The Burn Surgeon: How Anger Can Impede Healing
In 1978, Dr. Dabney Ewin, a surgeon specializing in burns, was on duty in a New Orleans emergency room when a man was brought in on a gurney. A worker at the Kaiser Aluminum plant, the patient had slipped and fallen into a vat of 950-degree molten aluminum up to his knees. Ewin did something that most would consider strange at best or the work of a charlatan at worst: He hypnotized the burned man. Without a swinging pocket watch or any other theatrical antics, the surgeon did what’s now known in the field of medical hypnosis as an “induction,” instructing the man to relax, breathe deeply, and close his eyes. He told him to imagine that his legs—scorched to the knees and now packed in ice—did not feel hot or painful but “cool and comfortable.” Ewin had found that doing this—in addition to standard treatments—improved his patients’ outcomes. And that’s what happened with the Kaiser Aluminum worker. While such severe burns would normally require months to heal, multiple skin grafts, and maybe even lead to amputation if excessive swelling cut off the blood supply, the man healed in just eighteen days—without a single skin graft.
As Ewin continued using hypnosis to expedite his burn patients’ recoveries, he added another unorthodox practice to his regimen: He talked to his patients about anger and forgiveness. He noticed that people coming into the ER with burns were often very angry, and not without reason. They were, as he put it, “all burned up,” both literally and figuratively. Hurt and in severe pain due to their own reckless mistake or someone else’s, as they described the accident that left them burned, their words were tinged with angry guilt or blame. He concluded that their anger may have been interfering with their ability to heal by preventing them from relaxing and focusing on getting better. “I was listening to my patients and feeling what they were feeling,” Ewin told me. “It became obvious that this had to be dealt with. Their attitude affected the healing of their burns, and this was particularly true of skin grafts. With someone who’s real angry, we’d put three or four skin grafts on, but his body would reject them.” Whenever a patient seemed angry, Ewin would help them forgive themselves or the person who hurt them, either through a simple conversation or through hypnosis.
Ewin, now eighty-eight and semiretired after practicing surgery and teaching medical hypnosis at the Tulane University School of Medicine for more than thirty years, became interested in hypnosis while he was a young doctor training under the legendary Dr. Champ Lyons, who pioneered the use of penicillin and treated survivors of the famous Cocoanut Grove nightclub fire in Boston in 1942. As Ewin learned to stabilize patients and conduct skin grafts, he wondered about an intriguing practice that he’d learned of from his great uncle. As an independently wealthy “man of leisure” in Nashville, this uncle had dabbled in hypnosis. He even held séances, which had become so popular in the late 1800s that First Lady Mary Todd Lincoln held them in the White House to attempt to reach the spirit of her dead son. (President Abraham Lincoln reportedly attended.) Many of the most popular séance leaders were eventually exposed as frauds exploiting the grief-stricken, but Ewin’s uncle found another forum for hypnosis that was less controversial than hypnotizing an audience into believing that dead friends were speaking to them. He hypnotized the patients of surgeon friends before they went under the knife in order to minimize their pain. (This was before anesthesia was widely used.)
Ewin took a few hypnosis courses to find out more. “I figured it couldn’t hurt,” he told me in his friendly New Orleans drawl when I reached him at home by phone. Once he started trying hypnosis on his burn patients, he noticed a difference immediately. If he could reach them within half an hour of the injury, the hypnotic suggestions of “coolness and calm” seemed to halt the continued burning response of the skin that usually occurs for twelve to twenty-four hours, leading to speedier recoveries. (While there are no empirical studies of hypnosis on burn patients and Ewin’s data is anecdotal, multiple studies do show that hypnosis can alleviate symptoms and improve medical outcomes in various scenarios, from asthma and warts to childbirth and post-traumatic stress disorder.)
Once Ewin began helping his patients forgive, he noticed even more improvement. “What you’re thinking and feeling affects your body,” he would explain to his patients, using the analogy of something embarrassing causing someone to blush. “What you’re feeling will affect the healing of your skin, and we want you to put all your energy into healing.” At this point, he would learn how the victim had unthinkingly opened a blast furnace without turning it off, or how the workmen at a construction site had repeatedly told the boss about a dangerously placed can of gasoline, to no avail.
“I’d do hypnosis with them and help them forgive themselves or the other person,” Ewin said. “I’d say, ‘You can still pursue damages through an attorney. You’re entitled to be angry, but for now I’m asking you to abandon your entitlement and let it go, to direct your energy toward healing, and turn this over to God or nature or whoever you worship. It’s not up to you to get revenge on yourself or someone else. When you know at a feeling level that you’re letting it go, raise your hand.’ Then I’d shut up, they’d raise their hand, and I’d know that skin graft was gonna take.” Ewin taught other burn doctors what he discovered, and has received letters from colleagues in burn units around the world thanking him for helping them achieve faster recovery times for their patients.
The Investor Turned Research Patron: How Forgiveness Hit Mainstream Science
Like Dabney Ewin, John Templeton was a son of the South, a man of letters who came of age during the Depression and combined his success with less mainstream pursuits. Born to a middle-class family in Winchester, Tennessee, in 1912, Templeton managed to put himself through Yale after the 1929 stock market crash and became a Rhodes Scholar at Oxford. He launched his career on Wall Street by taking the “buy low, sell high” mantra to the extreme, borrowing money at the onset of World War II to buy one hundred shares each in 104 companies selling at one dollar per share or less, including 34 companies that were in bankruptcy. He reaped a healthy profit on all but four. Templeton entered the mutual funds business in the fifties, eventually selling his Templeton Funds to the Franklin Group in 1992. Money magazine called him “arguably the greatest global stock picker of the century.”
Yet Templeton was equally passionate about spirituality, morality, and science, and how the scientific method could increase our understanding of life’s “Big Questions”—questions about the nature of consciousness and the role that love and creativity, compassion and forgiveness, play in all areas of human life. In 1987, Templeton founded the John Templeton Foundation, dedicated to funding scientific research “on subjects ranging from complexity, evolution, and infinity, to creativity, forgiveness, love, and free will.” With the motto “How little we know, how eager to learn,” Templeton sought research grantees who were “innovative, creative, and open to competition and new ideas.”
Templeton announced the Campaign for Forgiveness Research in 1997, a funding initiative for scientists in multiple disciplines who were interested in taking forgiveness out of the purview of religion and using rigorous scientific protocol to determine its effects on the body and mind. Spearheading the campaign was Dr. Everett Worthington, a psychology professor at Virginia Commonwealth University. One of the first psychologists to create therapeutic tools using forgiveness, he came to the topic through personal tragedy: His elderly mother was bludgeoned to death by an intruder, and, in part because of her death, his brother committed suicide. Struggling with rage and grief, Worthington switched his focus from marriage counseling to forgiveness. He designed a research framework for the Campaign for Forgiveness Research, Archbishop Desmond Tutu became a cochair for the campaign, and the Templeton Foundation provided a $5 million grant.
Between 1998 and 2005, the foundation, along with thirteen partners including the Fetzer Institute, a Michigan-based nonprofit that funds research and educational projects focused on love and forgiveness, dedicated $9.4 million to 43 scientific studies on the health impacts of forgiveness. Whereas before, Worthington and a few other researchers were alone in their pursuits (and most of their research was aimed at affirming their own therapeutic models), the Campaign for Forgiveness Research took a traditionally religious concept and placed it firmly on the scientific landscape. In addition to funding researchers directly, the campaign sparked dialogue and interest in the broader scientific community. While in 1998 there were 58 empirical studies on forgiveness in the research literature, by 2005, when the campaign concluded, there were 950.
Throughout the process, Templeton was highly engaged. Even into his eighties, he was known to walk waist-deep in the surf for an hour near his Bahamas home each morning before sitting down to read grant proposals. When he died at ninety-five, he was lauded by both the business and scientific communities. The Wall Street Journal called him the “maximum optimist,” whose confidence in rising stocks paid off and whose philanthropy left an enduring legacy. The leading scientific journal Nature wrote, “His love of science and his God led him to form his foundation in 1987 on the basis that mutual dialogue might enrich the understanding of both.”
While it’s up for debate whether the research Templeton funded has enriched our understanding of God, it certainly has enriched our understanding of forgiveness, demonstrating that what was traditionally seen as a religious ideal is actually an important skill for anyone, whether atheist, agnostic, or believer, who seeks to live a healthy, happy life.
The Science of Forgiveness
One of the researchers who participated in the Campaign for Forgiveness Research was Dr. Robert Enright, a developmental psychologist at the University of Wisconsin–Madison. Enright began contemplating forgiveness back in the mid-eighties. As a Christian, he’d been raised on Jesus’ teachings about tolerance and forgiveness. He asked himself: Could forgiveness help patients in a clinical setting? In spite of skeptical colleagues who ridiculed him for applying science to something so “mushy” and “religious,” he designed forgiveness interventions for therapy and studied their psychological and physiological impacts.
He began by developing therapies aimed at helping elderly women to forgive those who had wronged them in the past, and to help victims of abuse and incest to understand their tormentors without justifying the abusers’ actions. His initial findings were encouraging. His first study, which compared women undergoing forgiveness therapy with a control group who underwent therapy for emotional wounds without a forgiveness focus, found that the experimental group improved more in emotional and psychological health measures than the control group. It was published in the journal Psychotherapy in 1993. Afterward, Enright honed his therapeutic forgiveness tools, from helping people develop empathy—the ability to understand and share the feelings of another—toward aggressors, to learning to forgive and accept themselves, and tested them on a range of groups. Among battered women and “parental love–deprived college students,” for instance, those subject to forgiveness therapy showed more improvement in emotional and psychological health than control groups who received therapy without a forgiveness focus.
Enright’s forgiveness model has four parts: uncovering your anger, deciding to forgive, working on forgiveness, and discovery and release from emotional prison. All take place through therapist-patient dialogue. Uncovering anger means examining how you’ve both avoided and dealt with it, and exploring how the offense and resulting anger has changed your health, worldview, and life in general. The phase involves learning about what forgiveness is and what it’s not, acknowledging that the ways you’ve dealt with your anger up until now haven’t worked, and setting the intention to forgive. Next, working on forgiveness entails confronting the pain the offense has caused and allowing yourself to experience it fully, then working toward developing some level of understanding and compassion for the offender. The final phase includes acknowledging that others have suffered as you have and that you’re not alone (for some, this means connecting with a support group of people who have endured a similar experience), examining what possible meaning your suffering could have for your life (learning a particular life lesson, perhaps contributing to one’s strength or character, or prompting one to help others), and taking action on whatever you determine to be your life purpose.
Since developing that therapy model and pioneering the first studies, Enright and his colleagues have found positive results in drug rehabilitation participants (less anger, depression, and need for drugs compared to the control group receiving standard therapy), victims of domestic violence (decreased anxiety, depression, and post-traumatic stress disorder relative to the control group), and terminally ill cancer patients (more hope for the future and less anger than the control group).
When it comes to determining the existence of a causal relationship between forgiveness and physical health, Enright says the most definitive study he has done was conducted with a team of researchers on cardiac patients. Published in 2009 in the journal Psychology & Health, their analysis found that when cardiac patients with coronary heart disease underwent forgiveness therapy, the rate of blood flow to their hearts improved more than that of the control group, which received only standard medical treatment and counseling about diet and exercise. “It wasn’t that they were cured—these were patients with serious heart problems,” Enright says. “But they were at less risk of pain and sudden death.” Those results echo studies by another Templeton grantee, Charlotte Witvliet, a psychology professor at Hope College; and Sonja Lyubomirsky, a psychology professor at the University of California, Riverside, and author of numerous books on happiness, which found that people who forgive more readily have fewer coronary heart problems than those who hold grudges.
Perhaps the most comprehensive body of evidence showing links between forgiveness and health focuses on mood, says Dr. Frederic Luskin, the cofounder of the Stanford Forgiveness Project, an ongoing series of workshops and research studies at Stanford University. Researchers who measure emotional and psychological health outcomes following therapy that includes forgiveness are quantifying patients’ levels of anger, anxiety, and depression, concluding in multiple studies that forgiveness elevates mood and increases optimism, while not forgiving is positively correlated with depression, anxiety, and hostility. Like Enright, Luskin has developed ways to teach forgiveness in various places and with various groups, including war-ravaged populations in countries such as Northern Ireland and Sierra Leone, and he asserts that anyone—from jilted spouses to widows who have lost husbands to terrorism—can heal.
Luskin developed a weeklong “forgiveness training” delivered in a group setting. In it, he leads participants through a series of discussions and exercises. The first steps involve teasing apart what he calls “your grievance story,” which is usually formed by taking something personally that wasn’t necessarily personal, and then blaming someone for your feelings. His argument is that when you blame someone for how you feel instead of holding them to account for their actions, you keep yourself stuck in victimhood and inaction (resenting your ex for her drinking and destructive behavior, for instance, instead of just seeking a restraining order). Luskin has participants “find the impersonal in the hurt” by realizing how many other people have experienced a similar offense or disappointment and how common it is, as well as acknowledging that most offenses are committed without the intention of hurting anyone personally. (If your mother yelled at you, for example, she likely did so not because her goal was to hurt your feelings and forever damage your self-confidence, but because she was stressed or afraid.) This doesn’t negate that often there is a personal aspect to an offense, Luskin says, but it can lessen the pain and blame.
“When you don’t forgive you release all the chemicals of the stress response,” Luskin says. “Each time you react, adrenaline, cortisol, and norepinephrine enter the body. When it’s a chronic grudge, you could think about it twenty times a day, and those chemicals limit creativity, they limit problem-solving. Cortisol and norepinephrine cause your brain to enter what we call ‘the no- thinking zone,’ and over time, they lead you to feel helpless and like a victim. When you forgive, you wipe all of that clean.”
One of the main areas funded by the Templeton grant was the neuroscience of forgiveness. Around the time of the award, functional MRI, or fMRI, scanners were becoming increasingly common and sparking new discoveries in a variety of areas. The machines enable neuroscientists to capture X-ray images of people’s brains in action to observe blood flow and see which brain components are activated in which situations. In 2001, Dr. Tom Farrow of the University of Sheffield in the United Kingdom used fMRI scanners to conduct the first scientific study of the “functional anatomy” of forgiveness. Using ten subjects, he had each person climb into his laboratory’s fMRI scanner and asked them to answer a series of questions designed to evoke empathy and forgiveness. The empathy-related questions asked participants to consider potential explanations for someone’s emotional state (if your boss is unusually quiet or withdrawn, for instance, is it more likely that her child was expelled from school or that her child was caught shoplifting?), while the forgiveness-related questions asked people to evaluate which crimes they considered more forgivable (a neighbor who recently lost his job getting arrested for assaulting his girlfriend or for assaulting his boss?).
Farrow and his team found that empathy and “forgivability judgments,” basically contemplating whether a certain action deserves forgiveness, activate various parts of the frontal lobe, which is associated with problem-solving and reason. In contrast, a researcher named Dr. Pietro Pietrini at the University of Pisa in Italy showed in a 2000 fMRI study that anger and vengeance inhibited rational thinking and caused high activity in the amygdala, which is involved in the fight-or-flight response. Anger and rage, then, impede reason, but the tasks involved in the complex process of forgiveness activate the more recently evolved parts of our brain, such as the prefrontal cortex and posterior cingulate, which are concerned with problem-solving, morality, understanding the mental states of others, and cognitive control of emotions.
Having cognitive control means inhibiting impulsive reactions fueled by rage and hatred toward a wrongdoer. This can be done through thought, such as by devising a new, less upsetting interpretation of a painful event. When it comes to being hurt, this can mean viewing an infraction as less personal than you thought, or developing an understanding of someone’s actions by considering his point of view. Psychologists call this “reframing” a painful memory. It’s a key part of both Enright’s forgiveness therapy and Luskin’s forgiveness training. Taking things less personally is something I realized would benefit me and reduce a lot of my suffering. In my new relationship with Anthony, for instance, I would sometimes feel hurt when he teased me about something, whether my penchant for driving under the speed limit or the time I left a steak to thaw on the counter and his hundred-pound dog easily ate it. When I realized that he didn’t mean to hurt my feelings and was just making a good-natured joke, I was less likely to take offense and get upset.
Another way to reframe is to consider a range of possible points of view that led someone to act a certain way. This makes it more difficult to blame and demonize that person and continue generating the same level of resentment as you did before. I once spent days feeling resentful about a former editor’s criticism about a story—which I thought was harsh and took personally. When a colleague suggested that what he said likely came from a deep commitment to accuracy and excellence, I let it go and felt a lot better. A third way to reframe is to consider what constructive learning, meaning, or opportunity may have resulted from an offense and the suffering it caused. For Azim, that was the opportunity to work with youth and prevent violence, and for my more mundane example about editorial feedback, it was a lesson about being more diligent in checking my facts and considering my approach to a story.
Thanks to fMRI scanners, we can now identify the parts of the brain that make this sort of reframing practice possible. In one study, Farrow focused on two groups of people who struggle with empathy and, by extension, forgiveness: schizophrenics and people suffering from post-traumatic stress disorder. Both showed inhibited activity in the areas of the brain involved in forgiveness processes such as empathy and viewing another person’s perspective. But after ten weeks of therapy that included the discussion and practice of forgiveness (and antipsychotic drugs for the schizophrenics), those brain areas’ functions improved. While Farrow didn’t use a control group to isolate and test the therapeutic forgiveness intervention specifically, the findings confirm the earlier evidence of so-called forgiveness areas in the brain, and show that psychological treatments such as cognitive behavioral therapy can improve this aspect of brain function.
In a separate experiment, Pietrini asked ten participants to lie in the scanner and consider a fictional scenario in which they were wronged and then forgave. As with the prior studies, both the dorsal prefrontal cortex (involved in cognitive control) and the posterior cingulate (involved in understanding the mental states of others) lit up on the screen. But a third part was also involved: the anterior cingulate cortex, which mediates the perception and the suppression of moral pain (such as the feeling of being wronged). Pietrini’s interpretation? Forgiveness could be viewed as a sort of painkiller for moral distress.
When Pietrini presented his findings at a 2009 conference, he described them as evidence that forgiveness likely evolved as a way to overcome pain and alleviate suffering, and that even though it involves parts of the brain responsible for reason, it also requires a counterintuitive, and some would argue, irrational, choice: “You wronged me, but I forgive you, anyway.” “A great deal of evidence converges suggesting that forgiveness is a positive, healthy strategy for the individual to overcome a situation that otherwise would be a major source of stress from a psychological and neurobiological point of view,” he wrote to me in an e-mail. “The fact that forgiving is a healthy resolution of the problems caused by injuries suggests that this process may have evolved as a favorable response that promotes human survival.”
From “TRIUMPH OF THE HEART: Forgiveness in an Unforgiving World” by Megan Feldman Bettencourt. Published by arrangement with Avery, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC. Copyright © 2015 by Megan Feldman Bettencourt.