in patient populations will bereviewed in greater depth.

We are aware of only two published studies that have examined forgive-ness interventions in a cohort of patients with a specific chronic condition.The first study involved patients diagnosed with stage-1 hypertension (dias-tolic blood pressure 90 to 99 mmHG, and=or systolic blood pressure of 140to 159) (Tibbits, Ellis, Piramelli, Luskin, & Lukman, 2006). Patients wererandomly assigned to a forgiveness intervention or wait-list control group.Forgiveness education was offered during eight weekly meetings that lastedone and a half hours. Pre- and post-intervention assessments of angerexpression and blood pressure were measured. There was no statisticallysignificant decrease in blood pressure as a result of forgiveness education.

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However, there was a decrease in anger expression and decreases in angerexpression were associated with decreases in mean arterial blood pressure.These results suggest that forgiveness has its effect on cardiovascular para-meters through its reduction of anger.

The second study (Waltman et al., 2009) examined middle aged andelderly patients with coronary heart disease. Patients were each given anindividually administered ten-week forgiveness intervention. Pre- andpost-intervention and one month follow-up nuclear heart scans were per-formed. No changes were observed in the heart scans when comparingresults pre to post. There was, however, a significant improvement in heartscans from pretest to follow-up. Waltman et al. postulate that the physicaleffects of forgiveness enhancement may require time to manifest. To sum-marize, in both patient populations some cardiovascular benefits wereobserved as a result of forgiveness education training.

Forgiveness Training

The literature on the effects of forgiveness training on health is emerging andencouraging results are being documented. Though numerous approaches toforgiveness enhancement are available, three approaches have garneredsignificant attention. Each of these approaches will be examined in turn.

ENRIGHT’S MODEL

The first training program, developed by Enright and the Human Develop-ment Study Group (Enright, 1996) uses a process model of forgiveness. Itis a 20-step model that contains four phases: ‘‘uncovering,’’ ‘‘deciding,’’‘‘working,’’ and ‘‘deepening.’’ The first phase, ‘‘uncovering,’’ consists of eightsteps which include: 1) examining defenses, 2) confronting anger, 3) admit-ting shame, 4) becoming aware of cathexis, 5) becoming aware of cognitiverehearsal of the offense, 6) becoming aware that the victim may be compar-ing oneself to the offender, 7) realizing that oneself might be changed in apermanent and adverse way, and 8) altering one’s ‘‘just world’’ view. Thesecond phase, ‘‘decision,’’ consists of three steps which include: 1) under-standing that old patterns of coping are not working, 2) developing a willing-ness to consider forgiveness, and 3) developing a commitment to forgive theoffender. The third phase, ‘‘work,’’ consists of four steps including: 1) refram-ing the wrongdoer in the appropriate context, 2) developing empathytoward the offender, 3) developing compassion, and 4) acceptance of pain.‘‘Deepening,’’ the fourth and final outcome phase, consists of five stepsincluding: 1) finding meaning in the pain and forgiveness process, 2) devel-oping humility in understanding one’s own need for forgiveness, 3) recogniz-ing the support of others in the process, 4) finding new purpose in life, and5) internal emotional release and awareness of decreased negative and

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increased positive affect. Numerous studies document the efficacy of thisapproach (see Baskin & Enright, 2004).

WORTHINGTON’S MODEL

The second forgiveness training program was developed by Worthington(2001). It is a five-step model, titled REACH, for forgiving a specific offense.The model involves psycho-educational group work focused on recalling theevent (R), building empathy (E), giving an altruistic (A) gift of forgiveness, pub-licly committing (C) to forgiveness, and holding (H) onto the gains achieved. Inthe first step in the model, recalling the hurt centers on what the effects of beinghurt are. Often hurts produce anger and fear. At this step, the focus is on activi-ties that enable participants to recall the hurt while minimizing denial, anger,and fear and avoid falling into the role of victim and=or blamer. The second stepis intended to promote empathy for the victim’s offender. Empathy is critical inthe development of forgiveness using the REACH model. Therefore, work atthis step focuses victims’ thinking on what their offenders might have thought,seen, or felt, for example, when the hurtful event occurred.

The third step in the REACH model emphasizes the connection betweenempathy and altruism. It has been shown that empathy creates a motive toact altruistically (Batson, Ahmad, & Lishner, 2009). The focus of this step,then, is on developing an altruistic motive toward forgiveness. This isaccomplished through more deeply understanding the concepts of guilt,gratitude, and gifts. Committing and holding onto forgiveness are the fourthand fifth steps that help participants in maintaining a long-term commitmentto forgiveness. Individuals are encouraged to focus on the accomplished(perhaps only partially accomplished) task of forgiveness and continue towork through the process of forgiveness when needed.

LUSKIN’S MODEL

The third training program was developed by Luskin (2002). This programconsists of nine steps. The first step in Luskin’s model requires that an indi-vidual spend time thinking about and clearly articulating how they have beenhurt and how they feel about that experience. The second step involves com-mitting to feeling better and recognizing the process of forgiveness is for thebenefit of the victim=forgiver not the wrongdoer. In the third step, indivi-duals are taught the conceptual difference between forgiveness and rec-onciliation. That is, forgiveness is an intrapsychic process, whereas,reconciliation is an interpersonal and relational process. Achieving the for-mer does not require the latter. The fourth step encourages victims to keeptheir perspective in the present, depersonalize their experience of the hurtfulevent, and understand the distinction between their past and presentexperience. The fifth step involves learning stress relaxation techniques to

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modulate physiological arousal that occurs when thinking about the hurtfulevent. Coping with stress reactivity and negative emotion is a key to allowingother more positive experiences to gain precedence when thinking about ordiscussing the hurtful event. The sixth step in Luskin’s model emphasizes thatmany of the most desirable things in life (e.g., love, peace, respect) are thingsthat individuals typically have no power to control. For example, though anindividual may expect love and affection from family members, one cannotcompel others to provide it. This is what Luskin refers to as ‘‘unenforceablerules’’ or expectations that one cannot force others to meet. At this sixth step,individuals learn that though they may expect an apology or restitution, nonemay be made and it is incumbent upon the victim only to engage in the pro-cess of forgiveness on his=her own accord. The seventh step focuses onpotentially unexpected positive gains resulting from the experience of hurt.The eighth and ninth steps reinforce a sense of personal power in forgive-ness (step 8) and reframing the story of victimization into one of heroicendurance and success (step 9).

Although recent reviews (e.g., Baskin & Enright, 2004; Wade, Worthing-ton, & Meyer, 2005) have included a variety of different types of forgivenesseducation models, few have the systematic development and evaluation ofEnright’s, Luskin’s, or Worthington’s Models. At this point, these would beconsidered the gold-standards to forgiveness enhancing interventions. How-ever, there is an important difference between Luskin’s and Worthington’sapproaches and Enright’s. Enright’s approach is primarily a clinical, not aneducational model. Therapists lead clients through a specific set oftherapeutic steps to bring about forgiveness. On the other hand, Luskin’sand Worthington’s approaches are psycho-educational and focus on theempowerment of individuals as they learn forgiveness through the didacticand guided practice aspects of group leadership.

Enright’s approach is clinical and therapeutic. Luskin’s and Worthing-ton’s approaches are educational. For this reason, Luskin’s and Worthington’spsycho-educational approaches appear to be the more widely applicable andeasily distributed patient curriculums for forgiveness education. In fact, theseapproaches could be easily included in patient education already underwayin fibromyalgia and chronic fatigue clinics, which is in contrast to Enright’smethod that requires trained therapists and a counseling environment.Luskin’s and=or Worthington’s psycho-educational approach allows for thedevelopment of a forgiveness education ‘‘unit’’ within an existingfibromyalgia=chronic fatigue patient education curriculum.

Integrating Forgiveness Enhancement into Fibromyalgiaand Chronic Fatigue Syndrome Treatment

This paper reviewed fibromyalgia and chronic fatigue syndrome definitions,epidemiology, and the limited treatment options. We showed the critical role

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of anger in the experience of patients with these chronic illnesses. Patientswith these disorders often feel they have been treated unfairly and holdanger toward themselves or others, including health care providers (Falvo,2005; Hanson, 2000). As a result, we believe that forgiveness enhancementtraining may be an ideal means to empower patients to cope more effectivelywith negative emotions that may be contributing to exacerbated symptoma-tology. This thinking is clearly speculative at this point and will requiresystematic empirical evaluation to determine its validity.

A conceptual model is the next step to help guide future empirical work.Figure 1 posits a beginning point in our desire to show the power of forgive-ness education and the creation of a conceptual model for understanding themechanisms through which forgiveness works. Figure 1 illustrates what webelieve to be the major emotional consequences of fibromyalgia and chronicfatigue syndrome that are relevant to forgiveness. As reviewed earlier in thispaper, these negative emotional reactions have been linked to poorer healthoutcomes (Everson et al., 1998; H. S. Friedman et al., 2003; Gouin et al., 2008;Hanson, 2000; Iqbal et al., 2003; Player et al., 2007; Kautz, 2008).

We postulate in this model that the effect of forgiveness will act prim-arily through one of three avenues. First, as our review notes, forgivenesshas been shown to have a direct relationship with improved health (forreviews see Worthington et al., 2005; Worthington et al., 2007; Toussaintand Webb, 2005). Second, forgiveness will likely have some effect on healthoutcomes through its mitigating effect on anger, stress, resentment, and othernegative emotions (Thoresen et al. 2000; Toussaint & Webb, 2005;

FIGURE 1 Conceptual model of the negative emotional consequences of fibromyalgia andchronic fatigue, forgiveness, and improved health. Note. Dashed arrow represents speculativedirect connection.

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Worthington, 2006; Worthington & Wade, 1999). Third, central sensitizationof the nervous system is currently being discussed as a potential etiologicalculprit in these disorders (Bennett, 2005), and we believe a potential protec-tive relationship between forgiveness and central sensitization may exist,though this pathway is more speculative at this point and likely mediatedthrough stress and negative emotions (Van Houdenhove & Egle, 2004).Nonetheless, there is no reason to doubt that the mind body link operatesthrough forgiveness as an antidote to the toxic effects of stress and angerand the homeostatic changes in nervous system activation over arousalcauses.

Given the rising tide of interest in multidisciplinary treatment offibromyalgia and chronic fatigue syndrome, the timing is right for the devel-opment and testing of forgiveness curricula for use by chaplains, nurses, doc-tors, and other medical professionals. These curricula should be developedand continually refined through empirical testing and validation. Thoughthere are no existing cures for fibromyalgia or chronic fatigue, implementingcarefully designed and evaluated forgiveness enhancement interventionsholds promise for the optimal mind, body, and spirit multidisciplinary careof these patients.

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