The Role of Forgiveness in Rehabilitation

John Bauman, D.Min.
Director of Pastoral Care
Burke Rehabilitation Hospital
White Plains, New York

This article addresses the problem rehabilitation patients have when an unresolved need for forgiveness prevents them from feeling sufficient motivation to adequately participate in their physical, occupational, speech and recreation therapy in the rehabilitation hospital. Specifically addressed are the following questions: first, what is the role of forgiveness as it relates to the rehabilitation patient’s motivation to participate in rehabilitation therapy; and, second, what is the role of the chaplain who works with rehabilitation patients in order to, along with other goals, address the impediments to their active participation in their rehabilitation?

This article suggests that unresolved forgiveness issues be given more attention as factors that negatively affect patients’ motivation in their rehabilitation. This article also asserts that the chaplain has a specific responsibility to accurately diagnose and competently provide pastoral care for patients who experience decreased motivation to participate in their rehabilitation therapy due to an unresolved need to give or to receive forgiveness.

Some patients who have not forgiven or have not received forgiveness, in my view, experience decreased hope and decreased motivation to participate actively in their treatment plan. They may not know how to ask for forgiveness or how to receive and experience forgiveness. They may have a burden of guilt, an inner turmoil or rage, or a resulting depression. They may find it hard to believe that God, or someone whom they have offended, will forgive them. As a result, they often display decreased motivation to do their therapy.

Pastoral care for patients with spiritual issues involving forgiveness ranges from situations with more complicated psychological issues to patients with straightforward adjustments to new and difficult circumstances. For some patients, resolution of guilt can transpire rather quickly. Such patients tell their story, express anger, guilt, or remorse, and then offer their confession or make an apology. For a patient of faith, he or she may recount his or her story and subsequently pray to God asking for forgiveness. The issue is resolved and the individual moves forward with his or her rehabilitation. The effect of pastoral care with patients such as this is generally positive, relatively simple, and uncomplicated, though by no means less necessary or beneficial to the patient.

There are other patients, however, for whom a forgiveness process is more complex and it is upon such patients that this article focuses. Although the former group requires pastoral care, it is the latter group of patients who have acute difficulties asking for, receiving, and feeling forgiveness. This article discusses the pastoral care required to help such patients move forward with their rehabilitation and their lives. Patients who live with guilt and forgiveness issues can be found throughout the diagnostic spectrum of admitted rehabilitation patients. The following examples come from each of the units at Burke Rehabilitation Hospital.

Patients at a rehabilitation hospital may suffer from guilt due to a variety of causes, such as: patients who have smoked tobacco and have chronic obstructive pulmonary disease; patients who have not properly addressed their high blood pressure or weight and suffered a stroke; patients who have not properly addressed their diabetes resulting in one or more amputations; and patients who recklessly participated in risk-taking activities. There are cardiac patients who wish they had adhered more closely to their prescribed diets, especially those returning to the rehabilitation hospital after a second cardiac bypass operation. Finally, there are neurologically injured patients who feel guilty for making lifestyle choices that put them in the “wrong place at the wrong time,” or who feel guilty for driving recklessly or while impaired.

The chaplain, as a member of the rehabilitation team, has a unique opportunity to assist patients in understanding the role of forgiveness in the rehabilitation process and how it may have great bearing on the successful outcome of the patient’s hospitalization. When a chaplain leads a patient through a process of forgiveness, the patient often experiences increased motivation to participate more actively in physical, occupational, speech and recreation therapies in the rehabilitation hospital. In other words, the chaplain’s successful intervention enables the patient to lift his or her burden and enjoy a transformation of his or her motivation to participate in therapy.

Many patients of faith have the belief that God forgives them and that if they ask for forgiveness God will forgive them. When I ask, “Do you believe that God will forgive you?” more often than not patients of faith attest to their belief in God’s love and forgiveness. However, finding a way to move from the intellectual knowledge to the emotional reality of feeling forgiven is a complicated and difficult task for many (Casarjian, 1996, p. 135).

William Countryman writes, “The inability or refusal to forgive has become one of the great destructive elements in the modern world, both for individuals and for communities.”(Countryman, 1998, p. 1) As individuals and as collective groups, we tend to find it very hard to forgive people for the injuries they have caused us, and to receive forgiveness when we have harmed others.

Yet, as arduous as it may be for us to forgive others, it may be an even greater challenge for us to receive forgiveness and to truly feel forgiven within ourselves. Robin Casarjian underlines the difficulty of receiving forgiveness by saying, “Forgiving yourself is probably the greatest challenge that you will ever meet. It is, in essence, the process of learning to love and to accept yourself no matter what.”(Casarjian, 1992, p. 135)

So what exactly is forgiveness? In order to acquire an understanding of what forgiveness is, it may prove beneficial to first examine some of the things that it is not. William Countryman suggests there are five things that do not qualify as forgiveness.

First, forgiveness is not a “duty.”(Countryman, 1998, p. 2) Although most of us tend to perceive it as such, Countryman insists that forgiveness is not solely a matter of doing it because we are supposed to, but because we want to. Second, forgiveness is not is simply “making nice.”(Countryman, 1998, p. 5) It is not a matter of smoothing things over by saying, “I really didn’t mean it,” or “I’m really not that way.” The third thing forgiveness is not, is “denial.”(Countryman, 1998, p. 7) By claiming that something “wasn’t really so important,” or going so far as to tell ourselves that it never actually happened, we create a deception that stands as an obstacle to sincere forgiveness.

The fourth thing that forgiveness is not is simply a feeling (Countryman, 1998, p. 8). There is more to forgiveness than feeling forgiven or acting like one feels forgiven. We have the manipulative ability to trick others, as well as ourselves, into thinking that we have forgiven or been forgiven. The fifth thing that forgiveness is not is a “commodity” to be bought, earned, or won. For example, we do not earn forgiveness by acting ashamed of ourselves or acting blameless (Countryman, 1998, p. 10).

What is forgiveness? First, I agree with Dr. David Stoop’s assertion that “without anger, most forgiveness is superficial.”(Stoop, 1996, p. 223) Second, in addition to dealing with anger, forgiveness involves choice. A forgiveness process proceeds when we decide to forgive (Enright, 2001, p. 1). Third, forgiveness is a gift from God. Forgiveness, the letting go our feelings of resentment and revenge, is a gift from God, as is our ability to have compassion toward the offender. Forgiveness of the offender is a decision to change a relationship and, henceforth, not be controlled by resentment or anger toward the offender (Enright, 2001, p. 25).

Robert Enright provides a helpful four-phase forgiveness process that is useful in working with rehabilitation patients. A rewording of Enright’s work follows (Enright, 2001, pp. 249-58):

1. Uncovering phase: When an alliance of trust has been built, the patient, with the chaplain’s assistance, develops an awareness of his or her lack of motivation to participate in rehabilitation therapy and how the lack of motivation relates to a forgiveness issue that came up earlier in the interview. The patient gains an awareness of the affective, cognitive, psychological, and spiritual impacts of the injury. The chaplain reviews with the patient what forgiveness is and what it is not. The patient, with the chaplain’s assistance, works through defenses and resistances to feeling the impacts of the injury, and expresses, as appropriate, the affect surrounding the event.

2. Decision phase: The injured person or the offender addresses the reasons he or she has not been able to resolve the forgiveness issue. The patient, with the chaplain’s assistance, works through the patient’s defenses, resistance, and belief system issues surrounding forgiveness.

For patients of faith, an essential aspect of this phase is prayer. The patient asks for God’s help to be able to forgive or to be able to ask for forgiveness. When the patient has trouble praying, the chaplain can explore with the patient the reasons for that. If indicated, the chaplain may pray for the patient, asking God to help the patient be able to pray. The patient can pray to God asking for the love necessary to enter into a forgiveness process.

The patient names the reasons why he or she is unable to resolve the forgiveness issues. The patient releases the impediments to forgiveness, and decides not to pursue revenge or hold resentments. It is at this point that the patient decides to offer or receive forgiveness. With the chaplain’s help, the patient comes to understand that he or she can change his or her beliefs and expectations. The patient feels safe and supported enough to decide to proceed with a forgiveness process.

3. Work phase: The injured person experiences, accepts, and bears the pain of the injury. His or her perspective regarding the offender is then reframed, allowing a sense of empathy and compassion for the wrongdoer to develop. The patient comes to recognize cognitively and affectively the effect of his or her actions. The patient also comes to recognize the offender’s human qualities.

The patient integrates both the good and the bad in him or herself, or in the offender. The patient asks for forgiveness from the other person involved or asks for forgiveness from God. The chaplain helps the patient assess whether or not to seek reconciliation, or whether it might be wise not to seek reconciliation with the offender. The injured person no longer perceives the offender or him or herself as being completely evil (splitting), but instead recognizes the humanity that exists within the offender.

4. Outcome/deepening phase: The injured person discovers deeper meaning for himself or herself through the suffering associated with the injury. In addition, the patient’s relationship with the chaplain helps the patient recognize that he or she does not face suffering alone, but that he or she faces suffering with a chaplain and God alongside him or her. The offender becomes conscious of a decrease of negative feelings and thus experiences an internal emotional release. The rehabilitation patient experiences a release of guilt, anger, and depression, and experiences increased motivation to participate in his or her rehabilitation therapy.

A note of caution may be in order. After the chaplain diagnoses a forgiveness issue it is important to make an assessment regarding the patient’s psychological suitability for entering into a process that might help move the patient toward receiving or giving forgiveness. Certainly, the chaplain would not want to proceed if the patient might not be developmentally or cognitively able to handle a forgiveness process and might disintegrate psychologically.

The following is an example of a patient who assumed both the role of the offender and the role of the injured party. The patient, a woman in her late seventies, came to the rehabilitation hospital following hip replacement surgery. She showed little motivation to go to physical therapy, seemed to have little energy, and appeared to be angry with herself.

Her doctor had recommended that she undergo a total hip replacement after she injured herself while moving large pieces of furniture by bumping them repeatedly with her hip. She said she had been too proud to request anyone’s assistance in moving the furniture. In the aftermath of her injury and surgery, she said that she wished she hadn’t been so proud and wished she had asked for help.

During the early moments of the first pastoral visit, the patient (uncovering phase) identified the emotional and spiritual impacts of her injury. She was angry with herself for physically injuring herself. She described her anger as unrelenting. Together we concluded that her anger had led to depression and a lack of motivation to work toward improving her health.

She stated that she wanted to get past her anger (decision phase) and began sharing stories about how she had moved furniture in a similar way when she was younger (work phase). She then realized that perhaps she had not only injured herself during this recent episode, but also over a long period of time during similar episodes of moving furniture with her hip. “How stupid could I have been to do that to myself!” she exclaimed in frustration. “Why is it so hard for me to ask someone to help me?”

She began to consider the possibility that other people had, at one time or another, moved furniture just as she had done. They had the good fortune that she did not of moving furniture with their hips without apparently suffering hip injuries. As she pondered this, she decided that perhaps she wasn’t such a “stupid person,” but simply a person who had done something that she would have been better off not doing (just like so many other people who have done the same thing and may not have experienced hip damage) but that it was not an unusual thing for someone to do.

She transformed her self-perception from an “all or nothing” perception that she was a “stupid person” to a more balanced view of herself as someone who, like other people, had made a mistake, and was paying the price for that error in judgment. It was much easier for her to let go of her self-condemnation when she thought of herself as “person who had made a mistake,” than it was for her when she thought of herself a so-called “stupid person” (work phase).

She discovered that she did not need to hold on to her pride (outcome/deepening) once she began acknowledging herself as being imperfect and human just like everyone else. When she realized she was not alone, her anger toward herself decreased and her depression eased. She surmised that in the future she could even ask someone to help move furniture or perform other chores should she require assistance.

This patient benefited greatly from working through a forgiveness process and gained increased motivation to participate in her physical therapy with greater hope. She no longer had a burden of anger and guilt as she did her physical therapy. Enright’s four phases accurately guided and described the forgiveness process for this patient.

In retrospect, the uncovering phase for this patient entailed the greatest amount of effort. At the beginning of our interaction, she clearly felt frustrated by her situation. She longed for spiritual and emotional relief from her rage and depression. Nonetheless, with some effort she moved through the uncovering phase by naming her dilemma and by expressing her feelings about her dilemma. In the decision phase she determined that she wanted to make a change and explicitly decided to make a change by acknowledging that she was human and that she could ask for help. Full of relief, she accepted the new belief that she was as human as anyone else was, that she could make mistakes just as anyone else could, and that was “just fine” with her.

Enright’s model of a forgiveness process provides a framework to understand necessary steps patients take as they forgive or seek forgiveness. As I become clearer about the steps involved in a forgiveness process I become more aware of clues given by the patients that reflected potential forgiveness issues, and now have an idea about how to proceed as forgiveness issues emerge in our encounters. This facilitates successfully assisting patients in identifying the issues and assisting them as they move toward forgiving or asking for forgiveness.


Casarjian, Robin, (1992). Forgiveness: A Bold Choice for a Peaceful Heart (New York: Bantom Books), 135.

Countryman, William, (1998). L. Forgiven and Forgiving (Harrisburg, PA: Morehouse Publishing), 1.

Enright, Robert D., (2001). Forgiveness is a Choice: A Step-by-Step Process for Resolving Anger and Restoring Hope (Washington, D.C.: American Psychological Association), 25.

Stoop, David, & Masteller, James, (1996). Forgiving Our Parents, Forgiving Our Selves (Ann Arbor, MI: Servant Publishing), 223.