A Professional Development Workshop to Facilitate Self-Forgiveness Open Access

After committing an error or transgression, genuine self-forgiveness requires reconciliation with self, accountability for wrongdoing, connection with the human community, and a genuine commitment to change.¹  Self-forgiveness is positively associated with self-esteem, life satisfaction, and well-being, but negatively associated with neuroticism, depression, anxiety, and hostility.^2–6  Forgiveness of self and others has also been associated with physical health benefits,^7,8  a stronger immune system,⁹  and reduced cardiovascular reactivity.^10–13  Nevertheless, physicians find self-forgiveness particularly challenging,¹⁴  so acceptable evidence-based self-forgiveness tools to improve physicians' well-being are needed.^15–17 

The aim of this study was to determine if a brief workshop teaching self-forgiveness to medical educators at a national conference would be acceptable, feasible, and improve immediate measurements of self-forgiveness.

The study was conducted as a wellness self-forgiveness workshop for medical education professionals attending the March 2018 Association of Professors of Obstetrics and Gynecology/Council of Resident Education in Obstetrics and Gynecology Annual Meeting. Facilitators included a basic science faculty member who developed the audio imagery, a clinical medical educator who organized the workshop, and 2 residency program directors as moderators (table 1).

We used the Internal Family Systems (IFS) model for the guided imagery,^18–20  which involves synthesis of 3 paradigms: (1) normal multiplicity of the mind; (2) systems thinking; and (3) self-leadership. In IFS, the goal is balancing the input and roles of all parts as orchestrated by “Self” (provided as online supplemental material). In our guided imagery, participants are instructed to imagine and connect with 3 key parts of themselves: an “inner critic,” a “child-like” part, and the “true Self,” and to work toward self-forgiveness (provided as online supplemental material).²⁰ 

We used the 18-item Heartland Forgiveness Scale (HFS) to assess dispositional forgiveness.²¹  The HFS has 3 subscales that reflect a person's tendency to forgive oneself, other people, and uncontrollable situations (eg, a natural disaster or illness). A total HFS score of 18 to 54 indicates that one is usually unforgiving of oneself, others, and uncontrollable situations; a score of 55 to 89 is neutral; a score of 90 to 126 indicates that one is usually forgiving of oneself, others, and uncontrollable situations. Each item is scored on a 7-point scale; thus, the possible range of scores is 18 to 126. A score of 6 to 18 on any of the subscales indicates that one is usually unforgiving, a score of 19 to 29 is neutral, and a score of 30 to 42 indicates that one is usually forgiving.

The workshop was a 60-minute session in a large conference hall with 8 to 10 participants per table who remained together for the entire workshop. Participants discussed the same set of questions preworkshop and postworkshop, which were provided as multiple paper copies for each table, and written responses were collected. See table 1 for the workshop schedule.

To determine efficacy of the intervention, we compared preintervention HFS scores to the postintervention scores. Statistical analysis was performed using SPSS 21.0 (IBM Corp, Armonk, New York). Student's t tests were performed with calculation of 95% confidence interval and odds ratio, with a P value of < .05 taken as significant.

This study was approved by the Beaumont Health Institutional Review Board.

Medical education professionals (n = 91) who attended the workshop included graduate medical education (GME) managers (33%, 22 of 67), GME program directors (28%, 19 of 67), academic faculty (19%, 13 of 67), deans/clerkship directors (10%, 7 of 67), trainees (9%, 6 of 67), and 24 unclassified participants. Of these, 66% (44 of 67) were physicians and 34% (23 of 67) were nonphysicians with 24 unknown participants. Of the participants, 85% (62 of 73) were female, while 15% (11 of 73) were male, with 18 unknown participants. Participants were from the South (20%, 15 of 75), West (17%, 13 of 75), Midwest (31%, 23 of 75), and Northeast (32%, 24 of 75) US regions, with 16 unknown participants.

For baseline total HFS scores (n = 89), 53% (47 of 89) scored in the forgiveness range, 47% (42 of 89) scored in the neutral range, and no participant scored in the unforgiveness range. Postintervention (n = 64), significant increases were observed in total HFS scores, self-forgiveness subscores, and forgiveness of others subscores, but there was no change for forgiveness of uncontrollable situations subscale (table 2). We also compared the percentages of participants who were forgiving preintervention and postintervention (table 3).

Topics from the preintervention discussions included: (1) loss of control; (2) shame-and-blame punitive culture; (3) time constraints; (4) professional–personal life balance; and (5) perceived isolation. Postintervention discussions reflecting on the IFS framework included: (1) awareness and hope; (2) perceived time and motivational constraints; (3) need for training and utility of focused events; (4) benefit of self-reflection; and (5) institutional support and culture challenges. Feedback was generally positive; participants thought it was innovative, unusual, and experiential. They also noted difficulty with granting self-forgiveness.

Our participants had normal dispositional forgiveness, comparable to previous study results,^21–23  and this increased significantly with a brief 1-hour workshop. Importantly, this brevity, including the audio-guided imagery, increases the feasibility of using all or part of this workshop in different medical education and faculty development settings.

Our results are similar to those of a pilot study with medical students (n = 24) that found that the IFS-based intervention was highly effective in facilitating self-forgiveness, also assessed with the HFS.²⁴  This simplified, pragmatic, and brief audio condensation of IFS principles has proven effective in 2 very different environments—for individual participants listening in solitude and for a large group in an environment not ideally suited to self-reflection and emotional vulnerability. Therefore, this approach may have the flexibility to be utilized in various work and educational environments where time and space are often limited.

During the group discussions, recurring preintervention topics were guilt and shame. Guilt is generally focused on an event (ie, I did something wrong), whereas shame is a self-recriminating percept (ie, I am bad). Shame results in self-devaluation, self-criticism, and self-loathing,²²  and associated lower self-esteem and higher stress may increase the propensity to turn to alcohol or drugs to cope.²⁵  A “blame and shame” punitive culture in medicine is associated with stress and increased medical errors, while a “just and safe” culture can decrease stress and medical errors and improve patient safety.²⁶  Scherer et al²⁵  showed that a psychoeducational self-forgiveness intervention of three 90-minute sessions over 3 consecutive weeks for individuals who misuse alcohol can result in increased positive gains for self-forgiveness while decreasing shame and guilt. However, this format and time commitment would be more difficult to implement with busy health professionals.

Limitations of this study included a nonoptimal venue for potentially emotional work, a selection of participants who were a self-selected highly motivated and interested group from a single medical specialty, and an immediate assessment of outcomes. Furthermore, the nature of the transgression contemplated by participants was private and could have included either personal or professional behaviors.

In part, the workshop was conducted at a national conference to determine the interest and acceptability of the topic and the feasibility of the format. Based on our results, the authors utilized the audio intervention for 18 residents at Beaumont Hospital in Michigan with similar results. Furthermore, the self-forgiveness meditation audio has been made available on YouTube and is currently being piloted by other medical students and residents. A next step is the development of a longitudinal intervention.

For a group of medical education professionals, a brief IFS-based guided meditation coupled with focused small group discussions improved awareness about and tendency toward self-forgiveness.