Journal of Behavioral Medicine, Vol. 29, No. 1, February 2006 ( C 2006) DOI: 10.

1007/s10865-005-9038-z

Self-Forgiveness, Spirituality, and Psychological Adjustment in Women with Breast Cancer

Catherine Romero,1,2,6 Mamta Kalidas,3,4 Richard Elledge,3,4 Jenny Chang,3,4 Kathleen R. Liscum,2,5 and Lois C. Friedman1,3
Accepted for publication: May 23, 2005 Published online: December 15, 2005

We evaluated whether a self-forgiving attitude and spirituality were related to psychological adjustment among 81 women being treated for breast cancer at a medical oncology clinic in a county general hospital. Both a self-forgiving attitude and spirituality were unique predictors of less mood disturbance and better quality of life (ps < 0.001). These results are consistent with previous research that has demonstrated a positive relationship between spirituality and well-being. The ndings also suggest that self-forgiveness should be explored experimentally to determine whether it can protect against the psychological effects of breast cancer-related stress. Interventions targeting these characteristics could improve the quality of life and alleviate stress, especially in women with breast cancer in public sector settings.
KEY WORDS: breast cancer; forgiveness; spirituality; mood disturbance; quality of life.

INTRODUCTION Forgiveness involves decreases in negative thoughts, feelings, and behaviors towards an offender following an interpersonal transgression (McCullough et al., 1997, 1998). Ideally, it also involves fostering compassion and other positive responses to the offender, although not necessarily reconciliation (Enright et al., 1996). Researchers have made signicant progress in clarifying the nature of forgiveness (McCullough et al., 2000; Worthington, 1998) and in identifying interventions for helping victims of interpersonal
1 Menninger

Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas. 2 Ben Taub General Hospital, Houston, Texas. 3 Baylor College of Medicine, The Methodist Hospital Breast Care Center, Houston, Texas. 4 Department of Medicine, Baylor College of Medicine, Houston, Texas. 5 Department of Surgery, Baylor College of Medicine, Houston, Texas. 6 To whom correspondence should be addressed at Catherine Romero, Ph.D., Menninger Department of Psychiatry and Behavioral Sciences, Houston, Texas 77030; e-mail: romeroc@bcm.tmc.edu.

offenses forgive their offenders (e.g., McCullough et al., 1997; McCullough and Worthington, 1994). Such interventions are promising because forgiveness can confer numerous benets, including reductions in depression and anxiety (e.g., Al-Mabuk et al., 1995; Freedman and Enright, 1996; Mauger et al., 1992) and improvements in overall psychological well-being (Krause and Ellison, 2003; McCullough et al., 2001). Although forgiveness may not be the recommended response to some transgressions (Lamb and Murphy, 2002), it appears to be a benecial response to most mildly or moderately serious interpersonal offenses (Witvliet et al., 2001). Although most studies of forgiveness have focused on forgiveness of specic situations, research on a forgiving attitude or personality (Brown, 2003; Girard and Mullet, 1997; Mullet et al., 1998; Walker and Gorsuch, 2002) has also contributed to understanding why forgiveness is benecial. For example, Worthington and his colleagues (2001) have suggested that fostering a forgiving attitude towards others may be one among several warmth-based virtues that contribute to good physical and psychological health by promoting positive mood and 29
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30 interpersonal relationships. Little research exists examining this, however. Furthermore, more attention has been given to forgiveness of others than to forgiveness of ones self, that is, the tendency to avoid undue self-blame and guilt. The self-forgiving person acknowledges his or her own mistakes. However, the self-forgiving person also relinquishes self-resentment and harsh self-criticism (Enright et al., 1996). Inordinate guilt being a cardinal symptom of depression (American Psychiatric Association, 2000), a healthy selfforgiving attitude may be protective against depressed mood. Extremely self-punitive or self-critical people may view negative life events as punishment for their shortcomings. In contrast, self-forgiving people who do not blame themselves for negative life events may experience less distress when faced with such events. A forgiving attitude towards ones self and ones shortcomings, therefore, may be helpful in adjusting to serious illnesses, such as cancer. In contrast, self-blame for illness may lead to shame and guilt, which may in turn decrease quality of life. Self-attributions are particularly common among women with breast cancer (Glinder and Compas, 1999). For example, women may attribute their breast cancer to dietary choices, smoking, delay in seeking treatment, and so forth. Therefore, a self-forgiving attitude may be especially important for this patient population. Although the negative effects of guilt and depression on health-related quality of life are well recognized (e.g., Grassi et al., 1996; Iconomou et al., 2004), the benets of self-forgiveness remain largely unstudied (Enright et al., 1996). A forgiving attitude of others has been positively linked to empathy (McCullough et al., 1997) and religiousness (Gorsuch and Hao, 1993; McCullough and Worthington, 1999; Mullet et al., 2003), and negatively linked to anger (Konstam et al., 2001) and vengefulness (McCullough et al., 2001). The few studies that have looked at correlates of self-forgiveness have focused on personality variables such as neuroticism and extraversion (e.g., Maltby et al., 2001; Mauger et al., 1992; Ross et al., 2004). No studies have examined a self-forgiving attitude in relation to religiousness/spirituality, despite the importance that many religious traditions place on seeking and accepting forgiveness from God (Krause and Ellison, 2003). Furthermore, no research has explored selfforgiveness in individuals with medical illness. In contrast, several studies have established a link between religiousness/spirituality and health

Romero, Kalidas, Elledge, Chang, Liscum, and Friedman variables (see Powell et al., 2003, for a review). Spiritual and religious coping are common responses to major life stressors, including medical illness (e.g., Koenig et al., 1998; Pargament, 1997; Levine and Targ, 2002; Meraviglia, 2004; Tix and Frazier, 1998). Spirituality and religious coping, as opposed to other forms of coping, are more frequent among women, the elderly, the socioeconomically disadvantaged, African-Americans and people who are psychologically distressed (e.g., Holt et al., 2003; Koenig et al., 1988), suggesting that individuals who have limited access to secular resources and power may rely more on religion as a coping strategy (Pargament, 1997). Researchers have reported that religious coping is associated with psychological well-being in cancer patients (Ell et al., 1989; Meraviglia, 2004) and with fewer cognitive symptoms of depression among elderly medical patients (Koenig et al., 1995). Religious activities and spirituality are also associated with greater social support and psychological adjustment among medically ill hospitalized older patients (Koenig et al., 2004). In summary, spiritual and religious coping are common and often benecial responses to medical illness, including cancer, yet the mechanisms explaining these benets have not been adequately explored. The purpose of the current study was to examine whether spirituality and a self-forgiving attitude were related to quality of life and mood disturbance among women with breast cancer in a public sector outpatient clinic. We hypothesized that a self-forgiving attitude would mediate a positive relationship between spirituality and quality of life and would mediate a negative relationship between spirituality and mood disturbance. We also examined the relationship between demographic and medical characteristics (age, education, and time since diagnosis) and the dependent variables (quality of life and mood disturbance), to determine whether we would need to control for these variables in the mediational analyses.

METHODS Participants and Procedure Study and consent procedures were approved by the Baylor College of Medicine Institutional Review Board and the Harris County Hospital District. Participants were a convenience sample of women

Self-Forgiveness, Spirituality, and Psychological Adjustment receiving follow-up medical care for breast cancer at a medical oncology breast clinic in a county general hospital in Houston, Texas. Eligibility criteria included the ability to speak and understand English and to give written informed consent. Potential participants were asked if they would be willing to participate by their physicians. Interested patients met individually with one of the research assistants in the waiting area or an examining room, at which time they were guided through the informed consent procedure and had the questionnaires explained to them. Questionnaires were either completed by the patients themselves or read to them and completed by the research assistant. Because the research was conducted in a busy clinic, and to protect patient condentiality, the physicians were unable to provide data on those patients who declined to participate. Spirituality

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We assessed spirituality with a single item: How spiritual/religious do you consider yourself? Participants rated themselves on this dimension using a ve-point Likert-type scale (1: not at all; 5: very much).

Mood Disturbance To measure mood disturbance, we used the short version of the Prole of Mood States (POMS; Shacham, 1983). This measure contains 37 items and has six subscales measuring both positive and negative emotional states. Participants endorsed the degree to which they had experienced each emotion in the past week on a ve-point Likert-type scale (0: not at all; 4: extremely). We reverse-scored the positive emotional state items and then summed all items for a mood disturbance score, with higher scores indicating more psychological distress. The internal consistency (Cronbachs alpha) of this measure in the current study was very good: = 0.97.

Measures Questionnaires assessed demographic (age, race/ethnicity, marital and educational status) and medical information (time since diagnosis, type of surgery, and treatment in the previous 6 months), psychological adjustment, quality of life, self-forgiveness, and spirituality. The self-report questionnaires took approximately 2030 min to complete.

Quality of Life To measure quality of life, we used the Functional Assessment of Chronic Illness Therapy: general version (FACIT) scale (Cella, 1997). This 27-item scale has four subscales measuring physical well-being, social/family well-being, emotional wellbeing, and functional well-being, which can be added together for a global measure of health-related quality of life. Participants endorsed the degree to which each item had been true for them during the past 7 days, using a ve-point Likert-type scale (0: not at all; 4: very much). We used the total quality of life score, with higher scores indicating better quality of life. The internal consistency (Cronbachs alpha) of this measure in the current study was very good: = 0.94.

Forgiveness We used the Forgiveness of Self (FOS) scale (Mauger et al., 1992) to measure self-forgiving attitude. This 15-item scale taps general attitudes and practices related to the tendency to forgive ones self. Participants endorsed the degree to which they agreed with each item on a 6-point Likert-type scale (1: Strongly Disagree; 6: Strongly Agree). The wording of the items was generally in the direction of higher scores meaning less forgiveness (e.g., A lot of times I have feelings of guilt or regret for the things I have done.). However, to facilitate interpretation of the results, we reverse-scored these items, so that higher total scores would indicate greater forgiveness. The internal consistency (Cronbachs alpha) of this measure in the current study was adequate: = 0.77.

Statistical Analyses Statistical analysis was done in three stages. First, descriptive statistics were computed for mood disturbance, quality of life, self-forgiving attitude, and spirituality. Next, univariate correlations were

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Table I. Demographic and Medical Characteristics N Race/ethnicity African-American Hispanic Caucasian Marital status Single Married Divorced Widowed Education Less than 8 years Some high school High school/GED Some college College graduate Employed (yes) Type of surgery Mastectomy Lumpectomy No surgery Treatment in the last 6 months Chemotherapy Hormonal Radiation Chemotherapy plus radiation None 45 22 14 25 27 14 15 14 14 24 22 7 23 50 10 21 26 13 3 11 28 Percent of distribution 55.6 27.2 17.3 30.9 33.3 17.3 18.5 17.3 17.3 29.6 27.2 8.6 28.4 61.7 12.3 25.9 32.1 16.0 3.7 13.6 34.6

Romero, Kalidas, Elledge, Chang, Liscum, and Friedman

Table II. Descriptive Statistics for Psychosocial Measures Variable Self-forgiving attitude (FOS) Spirituality Mood disturbance (POMS) Quality of life (FACIT) Mean 59.72 3.95 44.28 78.21 SD 12.99 1.07 32.44 22.81 Range 3290 25 0127 18108 n 65 81 74 72

Note. FOS: Forgiveness of Self scale; POMS: Prole of Mood States; FACIT: Functional Assessment of Chronic Illness TherapyTotal Score.

been treated surgically with mastectomy, 12% with lumpectomy, and 26% had not had surgery. Sixty-ve percent had been treated in the previous 6 months with chemotherapy, hormonal treatment, radiation or some combination of the above. Table I presents complete demographic and medical data obtained for this sample.

Descriptive Statistics Means, standard deviations, and ranges of the scores for the psychosocial measures are presented in Table II. Patients mean mood disturbance score was 44.3 (SD = 32.4). This score was somewhat higher than that obtained from a sample of recently diagnosed (pretreatment) cancer patients with variable malignancies (M = 31.1, SD = 33.6; Cella et al., 1989). This difference between samples may reect the relatively greater length of time since diagnosis in our sample (M = 25.59 months, SD = 33.50) and the effects of treatment on mood. The patients mean quality of life score of 78.2 (SD = 22.8) was comparable to that reported for a sample of cancer patients with variable malignancies (Cella, 1997).

Note. Age (years): mean, 51.85; SD, 10.20; range, 2771. Time since diagnosis (months): mean, 25.59; SD, 33.50; range, 1168.

computed to examine relationships among the demographic, medical, predictor (spirituality and selfforgiving attitude), and outcome variables (quality of life and mood disturbance). Finally, multiple regression path analyses were used to test the hypothesized mediational models. A power analysis determined that at least 67 participants were needed to detect a medium effect (r = 0.30) at = 0.05 (onesided) with power = 0.80.

Univariate Relationships RESULTS Participants The mean age of the participants (N = 81) was 52 years. Fifty-six percent of the participants were African-American, 27% were Hispanic, and 17% were Caucasian. Sixty-ve percent were single, widowed or divorced, and 72% were unemployed. Sixty-ve percent had obtained at least a high school diploma or GED. The average time since diagnosis was 25.6 months. Sixty-two percent had Table III presents the Pearson correlation coefcients among the independent (age, time since diagnosis, self-forgiving attitude, and spirituality) and dependent (mood disturbance and quality of life) variables. There was a strong, signicant negative relationship between the dependent variables (p < 0.001), highlighting the inverse relationship between quality of life and mood disturbance. Because there was some overlap between the mood items and the emotional well-being (EWB) subscale of the quality of life measure, we also examined the correlation between mood and quality of life with the EWB items

Self-Forgiveness, Spirituality, and Psychological Adjustment

Table III. Pearson ProductMoment Correlation Coefcients Variable Time since Age diagnosis (1) 1 2 3 4 5
p

33

Self-forgiving attitude (3) 0.06 0.10

Mood Spirituality disturbance (4) 0.43 0.20 0.02 (5) 0.20 0.07 0.47 0.34

Quality of life (6) 0.20 0.06 0.46 0.38 0.81

(2) 0.13

< 0.01; p < 0.001.

removed. The negative relationship between quality of life and negative mood remained strong and signicant (r = 0.75, p < 0.001). Age and time since diagnosis were not signicantly related to mood disturbance or quality of life (ps > 0.05). There was a signicant negative relationship between self-forgiving attitude and mood disturbance (p < 0.001). There also was a negative relationship between spirituality and mood disturbance (p < 0.01). A signicant positive relationship was found between self-forgiving attitude and quality of life (p < 0.001). A signicant positive relationship also was found between spirituality and quality of life (p < 0.01). However, the relationship between spirituality and self-forgiving attitude was not significant (p > 0.05). We also conducted t-tests to determine whether level of education (high school graduate vs. non-graduate) was signicantly related to any of the other variables. Level of education was not associated with age, time since diagnosis, mood disturbance, quality of life, self-forgiving attitude or spirituality (ps > 0.05).

cation, and time since diagnosis were not signicantly related to quality of life or mood disturbance, these variables were not included in the models.

Mood Disturbance Spirituality and a self-forgiving attitude signicantly predicted mood disturbance scores, R = 0.61, F(2, 60) = 17.99, p < 0.001. Approximately 38% of the variance in mood scores was accounted for by the independent variables (R2 = 0.375). A self-forgiving attitude (t = 4.49; p < 0.001; = 0.46) and spirituality (t = 3.89; p < 0.001; = 0.40) were unique predictors of mood disturbance scores. A higher degree of both self-forgiveness and spirituality was associated with less mood disturbance.

Quality of Life Results showed that spirituality and a selfforgiving attitude signicantly predicted quality of life total scores, R = 0.61, F(2, 58) = 17.52, p < 0.001. Approximately 38% of the variance in quality of life scores was accounted for by the independent variables (R2 = 0.377). A self-forgiving attitude (t = 4.23; p < 0.001; =.44) and spirituality (t = 3.94; p < 0.001; = 0.41) were unique predictors of quality of life total scores, with greater self-forgiveness and spirituality associated with better perceived quality of life.

Multivariate Relationships Mediation requires a signicant correlation between the predictor variable (spirituality) and the mediator (a self-forgiving attitude), a signicant correlation between the mediator and the outcome variable (quality of life and mood disturbance) and a signicant drop in the correlation coefcient of the original predictor when the mediator is included in the model (Aiken and West, 1991; Holmbeck, 1997). Because spirituality and a self-forgiving attitude were not signicantly correlated, we could not perform the path analyses. However, we performed two multivariate regression analyses to examine the relative contribution of each variable to the prediction of quality of life and mood disturbance. Since age, edu-

DISCUSSION This study linked a self-forgiving attitude and spirituality to psychological adjustment in women with breast cancer in a public sector setting. The positive associations between spirituality and our measures of psychological adjustment are consistent

34 with previous research suggesting that spirituality and religious practices promote well-being in the general public (Parker et al., 2003) and in medical populations (e.g., Koenig et al., 2004; Meraviglia, 2004; Yates et al., 1981). Possible explanations for this relationship (e.g., reduction in illness-promoting behaviors, the relaxation response) have been discussed extensively (e.g., Powell et al., 2003; Seeman et al., 2003) but have not yet been conrmed empirically. Our prediction that a self-forgiving attitude may be one explanatory mechanism was not supported, as a self-forgiving attitude and spirituality were not signicantly related. However, the nding that a self-forgiving attitude signicantly predicted psychological adjustment represents one of the rst demonstrations of potential benets of selfforgiveness among cancer patients. Future research must identify other mechanisms through which spirituality and a self-forgiving attitude benet individuals with chronic illness. For example, perhaps the women in our study who were better able to forgive themselves spent less time ruminating over mistakes and shortcomings, freeing up cognitive resources to deal with the stress of being diagnosed with breast cancer and with treatmentrelated issues. In contrast, women who reported being more spiritual may have relied on religious coping practices to manage their mood and level of functioning. Given the weak association between self-forgiveness and spiritualityand the strong association of each variable with adjustmenteither route may be a viable means of coping with breast cancer. The strong negative relationship between mood disturbance and quality of life is not surprising, as research (e.g., Ell et al., 2005) suggests that negative mood (particularly depression) has deleterious effects on cancer patients quality of life. Although emotional reactions appear to be a large component of overall psychological adjustment to cancer, the relationship between mood and quality of life could not be attributed entirely to the presence of an emotional well-being (EWB) scale in the quality of life measure. This nding highlights the importance of treating depression and other negative mood states in patients with cancer. Despite the promising ndings, the current study had several limitations. Although a power analysis suggested sufcient power to detect medium to large effects, the sample size was relatively small, which may have obscured smaller effects (e.g., the effect of age on adjustment). Because those who declined to

Romero, Kalidas, Elledge, Chang, Liscum, and Friedman participate were not identied, it is unclear whether the ndings would generalize to all patients in a public outpatient clinic. Furthermore, there may be important cross-cultural differences that we could not explore within this sample, which was predominantly composed of highly religious African-American patients. In addition, compared to a sample of recently diagnosed patients (Cella et al., 1989), the patients in this sample had relatively greater mood disturbance (i.e., higher mood disturbance scores). Thus, additional research will be necessary to determine whether the ndings apply to relatively less distressed cancer patients. Another limitation was our exclusive reliance on self-report questionnaires for measuring the variables of interest. For example, the one-item measure of spirituality may not have detected as much variability in spirituality and religiousness as a behavioral or multi-item measure. The sample was also skewed on this measure, and although nonparametric tests yielded identical results to correlations described earlier, additional research is necessary to conrm the relationships within a normally distributed sample. Furthermore, the lack of a relationship between spirituality and a self-forgiving attitude may have been inuenced by this measurement limitation. However, the fact that the one-item measure was correlated with important outcomes suggests that spirituality should be studied in the future with more sophisticated instruments. Despite these limitations, the current study has important implications for the psychological treatment of women with breast cancer in public sector oncology clinics. Research suggests that depression is prevalent among low-income, ethnic minority women treated for breast cancer in public clinics, and that depression is related to pain, anxiety, and health-related quality of life (e.g., Ell et al., 2005). Thus, it is important to identify factors that are negatively related to psychological distress, such as spirituality and self-forgiveness, in order to develop interventions for this population. Because self-forgiveness and spirituality were statistically independent of each other, women with both qualities may be especially likely to experience higher quality of life while dealing with breast cancer, and those with neither quality may be at greater risk for psychological distress at this critical period. Future studies should investigate the effects of interventions that incorporate the current ndings. For example, integrating spirituality into medical care may be helpful for breast cancer patients.

Self-Forgiveness, Spirituality, and Psychological Adjustment Oncologists and nurses caring for these patients might inquire about the importance of spirituality in their patients lives as a way of predicting how well they are likely to cope with the stresses associated with breast cancer. When appropriate, patients could be referred to available resources to meet their spiritual needs. In light of the self-forgiveness ndings, discussions between oncologists and their breast cancer patients should routinely include reassurance that patients are not responsible for developing breast cancer and that it was not caused by anything they did. This study represents an important rst step in moving the concept of self-forgiveness from the realm of theory to that of empirical research, supporting the importance of both a self-forgiving attitude and spirituality for psychological well-being and adjustment to illness. REFERENCES
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