544132
research-article2014

HPQ0010.1177/1359105314544132Journal of Health PsychologyToussaint et al.

ArticleEffects of lifetime stress exposure
on mental and physical healthin young adulthood: How stressdegrades and forgivenessprotects health

Journal of Health Psychology
﻿1­–11© The Author(s) 2014
Reprints and permissions:sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1359105314544132
hpq.sagepub.com

Loren Toussaint1, Grant S Shields2,
Gabriel Dorn1 and George M Slavich3

Abstract
To examine risk and resilience factors that affect health, lifetime stress exposure histories, dispositional
forgiveness levels, and mental and physical health were assessed in 148 young adults. Greater lifetime stressseverity and lower levels of forgiveness each uniquely predicted worse mental and physical health. Analyses
also revealed a graded Stress × Forgiveness interaction effect, wherein associations between stress andmental health were weaker for persons exhibiting more forgiveness. These data are the first to elucidate
the interactive effects of cumulative stress severity and forgiveness on health, and suggest that developing amore forgiving coping style may help minimize stress-related disorders.

Keywords
coping, forgivingness, disease, mechanisms, stressLife stress is strongly associated with poor
mental and physical health (Cohen et al., 2007;
Slavich et al., 2010). These effects exceed thoseof other well-known risk factors, such as tobaccouse, excessive alcohol consumption, and physical inactivity (Holt-Lunstad et al., 2010), andaccount for substantial morbidity and mortality(Pedersen et al., 2011). Understanding how
stress impacts health, and what factors mitigate
these effects, is thus critically important.
One of the most important advances in thisarea of research involves the recent adoption ofa life-course perspective for studying stress andhealth (Graham et al., 2006; Lupien et al.,2009). Theorists now generally appreciate thatstress occurring over the lifespan can have acumulative effect on health; however, few

studies have actually measured lifetime stress
exposure and assessed the effects that such
exposure has on mental and physical health outcomes. This has occurred in part because no
system has existed for measuring cumulative

1Department of Psychology, Luther College, USA
2Department of Psychology, University of California,

Davis, USA
3Cousins Center for Psychoneuroimmunology andDepartment of Psychiatry and Biobehavioral Sciences,
University of California, Los Angeles, USA
Corresponding author:
Loren Toussaint, Department of Psychology,LutherCollege, Valders 340F, 700 College Drive, Decorah, IA
52101, USA.
Email: touslo01@luther.edu

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Journal of Health Psychology ﻿stress exposure in an efficient, cost-effective
manner. This issue has been addressed by thedevelopment of automated stress assessment
systems such as the Stress and Adversity
Inventory (STRAIN), which measures individuals’ lifetime exposure to different types ofstress that influence the onset and progressionof disease (Slavich and Epel, 2010). As a result,researchers are now poised to assess the effects
that cumulative life stress exposure has on
health and to examine factors that might modify
these effects.
One factor that may influence the effects thatcumulative stress exposure has on health is forgiveness. Forgiveness is the release of negative—and the potential enhancement of
positive—feelings, emotions, and behaviors
toward an offender (Enright et al., 1998).
Research has demonstrated that forgiveness is
associated with several mental health outcomes,
including less anxiety, depression, and othermajor psychiatric disorders (Hirsch et al., 2011;
Lin et al., 2004; Ryan and Kumar, 2005;
Toussaint and Cheadle, 2009a; Toussaint et al.,2008). Forgiveness is also associated with better
physical health and with physiological profiles
that underlie good health. In this context, forgiveness predicts fewer physical health symptoms, better overall physical health (Lawler et al.,2005; Seawell et al., 2014), healthier cardiovascular responses to stress (Lawler et al., 2003),
and lower rates of cardiovascular disease(Friedberg et al., 2007; Toussaint and Cheadle,
2009b; Waltman et al., 2009). As can be expected,
forgiveness is thus also associated with lower
rates of mortality (Krause and Hayward, 2013;
Toussaint et al., 2012).
Forgiveness has been conceptualized as anemotion-focused coping process or style that
can help people manage negative psychological and emotional experiences (i.e. unforgiveness) evoked by interpersonal conflict andstress (Strelan and Covic, 2006; Worthington
and Scherer, 2004). From this perspective, forgiveness is just one of several approaches that
individuals can use to cope; however, it has
been proposed as one of the more healthy
options for dealing with adversity (Worthington

and Scherer, 2004). Hence, to the extent thatthe victim of an offense can cope with the ensuing stress of unforgiveness through forgiveness, the negative effects of stress on healthshould be mitigated. Like many psychologicalconstructs, forgiveness can be both a state anda trait (Berry et al., 2001; Roberts, 1995). Trait
forgiveness has been called forgivingness, andhigh levels of forgivingness are thought to predispose a person to experience state forgiveness more often. Put another way, a stronger
dispositional proclivity toward forgiveness ishypothesized to increase the experience of forgiveness that in turn mitigates the negative
effects of stress. Forgivingness is thus a coping
style that may play a salutary role in the stress–
health relationship.
Studies have shown that perceptions of stressfully mediate associations between forgivenessand mental and physical health symptoms(Green et al., 2012), and that forgiveness partially mediates the link between traumatic stress
exposure and post-traumatic stress disorder
symptoms (Orcutt et al., 2005). In contrast to
this mediational work, little research has examined whether forgivingness moderates or buffers associations between stress and health,despite the fact that the transactional model andthe adapted stress and coping model of forgiveness offer the theoretical flexibility to consider
coping variables as both mediators and moderators (Lazarus and Folkman, 1984). Evidence
suggests that reductions in stress perceptions
may help explain why forgiveness is related tohealth (Green et al., 2012; Orcutt et al., 2005),
but to date it is not known if forgiveness offers
a protective benefit in the stress–health equation. Demonstrating a buffering effect of forgiveness on stress-related health symptoms
requires evidence of moderation.
To address these issues, we assessed thelifetime stress exposure histories, forgivingness levels, and mental and physical health of
148 young adults. Based on the aforementioned research, we hypothesized that greater
severity of lifetime stress exposure would be
associated with poorer mental and physicalhealth. We tested these associations using

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Toussaint et al.
indices of overall severity of exposure to
stress, but also assessed these effects using 20
different subdomain indices of stress exposure
across 2 time periods (i.e. early life, adulthood), 2 stressor types (i.e. acute, chronic), 11
life domains (e.g. housing, education, work,etc.), and 5 different social–psychologicalcharacteristics (e.g. interpersonal loss, physical danger, humiliation, etc.). Second, we
hypothesized that greater forgivingness would
be associated with better mental and physicalhealth. Finally, we hypothesized an interaction
between severity of lifetime stress exposureand forgivingness, such that higher levels of
forgivingness would buffer the negative effectsof stress severity across all domains on mental
and physical health symptoms.

MethodParticipants and procedures
Participants were 148 young adults recruitedfrom a mid-sized liberal arts college campus in
the Midwest. Most of the participants (99%)
began college in the past 4 years. The sample was
54 percent women, with a mean age of 19.32 years(standard deviation (SD) = 2.80). Less than 1 percent of participants were married, 29 percent
were in a serious relationship, 12 percent weredating, and 60 percent were single. Over 99 percent had no children. Participants provided written informed consent and completed all of themeasures online for course credit. Finally, allstudy procedures were approved by the local
Institutional Review Board.

Measures
Lifetime stress exposure. The STRAIN is an
online stress assessment system that measuresindividuals’ lifetime exposure to 96 different
types of acute and chronic stress that affecthealth (Slavich and Epel, 2010; see http://www.
uclastresslab.org/STRAIN). The system combines the reliability and sophistication of aninterview-based measure of stress with the simplicity of a self-report instrument. Questions

appear on the computer screen, and for eachendorsed stressor, users are asked a series offollow-up questions that ascertain the severity,
frequency, timing, and duration of the stressor.
Example items are, “Have you ever found outthat a partner was unfaithful to you?” and “Haveyou ever looked for a job for at least six months,
but were unable to find a stable job?” The validity of this question set has been demonstrated in
the context of predicting metabolic health(Kurtzman et al., 2012), cancer-related fatigue(Bower et al., 2014), and psychological andphysical health (Slavich and Epel, in preparation). Lifetime stressor “count” can range from0 to 96 and cumulative “severity” can range
from 0 to 480, with higher scores representing
higher stressor count and severity, respectively.1
In addition, 20 subscale scores can be computed
to index stress exposure occurring across 2 time
periods (early life, adulthood), 2 stressor types(acute, chronic), 11 life domains (housing, education, work, treatment/health, marital/partner,
reproduction, financial, legal/crime, death, lifethreatening situations, and possessions), and 5social–psychological characteristics (interpersonal loss, physical danger, humiliation, entrapment, and role change).
Forgivingness. The Heartland Forgiveness Scale(HFS) is an 18-item measure of forgivingness,
which assesses the general disposition toward
engaging in all types of forgiveness. Responses
are given on a 1 (almost always false of me) to
7 (almost always true of me) scale, and scores
can range from 18 to 125, with higher scores
representing more forgivingness. Psychometricwork on the HFS shows acceptable confirmatory factor analyses, convergent/divergent
validity, and internal and test–retest reliability(Thompson et al., 2005). Internal consistency
for the HFS for this study was excellent(α = .90).
Mental health symptoms. The Kessler 6 (K6)
measures nonspecific psychological distress.
Responses are given on a 1 (never) to 5 (very
often) scale, and scores can range from 6 to 30,
with higher scores representing more distress.

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Journal of Health Psychology ﻿

The K6 possesses excellent psychometric properties (Kessler et al., 2002, 2010). Internal consistency for the K6 for this study was excellent(α = .90).
Physical health symptoms. The 14-item Physical
Health Questionnaire (PHQ) assesses somatic
symptoms (Spence et al., 1987). Responses to
12 items are given on a 1 (not at all) to 7 (all thetime) scale, and responses to 3 items are given
on a 0 times to 7+ times scale. Scores range from
14 to 98, with higher scores representing more
physical health symptoms. Psychometric workon the PHQ shows acceptable exploratory andconfirmatory factor analysis, excellent convergent/divergent validity, and strong internal consistency (Schat et al., 2005). Internal consistency
for the PHQ for this study was good (α = .82).

Analyses
Preliminary analyses included descriptive statistics and bivariate correlations for all study
variables. Primary analyses included hierarchical regression models that examined direct andinteractive effects of lifetime stress severity andforgivingness on health. Life stress and forgivingness were entered as direct effects on Step 1,
and the Life Stress × Forgivingness interaction
effect was entered in Step 2.2 Simple slopes
analyses followed guidelines described by
Cohen et al. (2003). These analyses involved
examining the effects of life stress on health atlow, moderate, and high levels of forgivingness.
Data were examined for adherence to assumptions, and the alpha level was set at p < .05.

Results
Preliminary analyses
On average, participants experienced nearly 13
major life stressors each and rated those stressors as being moderately stressful (M = 3.08;
range = 1–5). Participants reported levels of
overall forgivingness that were relatively high(M = 87.56, SD = 15.20), and a moderate numberof mental (M = 13.91, SD = 5.24) and physicalhealth symptoms (M = 35.65, SD = 11.29). The
most frequently reported stressors involved
keeping up with the demands of college, deathof a close friend or loved one, isolation andloneliness, relationship difficulties, and financial problems. In bivariate analyses, most of the
20 stress severity indices were strongly associated with poorer health. As shown in Figure 1,
only reproductive-, legal/criminal-, death-, andtheft-related stressors were unrelated to health.
Given the consistency across stress indices, subsequent analyses utilized total stress severity
score as the main stress variable. Greater total
lifetime stressor severity was strongly associated with having more mental (r = .54, p < .001)
and physical (r = .55, p < .001) health symptoms.
In contrast to stress, forgivingness was negatively related to mental (r = −.48, p < .001) andphysical health symptoms (r = −.35, p < .001).
Additionally, greater lifetime stress severity was
negatively related to forgivingness (r = −.26,
p < .01, and r = −.33, p < .001, respectively). As
expected, participants experiencing more mental health symptoms also experienced more
physical health symptoms (r = .56, p < .001).

Primary analyses
Lifetime stress severity, forgivingness, and mental
health. As hypothesized, forgivingness significantly moderated the effects of lifetime stressseverity on mental health (β = −.173, p < .01; see
Table 1, Mental Health Model 2). Planned simple slopes analyses revealed a graded moderating
effect of forgivingness on mental health symptoms. Specifically, participants with low levelsof forgivingness (1.5 SDs or more below themean) showed the strongest associations between
lifetime stress severity and mental health symptoms (β = 0.68, p < .05), followed by participants
exhibiting moderate amounts of forgivingness(within 1.5 SDs of the mean) (β = 0.41, p < .05),
and finally by participants with high levels of
forgivingness (1.5 SDs or more above the mean)(β = 0.15, p > .05). This graded interaction effectis depicted graphically in Figure 2. Also as
hypothesized, lifetime stressor severity and forgivingness were both uniquely associated with

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Toussaint et al.

Figure 1. Associations between severity of lifetime stress exposure and (a) mental and (b) physicalhealth symptoms, categorized by stressor timing, type, primary domain, and core social–psychologicalcharacteristic. Error bars represent 95 percent confidence intervals (N = 148).

mental health symptoms, with greater lifetimestress severity predicting more mental healthsymptoms (β = 0.42, p < .001) and higher levelsof forgivingness predicting fewer mental
health symptoms (β = −0.34, p < .001) (seeTable 1, Mental Health Model 1).

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Journal of Health Psychology ﻿

Table 1. Hierarchical regression analysis examining direct and interactive effects of lifetime stress severity
and forgivingness on mental and physical health symptoms.
Predictor

Mental health

Physical healthModel 1B

SE B

Model 2βBModel 1
SE B

β

B

SE B

β

B

0.49***

0.27 0.17 0.49***−2.11 1.76 −0.19**−0.01 0.04 −0.02

0.29 0.07
0.22 0.03
Lifetime Stress Severity 0.09 0.01
Forgivingness−2.14 0.43 −0.34*** −0.33 0.76 −0.34** −2.58 0.96 −0.19**
Lifetime Stress−0.043 0.02 −0.17**
Severity × Forgivingness.39***.42***.34***
R2
2*****
F for ΔR
46.63
8.11
36.96***
0.42***

0.42***

Model 2SE B β.34***
0.10

SE: standard error.
*p < .05, **p < .01, ***p < .001, two-tailed (N = 148).

Figure 2. Associations between severity of lifetime stress exposure, forgivingness, and mental health.
As hypothesized, greater lifetime stress severity uniquely predicted more mental health symptoms, andhigher levels of forgivingness uniquely predicted fewer mental health symptoms. In addition, there was astrong graded Lifetime Stress Severity × Forgivingness interaction effect, demonstrating that forgivingness
significantly buffers the effects of lifetime stress severity on mental health (N = 148).

Lifetime stress severity, forgivingness, and physicalhealth. Next, the effects of lifetime stress severity and forgivingness on physical health symptoms were examined. Contrary to ourhypothesis, forgivingness did not moderate theeffects of cumulative lifetime stress severity on
physical health (β = −0.02, p > .05; see Table 1,
Physical Health Model 2). As hypothesized,
lifetime stressor severity and forgivingness
were both uniquely associated with physicalhealth symptoms, with greater lifetime stressseverity predicting more physical health symptoms (β = 0.49, p < .001) and higher levels of
forgivingness predicting fewer symptoms(β = −0.19, p < .01; see Table 1, Physical HealthModel 1).

Discussion
Although early and adulthood life stress are
known to be strongly associated with a broad
range of mental and physical health problems

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Toussaint et al.
(Cohen et al., 2007; Conway et al., 2014;
Slavich and Irwin, 2014; Taylor, 2010), few
studies have actually measured the severity oflifetime exposure to stress and examined its
effects on health. Moreover, the coping styles
that might moderate such effects remain unclear.
We addressed these important issues by studying 148 young adults who were well characterized with respect to their lifetime stress exposure
history, tendency to employ the coping style offorgivingness, and recent mental and physicalhealth symptoms. Consistent with prior workon early and adulthood life stress and health(Cohen et al., 2007; Graham et al., 2006; Lupien
et al., 2009; Pearlin et al., 2005), we found that
greater stress exposure severity over the lifespan was associated with poorer mental andphysical health. These effects were robust while
controlling for mental health symptoms in thephysical health models, and vice versa, andwere present for most of the 20 different stressseverity indices that we calculated using the
STRAIN.
Hypotheses regarding relations between forgivingness and mental and physical health werebased on research showing that people withcoping styles involving forgivingness have better overall health (Toussaint and Webb, 2005;
Worthington et al., 2007). The present data areconsistent with this research, but show for the
first time that forgivingness is a strong, independent predictor of mental and physical healthwhile controlling for the effects of lifetimestress severity on health. Prior research has
shown that associations between forgivenessand health are substantially attenuated or eliminated while controlling for perceptions of stress(Lawler et al., 2005). However, it is possiblethat a side effect of higher forgiveness is
reduced perceptions of stress. By measuring
actual lifetime stress severity and not merely
levels of general perceived stress, the present
findings offer new insight into how the effectsof stress might be offset by the independent
effects of forgivingness.
That forgivingness predicts mental andphysical health over and above stress severity
dovetails with intervention work showing thatfacilitating experiences of forgiveness improves
mental and physical health (Baskin and Enright,
2004; Wade et al., 2005; Waltman et al., 2009).
As such, personally cultivating this emotionfocused coping style may offer health benefits
independent of the life stressors that an individual might face. To the extent that forgivenesstraining can promote a more forgiving coping
style, then these interventions may help reducestress-related disease and improve humanhealth. Such interventions may be particularly
beneficial when delivered as a prevention strategy in early life, before individuals are exposed
to major adulthood life stressors and before disease processes have begun to take hold.
This study also examined whether forgivingness moderates the effects of lifetime stressseverity on health. Existing research in this area
has evaluated whether perceived stress mediates the effects of forgiveness on health, andhow forgiveness mediates the relation between
stress and health. Additionally, both theory andresearch suggest that forgivingness may moderate the effects of stress on health by acting as animportant coping style (Strelan and Covic,
2006; Worthington, 2003; Worthington andScherer, 2004). To our knowledge, however, no
studies to date have examined whether forgivingness moderates the effects of stress on
health. Here, we demonstrated for the first timethat forgivingness does buffer the negative
effects of lifetime stress severity on mental
health, and that this moderation occurs in a
graded fashion. Specifically, we found that lifetime stress severity was unrelated to mental
health for persons who were highest in forgivingness, significantly associated with poorer
mental health for persons exhibiting moderatelevels of forgivingness, and most strongly
related to poorer mental health for participants
exhibiting the lowest levels of forgivingness.
The present data do not reveal how forgivingness buffers the effects of lifetime stressseverity on mental health, but several explanations are possible. First, more forgiving individuals may have a more adaptive or extensive
repertoire of coping strategies that mitigate thenegative effects of stress on health. Consistent

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Journal of Health Psychology ﻿with this possibility, research has shown thatpeople with higher levels of forgivingness also
have a greater tendency to use problem-focused
coping and cognitive restructuring, and are lesslikely to use rumination, emotional expression,
and wishful thinking (Ysseldyk and Matheson,2008). Second, forgivingness may dampen
emotional, physiologic, or genomic components of the stress response that lead to poor
health (Slavich and Cole, 2013; Strelan andCovic, 2006; Worthington, 2003; Worthington
and Scherer, 2004). Finally, forgivingness may
facilitate healthier behaviors in the aftermath ofmajor life stress or may prompt a more active
approach to dealing with stress that involves
addressing the aspects of stress that are controllable (Webb et al., 2010, 2013). Additional
research is needed to evaluate how these different factors influence the effects of stress andforgivingness on health.
Contrary to our hypothesis, forgivingness
did not moderate the effects of lifetime stressseverity on physical health. This may haveoccurred because the sample included healthy
young adults. However, the average level ofphysical health symptoms was well above theminimum score for the scale and the standard
deviation was also relatively large, indicating amoderate level of somatic complaints and notable individual variability. Also, bivariate scatterplots (not shown) did not indicate skew or range
restriction. Finally, both stress exposure andforgivingness levels predicted significant
amounts of variability in physical health symptoms. In short, the fact that forgivingness did
not moderate the effects of stress on physicalhealth was not likely due to statistical issues.
Another possible reason for the contrasting
pattern of results for mental and physical health
may involve the fact that although participants
experienced approximately 13 different stressors (on average), these stressors may not exert
effects on physical health that are readily mitigated by forgivingness. This possibility is consistent with the “goodness of fit” hypothesis,
which suggests that a person’s coping style
must be relevant and useful for dealing with thetype of stress experienced for the method toconfer health benefits (Forsythe and Compas,
1987). In the present study, the most frequently
reported stressors involved dealing with educational demands, death of a close friend or loved
one, isolation and loneliness, relationship difficulties, and financial problems. These stressors
may well exert an immediate impact on mental
health processes (e.g. increased anger, frustration, or rumination) that are buffered by forgivingness, but have an effect on physical healthprocesses (e.g. increased inflammatory activity) that are not as strongly influenced by forgivingness (Berry et al., 2005; Finan et al.,2011; Michl et al., 2013; Slavich et al., 2010).
In short, the time-course of forgiveness-based
health benefits may differ for mental and physical health with the latter being more protracted.
Indeed, previous research has documented
delayed cardiovascular benefits of forgiveness(Waltman et al., 2009). Additional research isthus needed to identify the types of stress thatbest fit the forgivingness coping style and thatin turn benefit physical health. Given that the
STRAIN is a relatively comprehensive measureof lifetime stress exposure, it is unlikely that we
failed to assess major types or dimensions ofstress that could have interacted with forgivingness to affect health. Nevertheless, this presents
an interesting challenge for future studies—
namely, to determine if there are specific typesof stress for which forgivingness is an ideal
coping style that has physical health benefits.
Limitations of this study should also be noted.
First, this is a cross-sectional, correlational study
and, as such, conclusions about directionality
and causality cannot be made. At the same time,
recent longitudinal research has shown that forgiveness predicts health symptoms but that
health symptoms do not predict forgiveness(Seawell et al., 2014), making reverse causation
less likely. Second, although we focused on
major life stressors, other forms of stress may
also be relevant for mental and physical healthand may be buffered by forgivingness, including
daily hassles, role strain, and traumatic life stress.
Third, health was self-reported, and although themeasures we used were psychometrically sound,objective measures of health status should also

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Toussaint et al.
be investigated. Fourth, we did not examine
potentially important sex differences, and futurestudies with larger samples might address thisquestion. Finally, this study utilized a convenience sample. Additional research is thus needed
to examine the generalizability of the findings.
Notwithstanding these limitations, the present data are the first to demonstrate that lifetime stress severity and forgivingness both haveunique, independent effects on mental andphysical health. Moreover, they are the first toshow that forgivingness significantly moderates
the effects of lifetime stress severity on mental
health. Knowing that forgivingness buffers therelation between stress and poor health may
provide a unique opportunity for reducing
stress-related disease by developing programs
that help individuals cultivate greater forgivingness. More broadly, these findings address theimportant question of how key risk and resilience factors interact to influence mental andphysical health problems that cause substantial
morbidity and mortality.
Funding
This research was supported by National Institutes of
Health (NIH) grant R01 CA140933 and a Society in
Science—Branco Weiss Fellowship to George
Slavich, and by a University of California, Davis
Provost’s Fellowship in the Arts, Humanities, andSocial Sciences to Grant Shields.

Notes
1.

2.

The stressor count and severity correlation
exceeds .95. This occurs because stressor severity scores are based in part on how many stressors participants experience. Severity was usedas the stress measure in this study, although
results are virtually identical using stress countor severity.
Mental health was controlled for in models ofphysical health and vice versa. Results remained
virtually unchanged as a result of inclusion/
exclusion of the covariate.

References
Baskin TW and Enright RD (2004) Intervention studies on forgiveness: A meta-analysis. Journal ofCounseling & Development 82(1): 79–90.

Berry JW, Worthington EL, O’Connor LE, et al.
(2005) Forgivingness, vengeful rumination, andaffective traits. Journal of Personality 73(1):
183–226.
Berry JW, Worthington EL, Parrott L III, et al. (2001)
Dispositional forgivingness: Development andconstruct validity of the transgression narrative
test of forgivingness (TNTF). Personality andSocial Psychology Bulletin 27(10): 1277–1290.
Bower JE, Crosswell AD and Slavich GM (2014)
Childhood adversity and cumulative life stress:
Risk factors for cancer-related fatigue. ClinicalPsychological Science 2(1): 108–115.
Cohen J, Cohen P, West SG, et al. (2003) Applied
Multiple Regression/Correlation for the
Behavioral Sciences (3rd edition). New York:
Routledge.
Cohen S, Janicki-Deverts D and Miller GE (2007)
Psychological stress and disease. Journal of theAmerican Medical Association 298(14): 1685–
1687.
Conway CC, Slavich GM and Hammen C (2014)
Daily stress reactivity and serotonin transporter
gene (5-HTTLPR) variation: Internalizing
responses to everyday stress as a possible
transdiagnostic phenotype. Biology of Mood &Anxiety Disorders 4(1): 2.
Enright RD, Freedman S and Rique J (1998) The
psychology of interpersonal forgiveness.
In: Enright RD and North J (eds) Exploring
Forgiveness. Madison, WI: University of
Wisconsin Press, pp. 46–62.
Finan PH, Zautra AJ and Wershba R (2011) The
dynamics of emotion in adaptation to stress. In:
Contrada RJ and Baum A (eds) The Handbookof Stress Science: Biology, Psychology, andHealth. New York: Springer, pp. 209–220.
Forsythe CJ and Compas BE (1987) Interaction of
cognitive appraisals of stressful events andcoping: Testing the goodness of fit hypothesis.
Cognitive Therapy and Research 11(4): 473–
485.
Friedberg JP, Suchday S and Shelov DV (2007) The
impact of forgiveness on cardiovascular reactivity and recovery. International Journal of
Psychophysiology 65(2): 87–94.
Graham JE, Christian LM and Kiecolt-Glaser
JK (2006) Stress, age, and immune function: Toward a lifespan approach. Journal of
Behavioral Medicine 29(4): 389–400.
Green M, DeCourville N and Sadava S (2012)
Positive affect, negative affect, stress, and social

Downloaded from hpq.sagepub.com at UCLA on August 28, 2014

10

Journal of Health Psychology ﻿

support as mediators of the forgiveness-healthrelationship. Journal of Social Psychology
152(3): 288–307.
Hirsch JK, Webb JR and Jeglic EL (2011)
Forgiveness, depression, and suicidal behavior
among a diverse sample of college students.
Journal of Clinical Psychology 67(9): 896–906.
Holt-Lunstad J, Smith TB and Layton JB (2010)
Social relationships and mortality risk: A metaanalytic review. PLoS Medicine 7(7): e1000316.
Kessler RC, Andrews G, Colpe LJ, et al. (2002)
Short screening scales to monitor population
prevalences and trends in non-specific psychological distress. Psychological Medicine 32(6):959–976.
Kessler RC, Green JG, Gruber MJ, et al. (2010)
Screening for serious mental illness in the general population with the k6 screening scale:
Results from the WHO World Mental Health(WMH) survey initiative. International Journalof Methods in Psychiatric Research 19(S1):
4–22.
Krause N and Hayward RD (2013) Self-forgivenessand mortality in late life. Social Indicators
Research 111(1): 361–373.
Kurtzman L, O’Donovan A, Koslov K, et al. (2012)
Sweating the big stuff: Dispositional pessimism exacerbates the deleterious effects of life
stress on metabolic health. European Journal of
Psychotraumatology 3: 1.
Lawler KA, Younger JW, Piferi RL, et al. (2003) Achange of heart: Cardiovascular correlates offorgiveness in response to interpersonal conflict. Journal of Behavioral Medicine 26(5):373–393.
Lawler KA, Younger JW, Piferi RL, et al. (2005)
The unique effects of forgiveness on health: An
exploration of pathways. Journal of Behavioral
Medicine 28(2): 157–167.
Lazarus RS and Folkman S (1984) Strss Appraisal,
and Coping. New York: Springer.
Lin W-F, Mack D, Enright RD, et al. (2004) Effects
of forgiveness therapy on anger, mood, and vulnerability to substance use among inpatient substance-dependent clients. Journal of Consulting
and Clinical Psychology 72(6): 1114–1121.
Lupien SJ, McEwen BS, Gunnar MR, et al. (2009)
Effects of stress throughout the lifespan on thebrain, behaviour and cognition. Nature Reviews
Neuroscience 10(6): 434–445.
Michl LC, McLaughlin KA, Shepherd K, et al.
(2013) Rumination as a mechanism linking

stressful life events to symptoms of depression
and anxiety: Longitudinal evidence in earlyadolescents and adults. Journal of Abnormal
Psychology 122(2): 339–352.
Orcutt HK, Pickett SM and Pope EB (2005)
Experiential avoidance and forgiveness as
mediators in the relation between traumaticinterpersonal events and posttraumatic stressdisorder symptoms. Journal of Social andClinical Psychology 24(7): 1003–1029.
Pearlin LI, Schieman S, Fazio EM, et al. (2005)
Stress, health, and the life course: Some conceptual perspectives. Journal of Health and Social
Behavior 46(2): 205–219.
Pedersen AF, Bovbjerg DH and Zachariae R (2011)
Stress and susceptibility to infectious disease. In:
Contrada RJ and Baum A (eds) The Handbookof Stress Science: Biology, Psychology, andHealth. New York: Springer, pp. 425–445.
Roberts RC (1995) Forgivingness. American
Philosophical Quarterly 32(4): 289–306.
Ryan RB and Kumar VK (2005) Willingness toforgive: Relationships with mood, anxiety andseverity of symptoms. Mental Health, Religion& Culture 8(1): 13–16.
Schat ACH, Kelloway EK and Desmarais S (2005)
The physical health questionnaire (PHQ):
Construct validation of a self-report scale ofsomatic symptoms. Journal of Occupational
Health Psychology 10(4): 363–381.
Seawell AH, Toussaint LL and Cheadle ACD (2014)
Prospective associations between unforgiveness and physical health and positive mediating mechanisms in a nationally representative
sample of older adults. Psychology & Health
29: 375–389.
Slavich GM and Epel ES (2010) The Stress andAdversity Inventory (STRAIN): An AutomatedSystem for Assessing Cumulative Stress
Exposure. Los Angeles, CA: University ofCalifornia, Los Angeles.
Slavich GM and Epel ES (in preparation) STRAIN,
an automated measure of cumulative life stress:
Associations with psychological and physicalhealth.
Slavich GM and Cole SW (2013) The emerging field of human social genomics. ClinicalPsychological Science 1(3): 331–348.
Slavich GM and Irwin MR (2014) From stress to
inflammation and major depressive disorder: A
social signal transduction theory of depression.
Psychological Bulletin 140(3): 774–815.

Downloaded from hpq.sagepub.com at UCLA on August 28, 2014

11

Toussaint et al.
Slavich GM, O’Donovan A, Epel ES, et al. (2010)Black sheep get the blues: A psychobiological model of social rejection and depression.
Neuroscience and Biobehavioral Reviews
35(1): 39–45.
Spence JT, Helmreich RL and Pred RS (1987)
Impatience versus achievement strivings in thetype a pattern: Differential effects on students’
health and academic achievement. Journal ofApplied Psychology 72(4): 522–528.
Strelan P and Covic T (2006) A review of forgiveness process models and a coping framework
to guide future research. Journal of Social andClinical Psychology 25(10): 1059–1085.
Taylor SE (2010) Mechanisms linking early life
stress to adult health outcomes. Proceedings of
the National Academy of Sciences of the UnitedStates of America 107(19): 8507–8512.
Thompson LY, Snyder CR, Hoffman L, et al. (2005)
Dispositional forgiveness of self, others, and situations. Journal of Personality 73(2): 313–359.
Toussaint L and Cheadle A (2009a) Unforgivenessand lifetime prevalence of psychopathology:
Findings from an epidemiological study ofUnited States adults. In: Evans MT and Walker
ED (eds) Religion and Psychology. New York:
Nova Publishers, pp. 97–134.
Toussaint L and Cheadle A (2009b) Unforgivenessand the broken heart: Unforgiving tendencies,
problems due to unforgiveness, and 12-monthprevalence of cardiovascular health conditions.
In: Evans MT and Walker ED (eds) Religion
and Psychology. New York: Nova Publishers,
pp. 135–170.
Toussaint L and Webb JR (2005) Theoretical andempirical connections between forgiveness andmental health and well-being. In: Worthington
EL (ed.) Handbook of Forgiveness. New York:Brunner-Routledge, pp. 349–362.
Toussaint LL, Owen AD and Cheadle A (2012)
Forgive to live: Forgiveness, health, and longevity. Journal of Behavioral Medicine 35(4):375–386.

Toussaint LL, Williams DR, Musick MA, et al.
(2008) The association of forgiveness and
12-month prevalence of major depressive episode: Gender differences in a probability sample of U.S. adults. Mental Health, Religion &Culture 11(5): 485–500.
Wade NG, Worthington EL and Meyer JE (2005)
But do they really work: A meta analysis ofgroup interventions to promote forgiveness. In:
Worthington EL (ed.) Handbook of Forgiveness.
New York: Brunner-Routledge, pp. 423–440.
Waltman MA, Russell DC, Coyle CT, et al.
(2009) The effects of a forgiveness intervention on patients with coronary artery disease.
Psychology & Health 24(1): 11–27.
Webb JR, Hirsch JK, Visser PL, et al. (2013)
Forgiveness and health: Assessing the mediating effect of health behavior, social support, and interpersonal functioning. Journal of
Psychology 147(5): 391–414.
Webb JR, Toussaint L, Kalpakjian CZ, et al. (2010)
Forgiveness and health-related outcomes amongpeople with spinal cord injury. Disability andRehabilitation 32(5): 360–366.
Worthington EL (2003) Forgiving and Reconciling:
Bridges to Wholeness and Hope. Downers
Grove, IL: InterVarsity Press.
Worthington EL and Scherer M (2004) Forgivenessis an emotion-focused coping strategy thatcan reduce health risks and promote healthresilience: Theory, review, and hypotheses.
Psychology & Health 19(3): 385–405.
Worthington EL, Witvliet CVO, Pietrini P, et al.
(2007) Forgiveness, health, and well-being: A
review of evidence for emotional versus decisional forgiveness, dispositional forgivingness, and reduced unforgiveness. Journal of
Behavioral Medicine 30(4): 291–302.
Ysseldyk R and Matheson K (2008) Forgivenessand coping. In: Malcolm W, DeCourville N
and Belicki K (eds) Women’s Reflections on the
Complexities of Forgiveness. New York: Taylor& Francis, pp. 143–163.

Downloaded from hpq.sagepub.com at UCLA on August 28, 2014