The effect of “Forgiveness therapy” on depression and low self-esteem for a victim of abuse: A Case study
 
Jeledan, Tagreed Malik
Taibah University, Saudi Arabia.
 
Abstract:
It has been said before that “No one forgives with more grace and love than a child”.  And also no one can compete the child with his outstanding memory which can’t forget deep injuries during childhood, especially when these multiple abuses come from his/her parents and other relatives. Being physically abused, emotionally abused, and neglected from her biological parents and sexually abused from one of her relatives, this 25 years old female, who is a student in the university, suffers from severe depression and very low level of self-esteem.

The current research aims at decreasing the client’s depression and improving her self-esteem through case study techniques, assessing her needs, fears, deep feelings and behavior using a variety of methods, including projective tests, life history, interviews and direct observation of her behavior.  

The researcher will attempt to help this female using the techniques of the “Forgiveness Therapy” which is described by a number of clinicians and researchers as a promising approach to anger-reduction, depression healing and the restoration of general emotional and mental health. Key words: Forgiveness Therapy, depression, self-esteem, child abuse, physical abuse, emotional abuse, neglect, sexual abuse, childhood, case study, clinical psychology.
 
 
Theoretical and Research Bases
A review of the literature shows that the study of forgiveness and its therapeutic application has been taken up by researchers and clinicians in the fields of psychology, counseling, and family therapy. Researchers and therapists have recently begun promoting forgiveness therapy as a means of coping with interpersonal conflict (Landry, Rachal, Rachal, & Rosenthal, 2005). (Bono and McCullough, 2006) reported that forgiveness could be successfully promoted through clinical interventions.

Forgiveness is a process (or the result of a process) that involves a change in emotion and attitude regarding an offender. Enright describes forgiveness then, as a psychological response that includes six components: absence of negative affect, judgment, and behavior toward an offender, and the presence of positive affect, judgment, and behavior toward the same offender. These occur in the face of deep, unfair, hurt. (Enright, 2001). Most scholars view this as intentional and voluntary process (Fincham, 2000; Worthington, 2005; Philpot, 2006), driven by a deliberate decision to forgive. This process results in decreased motivation to retaliate or maintain estrangement from an offender despite their actions, and requires letting go of negative emotions toward the offender. (Philpot, 2006).

(Fayyaz, & Besharat, 2011) foundthatfailure to forgive might prolong certain negative emotions (e.g., anger) that eventually lead to depression. Unforgiving people keep severe negative feelings like anger, which will be lead to depression. It has been shown that people who tend to ruminate past unhappiness or victimized experiences are less likely to forgive others. On the other hand, depression has a negative effect on the tendency to forgive. The findings showed that pre-existing levels of depression that participants brought in to the experiment influenced in forgiveness (Tse & Cheng, 2006)

A person who forgives others over past mistakes heals himself from pain felt due to deep hurt. Forgiveness leads to lower level of anger, depression and anxiety but high level of life satisfaction. People showing un-forgiving attitude toward others are more likely to have depression and posttraumatic stress disorder. (Sadiq & Ali, 2012)

(Enright and the Human Development Study Group, 1991) proposed four phases in which 19 steps of forgiveness occur. The definition of forgiveness of Enright and colleagues contains several more essential elements.  A core emphasis of this conceptualization of forgiveness is the decrease in negative responses to the wrongdoer across the realms of cognition, emotion, and behavior (or potential behavior) toward the offender. (Pp. 123-152).  

The recent client description of her daily life activities, her feelings, and the quality of her thinking style, in general, were replete with emotional, cognitive, and behavioral distortions. Therefore, the definition of Enright for forgiveness can be used here to present a proper therapy, which could be reasonable treatment for this client.
 
Case Introduction
The client, referred to by the pseudonym “Amal”, was 25-years-old biology student in her fourth semester, who came to the researcher as a member of the university student-counseling center complaining of loss of any interests in life. She was unmarried though lots of students get married at this age. She had 2 elder a brother and a sister and another 4 younger brothers and sisters.

Amal was a very shy women, her eye contact with others was minimal, primarily directed to the floor, her voice was very low and trembling revealing fear and self-distrust, along with a neglected appearance and average grades.

At intake, she admitted to having thoughts of death (e.g., “Sometimes I would like to disappear from this world and have no problems or responsibilities”) but no suicidal intent or plan. She denied symptoms of anxiety, mania, or psychosis. Amal insisted to meet the researcher to put an end to her misery and feelings of depression, low self esteem and she said “I contempt myself  ... “
 
History
Amal reported she had been facing difficulties with her parents, brothers and sisters. She is unmarried and in our society it’s obligatory to live with the parents until she get married and regularly girls feel secure and satisfied as their parents take good care of them, but for Amal the case is different. Amal complains of parents’ neglect, contempt, hitting, sarcastic words, and avoidance. Her father stays most of the time outside their home. He watches TV while at home and avoids communication with his children and wife. He always hits and hurts her feelings. She says, “I feel so afraid of him... I never talk to him... I feel he is never proud or satisfied with us“. Though her mother is a nonworking woman, yet Amal feels neglected by her mother also, and she feels her mother is a passive person and isolated from every one even from her own children. The mother shouts at her children in front of strangers and doesn’t care about her appearance or her children’s. Amal says “My mother is not a normal person and my father stressor her”.  

This outlined the relation between our case and her parents and the feelings of fear, distrust, neglect, threat, contempt that prevail at home. She felt that her speech was worthless, so she became speechless. She always hates her birthdays and they make her sad and cry.

When she was 17 years old, while she was walking in the street coming back from school, someone attacked her and dragged her inside a building where no one can see them and raped her and because of her bad relation with her family she didn’t tell anyone. Since then, she fears walking in the street and imagines someone will attack her constantly. She went to a psychiatrist and diagnosed her case as depression and prescribed pills for her but she wants to be cured with no pills so she came to me. She has a strong will to be better. She complained also of continues nightmare of a vision of a man or a woman chasing her and has had difficulties falling asleep at night. She feels that she will never be loved by anybody and thus she will not get married in the future.

Academically, Amal reported that she had been an average student and complained of difficulty of concentration while studying. She has no friends and she feels that no one loves her. She related that she doesn’t enjoy the company of others and she dislikes being in focus of attention of others and she doesn’t have friends whom she can lean to for support. Amal stated that she prefers to stay alone in her room isolated from her family at home which indicates difficulties of social adjustment and communication with others. She concentrated totally on the past and she lacks of any purpose in life. She literally said,” My thoughts are totally paralyzed, my will is stolen from me”. Her goals and aims in life do not receive any conceived support from her family, but only criticism and pointing out her failure. She felt she could never do anything right. Her painful past runs all the time on her mental screen without conscious request.
 
Assessment

Amal was self-referred to the student counseling services at the university. Pretreatment evaluation was taken including a detailed history-gathering interview that included all her family members’ input. Three empirical measures were employed before and after treatment:  1 - The Beck Depression Inventory (BDI), The BDI is a widely used screening measure of clinical depression with excellent psychometric properties (Beck & Steer, 1987). 2 - Enright Forgiveness Inventory (EFI)- The EFI is a 60-item self-report scale constructed by Enright (1991) using a Likert scale ranging from one to six, comprised of three subscales items: emotional forgiveness, items one to 20 measure one’s present feelings; behavioral forgiveness, items 21 to 40 measure one’s present behaviors; and cognitive forgiveness, items 41 to 60 measure one’s present thoughts. Psychometric characteristics of the EFI were measured in many studies (Enright, 1991). Cronbach’s alphas of each subscales of EFI is reported which at least is 0.93 and at highest is 0.98 which indicates high internal consistency of the EFI. Correlation coefficients between cognitive, emotional and behavioral subscales was measured 0.80 which shows that all three subscales evaluate one construct and the EFI has a high reliability (Enright, 1991 ( . 3 - The Rosenberg Self-Esteem Scale (RSES), is a 10-item psychometrically established measure of global self-esteem. Subject rated the items on a scale from one (strongly agree) to four (strongly disagree); higher scores reflect higher self-esteem.

Amal’s scores on the BDI and EFI and RSES shows high range of depression, a low range of self-esteem and forgiveness on the three levels emotional, behavioral, and cognitive.

 
Table 1- Amal’s clinical scores: Initial Assessment
 
The TAT was constructed to help identify drives, emotions, sentiments, complexes, conflicts of her personality and is used to gain a better understanding of her vision of herself and for life in general, and to enhance the psychotherapeutic process.( Aronow, E., Weiss, K., Reznikoff, M., 2001)

A diagnosis of Major Depressive Disorder and low self-esteem seemed most appropriate based on the tests results; she suffered psychologically distressing symptoms or major depressive episodes that include at least 3 years of a depressed mood or loss of interests, accompanied by, insomnia nearly every day, fatigue or loss of energy, feelings of worthlessness or excessive guilt, diminished ability to think or concentrate. (DSM-IV-TR; APA, 2000)
 
Case Conceptualization
Based on the assessment results, it was concluded that she needed two ways to practice forgiveness: First to practice forgiveness as an option to facilitate healthy functioning for Amal towards her parents who still in her life, second one towards an offender whose existence vanished from her life. She needs to deal with unresolved feelings towards both of them.

It is important that Amal goes through forgiveness’ sessions and then, Amal’s ability to forgive both parties should increase, eventually, her depression should decrease and her self-esteem should get better. I assumed that her recent depression and low self-esteem are normal results for her perception of her bad experiences and abuses in the past that have happened to her, and that those experiences help determine how she thinks, feels, and behave towards herself and others. Therefore, it is highly important that she make a decision to achieve a dramatic conversion and change her recent judgment towards her parents’ and the offender’s behavior. Amal received counseling services free of charge due to her full-time student status.
 
Course of Treatment
The therapy conducted basically on the eclecticism and integration of more than one approach in therapy including: cognitive-behavioral, humanistic, spiritual and some major steps of Enright and the Human Development Study Group (1991) 4 fazes of forgiveness (Uncovering, decision, work and deepening).

 Because Amal reported severe depressive symptoms, thus her negative cognitions were targeted first. Collaboratively, Amal and her therapist ran dialogue that focused on examination of her thought patterns, which revealed disturbed thinking and unrealistic expectations from herself and others. A focus made on the cognitions to help improve her behaviors. In addition the therapy focused on her negative emotions which was aroused by her low self-esteem like her deep feelings that no one loves her and that she don’t deserves any love at all; that’s why she withdrew, avoided and isolated from social life and practiced being invisible in the background. The therapist thus, aimed to offer supportive words and actions to win her trust and cooperation. Goals for therapy included diminishing depressive symptoms, building positive self-steam, reducing her anger, pain and hatred towards her parents, and improving her academic level at college.   

Treatment consisted of 21 individual sessions each one was 50 minutes, started from February to June 2013. Treatment initially began with establishing strong, collaborative therapeutic alliance since it fosters a great sense of self-efficacy in the client and challenges negative perceptions of herself, world, and future. (Beck et al., 1979) 

During the first three sessions, Amal began to realize that she is experiencing a psychological distance from her painful conflict, withdrawal and repression was mainly her defenses in order to alleviate discontent. She was aware of the sorrow and  shame that she was experiencing long time ago, along with thoughts of refusal, anger and hatred towards her parents and the abuser. The therapist aimed at helping her realize these thoughts and feelings along with respect, understanding and empathy. Amal felt exhausted many times during and after these sessions and that was expected due to the emotional disclosure. She was able to describe all what she could remember from her negative experiences in an attempt to help her explain that the reason for them to happen lies not within herself as she thought was. 

Then, 4 to 6 sessions Amal reached more of self-awareness of her dilemma and practiced cognitive rehearsal of the hurtful scene in her mind. She learned to share her true feelings and express herself without fear of unacceptance.  She reached the decision that she needs real steps to overcome her grief and anger and realized that focusing on the painful past is not the right endeavor. Amal began to realize that there must be a “change of heart” toward the hurtful events and the injurer (the parents and the abuser). The therapist had to add quotations from Quran and Prophet Mohammed’s sayings and told her about forgiveness in Islamic religion as a starting point to this conversion, and that was effective, not from a religious obligation, but from a deep insight and understanding of the usefulness of the process of forgiveness and its incredible self and sorrow relief. She discovered her continues negative ideas about herself and others around her which caused her low self-esteem. Then she began to consider forgiveness as an option and decided to “letting go of past hurt and bitterness”. Once forgiveness has occurred, positive outcomes at both the interpersonal and intrapersonal levels can be expected. A crucial interpersonal outcome associated with forgiveness is reconciliation, defined as a “reestablishment of the pre offense relationship that began to appear between her and her parents”. Riek & Mania (2012)

Amal made a commitment to forgive and she did it by her mind and not necessarily altering it by words. Amal realized that she herself has needed other’s forgiveness in the past and that nobody is perfect. Amal was able to acknowledge and accept the permanent change in herself because of the abuse. Then the therapist was able through imaginative exercise to perform a spiritual surgery inside Amal’s soul and perform a scene where Amal is looking at the abuser who turned much weaker and smaller than actual size and imagine him seeking forgiveness. The client then took her time and decided to forgive him mentally and send hem peaceful words. 
   
By the 7 through 9 sessions she began to achieve good emotional progress towards her parents and towards the abuser. She began to recognize that her father was basing his negative evaluation of her on his own disappointments and bitterness caused by his feelings of inadequacy. She also is aware that her mother is emotionally unstable, lack parenting skills, has low self-esteem and other negative dispositions. She finally realized that all these faults of her parents do not lay within her after all. She developed empathy towards them and considered the parent’s own abusive childhood and the environmental events surrounding the parent’s own personality formation. This does not excuse the parental abuse but it allows Amal to understand the injustice done to her. She decided to rebuild a good relation between her and her parents for the present and future. She practiced exercises such as “placing oneself in the other person’s shoes” in order to develop an understanding of the offender’s troubled feelings and decrease anger and pain for the injured. She began to accept pain and injustice. The therapy also focused on spiritual ideas e.g. Islam emphasizes justice and punishment of the wrong doers, but it equally strongly emphasizes mercy, kindness and love. Justice, law and order are necessary for the maintenance of a social order, but there is also a need for forgiveness to heal the wounds and to restore good relations between the people. We must keep in mind that as much as we need Allah’s forgiveness for our own sins and mistakes, we must also practice forgiveness towards those who do wrong to us.

After the 10 until the 15 sessions we tried to practice different ways to absorb the pain and the psychological scars and accepting the injustice for the aim of releasing it in a healthy way instead of responding revengefully because forgiveness stop the cycle of revenge. She learned to overcome her guilt to love herself and to think about her own benefits and dreams. She started to feel more responsible about her life and not blame others for her misery. She also succeeded in writing a list of her good qualities and was able to read it every day out loud during therapy. She started to value herself more, read more, get extra courses, join a healthy club, and integrate socially with her friends but not so much because still there are lots of boundaries which she have build.

By the 15 through 21 sessions the therapist explained to Amal that poor studying will result in self-defeating and jeopardizes her future, and her life goals. So, she began to pay attention to her study and realized she must improve her grades to feel better at the end. This leaded her to define her goals in life more clearly and wrote them down. She began to ask her professors about some points in the courses that indicate improvement. She began to improve her relation with her mother in fact she was able to offer a gift and a hug to her mother on her birthday, which surprised her a lot. She started to build a little communication with her brothers and sisters.

Research findings prove that forgiveness is the first step and the most substantial one to achieve real self-healing and inner peace. Pain and unfair hurt of the heart will never diminish until forgiveness settles there and wipe it first. This is consistence with the emphasizing on forgiving each other in Quran and other Muslim's resources.

The findings of the present study support researches that mentioned the negative relation between depression and forgiveness. Our study conducted in Saudi Arabia which most of people are Muslims and try to obey Quran's orders. Emphasizing on forgiving each other in Quran and other Muslim's resources persist them in it. Comparing the forgiveness Mean in different cultures can help us to make newer interventions for forgiveness therapy
 
Follow up
After finishing treatment and tow month later, Amal has slowly developed a desire for respect, enhanced communication and a tendency for forgiving her parents and overcome the past experiences, therefore, she needed her parents to do the same too because she treated them with disrespect as a defense mechanism for their past abuse towards her. After the therapy ended, she faced some troubles with her parents because they also needed to change them selves in order for the therapy to succeed. With the help of the therapist, they were told that they should abandon all kinds of aggression toward their children in the future and that the element of respect is a must component within the family daily life along with safe environment. At the beginning they refused to meet the therapist and they disagreed with her, but later on they approved the therapy.

 Dealing with a case of child abuse which started at childhood and continued uncured till adulthood is very demanding because painful memories keep stressing the abused person consciously and subconsciously and no one can predict when bad feelings, depression and low self esteem could appear again even after the case have been improved significally. These negative feelings could raise again unexpectedly, after a crisis or a sudden deep shock or an embarrassing situation or even an attack from others towards her self. I think it could raise again every time she faces an un usual attack towards her self but due to the therapy she will try to enhance her communication, exercise her mental stability, practice self respect, attain personal demands, and sustain for her self good relations with others based on respect for all sides including her own.  She will be able gradually to get her self better reactions towards stressors of life because she started already doing so. The course of treatment included relaxation endeavors which contained within it lots of positive massages directed to the subconscious in contempt to deepen the therapy. 
 
 
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