Forgiveness and suicidal behavior in primary care

Journal of Spirituality in Mental Health

ISSN: 1934-9637 (Print) 1934-9645 (Online) Journal homepage: http://www.tandfonline.com/loi/wspi20

Forgiveness and suicidal behavior in primary care: Mediating role of future orientation Jessica Kelliher Rabon, Jon R. Webb, Edward C. Chang & Jameson K. Hirsch To cite this article: Jessica Kelliher Rabon, Jon R. Webb, Edward C. Chang & Jameson K. Hirsch (2018): Forgiveness and suicidal behavior in primary care: Mediating role of future orientation, Journal of Spirituality in Mental Health, DOI: 10.1080/19349637.2018.1469454 To link to this article: https://doi.org/10.1080/19349637.2018.1469454

Published online: 31 May 2018.

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JOURNAL OF SPIRITUALITY IN MENTAL HEALTH https://doi.org/10.1080/19349637.2018.1469454

Forgiveness and suicidal behavior in primary care: Mediating role of future orientation Jessica Kelliher Rabona, Jon R. Webba, Edward C. Changb, and Jameson K. Hirscha a Department of Psychology, East Tennessee State University College of Arts and Sciences, Johnson City, Tennessee, USA; bDepartment of Psychology, University of Michigan, Ann Arbor, Michigan

ABSTRACT

ARTICLE HISTORY

Forgiveness, a cognitive-emotional and behavioral reduction of negative responses to offenses, is directly related to less suicide risk, but may be indirectly related via its relation with future orientation, the ability to envision a positive future. In 100 rural primary care patients, we examined the association between selfforgiveness, other-forgiveness, and forgiveness by God and suicidal behavior, with future orientation as a mediator. Forgiveness was related to greater future orientation and, in turn, to, less suicidal behavior. Addressing the past may promote adaptive views of the future and reduce suicide risk, results suggesting potential temporal and forgiveness-based points for suicide prevention.

Received 16 November 2017 Accepted 23 April 2018 KEYWORDS

Forgiveness; future orientation; suicide; suicidal behavior; primary care

Suicide and suicidal behaviors are significant public mental health concerns, and although much research has focused on suicide risk factors, understanding protective factors is also essential for effective suicide prevention (Beautrais, Collings, Ehrhardt, & Henare, 2005). As well, a better understanding of such factors as they occur in key catchment settings, such as primary care, is critical for implementation of targeted interventions to prevent suicide. Primary care physicians are often the initial point of contact when seeking mental health services (Ray-Sannerud et al., 2012), and suicidal behaviors are frequent in primary care settings; for instance, approximately 2.4% of primary care patients exhibit suicidal behavior (Younes et al., 2015). Of note, approximately 45% of those who die by suicide contact their general practitioner in the month before death (McDowell, Lineberry, & Bostwick, 2011), and 22% do so in the week prior to death (Draper, Snowdon, & Wyder, 2008). In contrast, only about 20% of those who die by suicide see a mental health professional in the month before death (McDowell et al., 2011). Educating primary care providers on the recognition and assessment of

CONTACT Jameson K. Hirsch [email protected] Department of Psychology, East Tennessee State University, 420 Rogers Stout Hall, Johnson City, TN 37614, USA. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wspi. © 2018 Taylor & Francis Group, LLC

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suicidal behavior, including risk and protective factors, may reduce likelihood of patient suicidal behavior (McDowell et al., 2011). One such protective factor is forgiveness, which is conceptualized as a reduction of negative cognitive, behavioral and affective responses to offense, and which may involve numerous contexts (e.g., self-forgiveness, forgiveness of others, and forgiveness by God) and can be delivered through various methods (e.g., offering, seeking, feeling; Hirsch, Webb, & Jeglic, 2011; Toussaint & Webb, 2005). Further, forgiveness does not necessarily involve compensation, surrendering accountability, or resolution but, rather, is an internal, comprehensive and deliberate process (Webb, Hirsch, Toussaint, 2015). Forgiveness is beneficially related to many health outcomes; for example, self-forgiveness is related to increased physical health and psychological wellbeing (Davis et al., 2015), forgiveness of others is related to better medical wellbeing (e.g., better immune functioning, lower blood pressure) (Wilson, Milosevic, Carroll, Hart, & Hibbard, 2008), and forgiveness of self, others, and by God are related to less risk of depression (Toussaint, Williams, Musick, & Everson-Rose, 2008). Although research is limited, the extant literature suggests that themes related to forgiveness are intertwined with attempted or completed suicide, proposing that a lack of forgiveness disrupts psychological wellbeing and interpersonal functioning, heightening the risk for a suicide attempt (Sansone, Kelley, & Forbis, 2013). Further, evidence suggests forgiveness is inversely related to suicidal behavior (Hirsch et al., 2011; Nsamenang, Webb, Cukrowicz, & Hirsch, 2013; Webb, Hirsch, Visser, Brewer, 2013). The association between forgiveness and positive health outcomes may operate through direct and indirect mechanisms (Worthington, Berry, & Parrott, 2001). The direct effect may function, partially, through its association with reductions in rumination related to unforgiveness, resulting in fewer negative emotional responses (Worthington et al., 2001). In contrast, an indirect effect may function through mediating associations with variables such as health behavior, interpersonal functioning, and social support (Webb et al., 2013; Worthington et al., 2001), as well as cognitive-emotional and motivational factors, including future orientation. Already well-established as a protective factor, future orientation (FO) is conceptualized as a person’s expectations about the changeability of their future for the better (Hirsch, Molnar, Chang, & Sirois, 2015), and involves the ability to think about the future positively, have a positive mood about the future, and identify future goals and develop strategies to attain them (Hirsch et al., 2006). Notably, suicidal persons tend to engage in future thinking that lacks an ability to see positive future events (MacLeod et al., 2005). As a protective factor, FO may reduce suicide risk via its influence as a catalyst of volitional and goal-directed thoughts and behaviors that allow transcendence of current stressful circumstances through prospection about purposeful and meaningful future goals (O’Connor, Smyth, & Williams, 2015; Seligman, Railton, Baumeister, & Sripada, 2013).

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How one thinks about the future is a robust contributor to overall wellbeing (Danchin, MacLeod, & Tata, 2010) and, in general, adaptive future orientation is related to enhanced wellbeing and better psychological outcomes (e.g., reduced depression and suicide risk), including in medical patients (Hirsch et al., 2007; Ridder, Schreurs, & Bensing, 2000; Safren, Radomsky, Otto, & Salomon, 2002). In contrast, a negative future outlook is related to greater psychopathology and suicidal behavior (Danchin et al., 2010). As noted, forgiveness appears to exert beneficial effects, in part, by reducing negative, ruminative views of the past (Worthington et al., 2001), but may also function by promoting positive thoughts and mood about the future instead and, thereby, reducing suicide risk (Hirsch et al., 2007). This premise has not been previously examined; however, previous literature indicates that forgiveness promotes other future-oriented constructs such as hope (Baskin & Enright, 2004; Luskin, Ginzburg, & Thoresen, 2005) and optimism (Harris et al., 2006). In the current study, at the bivariate level, we hypothesized that forgiveness and future orientation would be negatively related to suicidal behavior, and that forgiveness would be positively related to future orientation. At the multivariate level, we hypothesized that forgiveness (of self, of others, and feeling forgiven by God) would be related to suicidal behavior and that future orientation would mediate this association, such that more forgiveness would be related to greater future orientation and, in turn, to less suicidal behavior.

Method Participants

Participants (N = 100) were recruited from a rural, primary care clinic serving working uninsured patients in a Southeastern Appalachian region of the United States. Participants were primarily female (n = 71; 71.0%), and White (n = 93; 93.0%), with 3.0% Black (n = 3), 1.0% Asian (n = 1), and 2.0% other or don’t know (n = 2). Participants had a mean age of 42.04 (SD = 12.81), ranging from 18 to 64 years of age. The majority of participants worked full-time (n = 42; 42.0%) or part-time (n = 31; 31.0%), with the overwhelming majority of participants earning less than $30,000 per year (n = 92, 92.0%). Our study was approved by an Institutional Review Board and research assistants handed out packets at the local primary care clinic which could be either filled out on location on brought home and mailed to the researchers. All participants completed an informed consent process and received $15.00 for completion of survey materials. Our use of a rural, primary care sample is important, as rural patients often lack access to mental health services or are reluctant to access services

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due to stigma (Hirsch & Cukrowicz, 2014). Rural individuals are also more likely to experience disproportionate levels of poverty and low education, poor health, and have greater access to firearms and higher suicide rates than urban counterparts (Nsamenang et al., 2013; Searles, Valley, Hedegaard, & Betz, 2014). Measures

In addition to assessing demographic characteristics, including age, sex, and race, we measured forgiveness of self and others, and forgiveness by God, using the Brief Multidimensional Measure of Religiousness/Spirituality (Fetzer Institute, 2003), which includes three single items measuring forgiveness: forgiveness of self (“I have forgiven myself for things that I have done wrong”), forgiveness of others (“I have forgiven those who hurt me”), and feeling forgiven by God (“I know that God forgives me”). Each item is scored on a 4-point Likert scale ranging from 1 (always or almost always) to 4 (never). In the current study, items were reverse-scored, such that higher scores were indicative of greater levels of forgiveness. These single-item measures assess the tendency for forgiveness across three domains, but are not linked to a specific transgression, and have been used in previous forgiveness research involving suicide (Hirsch et al., 2011; Hirsch, Webb, & Jeglic, 2012). The total score of these items has fair internal consistency and test re-test reliability in adolescents (Harris et al., 2008) and in primary care samples (Nsamenang et al., 2013); Cronbach’s alpha in our sample was fair (α = .65). Future orientation was assessed using the Future Orientation Scale (Edelstein et al., 2009; Hirsch et al., 2006), a six-item measure that assesses the ability of participants to consider a possible future via items focused on the variability of the future, attainment of future goals, and prospective improvement of emotional functioning. Item examples include: “Tomorrow I may feel better,” “I have the hope that things will improve and the future will be happier,” and “I have future plans I am looking forward to carrying out.” Respondents rate each item on a Likert-type scale according to “how important each reason is to you for dealing with stressors” ranging from 1 (extremely unimportant) to 6 (extremely important), with higher scores indicating a more-adaptive future orientation. This scale has strong psychometric properties in both clinical and primary care samples (Hirsch et al., 2006, 2007), and internal consistency for our sample was good (α = .87). Suicidal thoughts and behaviors were assessed using the Suicidal Behaviors Questionnaire–Revised (SBQ-R; Linehan, Goodstein, Nielsen, & Chiles, 1983; Linehan & Nielsen, 1981; Osman et al., 2001), which has four items assessing lifetime suicide ideation and attempts, frequency of ideation in the past year, communication of suicidal behavior, and likelihood of a future suicide


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attempt. Items are scored using a Likert-type scale, with between 5 and 7 response choices per item, and are summed for a total score (range = 3–18). The SBQ-R has excellent reliability and validity in use with clinical (Osman et al., 2001) and primary care samples (Nsamenang et al., 2013). Cronbach’s alpha for our sample was acceptable (.74).

Results Statistical analyses

Bivariate correlations were used to examine associations between, and independence of, study variables. Although total forgiveness was highly related to its subscales of forgiveness of self (p = .86) and forgiveness of others (p = .77), no other associations exhibited multicollinearity (p > .07; O’Brien, 2007). Mediation analyses (10,000 bootstrapped samples) consistent with Preacher and Hayes (2008) were conducted to test whether future orientation mediates the association between forgiveness and suicidal behaviors. Three forgiveness-based (independent [IV]) models were constructed for the SBQ-R total score (dependent variable [DV]), for forgiveness of self, forgiveness of others, and feeling forgiven by God. Future orientation (mediator variable [MV]) was examined as a mediator in all models. Numerous effects and outcomes are possible in mediation (Preacher & Hayes, 2008). A total effect (c) refers to the relation between IV and DV without controlling for MV. A direct effect (c’) refers to the relation between IV and DV after controlling for MV. A total indirect effect (ab) refers to the role of the MV in the relation between IV and DV. Mediation analyses can produce five different results: (a) total effect (c); (b) direct effect (c’); (c) indirect only effect, where ab is significant but c and c’ are not significant; (d) partial mediation, where there is a decrease from c to c’, yet c’ remains significant, and (e) full mediation, where these is a decrease from c to c’ and c’ falls out of significance (Preacher & Hayes, 2004). In all analyses, age, sex, and race were covaried. Although, in our sample, age, sex, and race were not significantly correlated with our variables of interest at the bivariate level, previous literature indicates a strong association between these demographic characteristics and forgiveness (Davis et al., 2015), future orientation (Yu & Chang, 2016), and suicidal behavior (Beautrais et al., 2005). Significant (p ≤ .05) bivariate associations were observed in the expected directions (See Table 1). Total forgiveness, self-forgiveness, other-forgiveness, and forgiveness by God were all positively and significantly correlated to future orientation. Self-forgiveness, other-forgiveness, and future orientation were negatively associated with suicidal behaviors. Feeling forgiven by God was not significantly related to suicidal behaviors. In multivariate analyses (see Figure 1), the direct effect of self-forgiveness on suicidal behaviors (DE = −.48, SE = .35, p = .17) was no longer significant, when FO was added (IE lower 95% CI = −.87, upper 95% CI = −.13), indicating

M [SD] 42.04 [12.81] — — 3.16 [0.77] 3.18 [0.73] 3.67 [0.68] 4.81 [1.01] 4.90 [2.50] Age — .038 −.098 .065 −.015 .107 .092 −.072

Sex — — −.145 .047 .189 .097 .150 .143

Race — — — .060 .055 −.272** .046 −.054

Self-forgiveness — — — — .574** .379** .483** −.284**

Forgiveness of others — — — — — .180 .246* −.239*

Forgiveness by God — — — — — — .348** −.075

Future orientation — — — — — — — −.342**

Note. Forgiveness = Brief Multidimensional Measure of Religiousness/Spirituality forgiveness total and subscale scores; future orientation = Future Orientation Scale; suicidal behaviors = Suicidal Behaviors Questionnaire–Revised. *p < .05; **p < .01.

Variable Age Sex Race Self-forgiveness Forgiveness of others Forgiveness by God Future orientation Suicidal behavior

Table 1. Bivariate correlations of study variables.

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Future Orientation b1 = -.73** b2 = -.79** b3 = -.97***

a1 = .61*** a2 = .31* a3 = .55*** c1 = -.92** c2 = -.95** c3 = -.36

Suicidal Behaviors

Forgiveness c’1 = -.48 c’2 = -.70* c’3 = -.17

Figure 1. Mediation analyses—forgiveness, future orientation, and suicidal behavior. Note. Illustration of mediation models. a1 = the direct effect of self-forgiveness on future orientation; b1 = the direct effect of future orientation on suicidal behaviors; c1 = total effect of self-forgiveness on suicidal behaviors; c’1 = direct effect of self-forgiveness on suicidal behaviors via future orientation. a2 = the direct effect of forgiveness of others on future orientation; b2 = the direct effect of future orientation on suicidal behaviors; c2 = total effect of forgiveness of others on suicidal behaviors; c’2 = direct effect of forgiveness of others on suicidal behaviors via future orientation. a3 = the direct effect of forgiveness by God on future orientation; b3 = the direct effect of future orientation on suicidal behaviors; c3 = total effect of forgiveness by God on suicidal behaviors; c’3 = direct effect of forgiveness by God on suicidal behaviors via future orientation. *p < .05; **p < .01; ***p < .001.

mediation. The direct effect of forgiveness of others (DE = −.70, SE = .33, p = .04) reduced in significance when FO was added (IE lower 95% CI = −.67, upper 95% CI = −.01), indicating mediation. The total and direct effects were not found to be significant between forgiveness by God and suicidal behavior; however, according to Hayes (2013), total and direct effects do not have to be significant in order for indirect only effects to be found. Therefore, an indirect only effect (IE lower 95% CI = −1.13, upper 95% CI = −.13) existed between forgiveness by God and suicidal behavior via future orientation.

Discussion We examined the relation between forgiveness and suicidal behavior, and the potential mediating role of future orientation, in a sample of primary care patients, finding that greater forgiveness is associated with less suicidal behavior, and its influence on positive future orientation may be one mechanism of action by which it reduces suicide risk. Partially supporting bivariate hypotheses, forgiveness of self and forgiveness of others, but not forgiveness by God, were negatively related to suicidal behaviors. All subtypes of forgiveness were positively related to future orientation, and future orientation was negatively related to suicidal behaviors.

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Supporting multivariate hypotheses, future orientation mediated the relation between self-forgiveness and suicidal behavior and the relation between forgiveness of others and suicidal behavior. An indirect only effect existed between forgiveness by God and suicidal behavior via future orientation. Our results replicate past studies indicating beneficial effects of forgiveness and future orientation and supporting their role as independent protective factors against suicidal behavior (Hirsch et al., 2007, 2011). We also offer preliminary evidence for a potential mechanism whereby religious, existential or spiritual factors, such as forgiveness, are beneficially associated with health outcomes; that is, such factors may promote an adaptive sense of future orientation. The inability to be forgiving (i.e., unforgiveness) can deleteriously impact cognitive processing and mood and may thwart not only the ability to envision meaningful personal goals, but also the volition and motivation necessary to make progress toward goals (Ingersoll-Dayton, Torges, & Krause, 2010). Inability to self-forgive may also contribute to feelings of burdensomeness, further perpetuating feelings of guilt via rumination about one’s perceived offense (Tangney, Boone, & Dearing, 2005). Forgiving oneself may reduce self-condemning thoughts, forgiving others may reduce negative thoughts and emotions toward offenders, and feeling absolved by God may promote a cathartic “letting go” of past offenders/offenses, perhaps resulting in greater availability of cognitive-emotional energy to invest in future-oriented thoughts and goals (Krause & Ellison, 2003; Lavender & Watkins, 2004). With the emotional and volitional “release” provided by forgiveness, individuals may be better able to engage, both psychologically and behaviorally, in future-oriented activities, rather than remaining overly engaged with the negative present or negative past (Smith, Alloy, & Abramson, 2006); as a result, suicide risk may be reduced. Limitations

Our novel findings must be viewed in the context of minor limitations, including our use of a primarily White and female sample, which restricts generalizability. Further, our use of cross-sectional data precludes examination of causal relationships, and bidirectionality is a possibility; for instance, forgiveness may mediate the relation between future orientation and suicidal behavior. However, our ordering of variables aligns with previous research suggesting forgiveness promotes positive thoughts and mood about the future (Hirsch et al., 2007). Additionally, although research suggests that use of single-item measures are appropriate and can substitute multiple-item measures in many instances (Gardner, Cummings, Dunham, & Pierce, 1998), the use of single-item measures of forgiveness is less than ideal; therefore, the utilization of more comprehensive measures of forgiveness in future research is warranted. Longitudinal research with larger and diverse samples, and using more well-validated measures, is required to confirm our findings.


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Implications

Despite limitations, our findings may have important practical applications to aid in the reduction of suicide risk in primary care patients. Positive psychological protective factors such as forgiveness (e.g., for personal role in illness; for another’s role in illness or injury; feeling punished by God via illness) and future orientation (e.g., adhering to medical recommendations; setting and working toward health goals) may often be overlooked commodities available to clinicians in their efforts to ameliorate psychological dysfunction and suicide risk (Hamilton, 2000; Yip et al., 2005). Educating primary care health providers on the identification of protective factors, such as forgiveness and future orientation, in addition to typically assessed risk factors, may provide a greater number of potential targets for suicide prevention. Therapeutically bolstering forgiveness, perhaps via forgiveness-based interventions such as the process model of forgiveness (Enright & Coyle, 1998) or REACH model (Worthington, 1998), may reduce depression and anxiety, and bolster self-esteem and hope (Lundahl, Taylor, Stevenson, & Roberts, 2008). Additionally, enhancing future orientation, perhaps by promoting optimism and encouraging goal striving, may reduce suicide risk, as adaptive future orientation is related to enhanced wellbeing and better psychological outcomes (Hirsch et al., 2007; Ridder et al., 2000; Safren et al., 2002). For example, Motivational Interviewing may be utilized to facilitate intrinsic motivation in suicidal patients, encouraging them to develop attainable goals (Miller & Rollnick, 1991). Future-oriented group training, which promotes goal directed and future-oriented behavior through the combination of cognitive therapy, problem solving therapy, and future thinking, may also aid in reducing suicide risk and its associated symptoms (e.g., hopelessness; Van Beek, Kerkhod, & Beekman, 2009). Positive psychological exercises, such as writing a forgiveness letter, may also be used to promote adaptive future orientation in suicidal individuals (Huffman et al., 2013). In conclusion, we found that forgiveness was related to future orientation and, in turn, to lower levels of suicidal behavior in a sample of primary care patients. Forgiving oneself or others, or feeling forgiven by God, may promote an adaptive view of the future, perhaps via a forgiveness-based cognitive-emotional release, whereby mental energies can be focused on the changeability of the future rather than offenses of the past. This positive outlook on future events may, in turn, reduce the likelihood of engaging in suicidal behaviors. Future research is needed to determine causal relations between these variables; however, our findings represent a first step in understanding the relations between forgiveness, future orientation, and suicidal behavior, and their potential applicability to the prevention of suicide.

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Funding This study was not funded by an external source.

Conflict of Interest The authors declare that they have no conflict of interest.

Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent Informed consent was obtained from all individual participants included in the study.

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