Forgiveness Therapy to Reduce Violent Behavior in Individuals with Schizophrenia: A Case Study

Rohman Hikmat ^1,†, Iyus Yosep ^2,†,*, Popy Siti Aisyah ^1,†, Shella Febrita Puteri Utomo ^1,†

1. Nursing Department, Faculty of Health Science, Universitas ‘Aisyiyah Bandung, Jl. K.H. Ahmad Dahlan Dalam No.6, Turangga, Kec. Lengkong, Kota Bandung, Jawa Barat, Indonesia

2. Department of Mental Health, Faculty of Nursing, Universitas Padjadjaran, Sumedang, Jawa Barat, Indonesia

† These authors contributed equally to this work.

* Correspondence: Iyus Yosep

Academic Editor: Armida Mucci

Received: December 03, 2024 | Accepted: March 23, 2025 | Published: March 26, 2025

OBM Neurobiology 2025, Volume 9, Issue 1, doi:10.21926/obm.neurobiol.2501281

Recommended citation: Hikmat R, Yosep I, Aisyah PS, Utomo SFP. Forgiveness Therapy to Reduce Violent Behavior in Individuals with Schizophrenia: A Case Study. OBM Neurobiology 2025; 9(1): 281; doi:10.21926/obm.neurobiol.2501281.

© 2025 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

Schizophrenia is a complex and severe mental disorder that affects approximately 1% of the global population, with similar prevalence rates observed in Indonesia [1]. According to the World Health Organization (WHO), schizophrenia commonly emerges during the productive years of life, posing significant challenges not only for individuals but also for families and healthcare systems [2]. At the national level, the 2018 Basic Health Research (Riskesdas) reported that the prevalence of severe mental disorders, including schizophrenia, reached 7 per 1,000 population [3]. Individuals with schizophrenia often experience persistent symptoms such as hallucinations, delusions, cognitive impairments, and emotional dysregulation, which can affect their ability to function socially and lead to an increased risk of social isolation and stigma [4].

A critical concern in the management of schizophrenia is the risk of aggressive behaviors in some individuals, which can be influenced by a combination of psychotic symptoms, past traumatic experiences, emotional dysregulation, and environmental stressors [5]. However, it is essential to emphasize that individuals with schizophrenia are more likely to be victims of violence rather than perpetrators [6]. Misconceptions about schizophrenia and violence contribute to social stigma, which further exacerbates social isolation and hinders effective community integration and rehabilitation efforts [7]. The emotional distress resulting from stigma, rejection, and unresolved trauma may contribute to occasional aggressive reactions in specific individuals. This highlights the need for a more nuanced understanding of the factors underlying aggressive behaviors in schizophrenia, rather than attributing violence as an inherent characteristic of the disorder.

Pharmacological treatment with antipsychotic medications remains the primary approach for managing schizophrenia symptoms, including hallucinations and delusions. However, medication alone is often insufficient to address emotional dysregulation and aggression, particularly in patients with histories of trauma or inadequate social support [8]. Some patients may also exhibit treatment resistance or experience adverse side effects, leading to challenges in adherence [9]. Therefore, comprehensive psychosocial interventions are essential to complement pharmacological treatment by targeting underlying emotional and social factors that contribute to aggressive behaviors [3].

Several psychosocial interventions have been explored to address aggression in schizophrenia, including cognitive-behavioral therapy (CBT), anger management training, and trauma-focused interventions [10,11]. Studies suggest that CBT can help patients restructure maladaptive thoughts and improve emotional regulation, reducing aggressive tendencies [12]. Similarly, trauma-informed care has been recognized as beneficial in addressing unresolved trauma, which can contribute to emotional dysregulation and aggression in individuals with schizophrenia [13]. While these approaches have shown promise, there is still a need to explore additional psychosocial interventions that specifically address emotional distress, interpersonal conflicts, and unresolved trauma in this population.

Forgiveness therapy is a psychological intervention that aims to help individuals process and release emotions such as resentment, frustration, and distress associated with past traumatic experiences and interpersonal conflicts [14]. This therapy is rooted in cognitive-behavioral and emotional regulation theories, emphasizing the role of forgiveness in reducing emotional burdens, fostering self-acceptance, and improving interpersonal relationships [15,16]. Research has demonstrated the efficacy of forgiveness therapy in various populations, including individuals with PTSD and depression, by reducing symptoms of emotional hyperreactivity and promoting psychological well-being [17]. In schizophrenia, unresolved trauma and social rejection may contribute to heightened emotional distress, which, in turn, can increase the risk of aggressive reactions [18]. By fostering emotional regulation and cognitive restructuring, forgiveness therapy holds potential as a complementary approach to help individuals with schizophrenia manage distress and improve interpersonal functioning.

Forgiveness therapy not only addresses emotional regulation but also contributes to the reduction of hostility and improvement of social functioning in individuals with schizophrenia. Studies suggest that persistent negative emotions, such as resentment and anger, can exacerbate psychotic symptoms and hinder social reintegration [19]. By promoting empathy, self-reflection, and a shift in perspective, forgiveness therapy encourages individuals to rebuild trust and engage in more adaptive social interactions [6,20]. This is particularly relevant for individuals with schizophrenia who often experience social withdrawal and interpersonal difficulties due to past trauma or perceived rejection. Integrating forgiveness therapy into treatment plans may provide a holistic approach to enhancing emotional stability and social well-being in individuals with schizophrenia [21].

The psychological mechanisms through which forgiveness therapy may reduce aggressive behavior in schizophrenia involve emotional processing, cognitive restructuring, and stress reduction. Emotional processing enables individuals to acknowledge and work through past traumas, while cognitive restructuring helps in reframing maladaptive thoughts associated with anger and resentment [22]. Additionally, forgiveness therapy incorporates relaxation techniques and self-compassion exercises, which contribute to reducing physiological arousal and stress levels, factors that are often linked to aggression in individuals with schizophrenia [23,24].

Given the complexity of schizophrenia and the multifaceted nature of aggressive behaviors, this study employs a case study approach to provide an in-depth exploration of the application of forgiveness therapy for a schizophrenia patient exhibiting violent behavior. A case study allows for a detailed analysis of therapy implementation, patient responses, and potential mechanisms of change, offering insights that may inform future research and clinical practice.

1.1 Study Objectives

This study aims to examine the role of forgiveness therapy in supporting individuals with schizophrenia, particularly in managing emotional distress, reducing aggression, and improving psychological well-being. Specifically, it seeks to:

1. Describe the implementation of forgiveness therapy in a schizophrenia patient with violent behavior.
2. Explore the psychological mechanisms through which forgiveness therapy may contribute to aggression reduction.

2. Case Report

Mr. M, a 19-year-old man, was taken to the hospital on November 18, 2024, due to episodes of emotional distress and aggressive behavior. According to reports, the patient exhibited frustration by slamming tables, speaking loudly, and breaking objects, including glass, during a family conflict. Upon examination, he appeared restless and occasionally looked around the room. Physical examination showed no significant medical issues: weight 55 kg, height 167 cm, blood pressure 130/91 mmHg, pulse 120 beats per minute, temperature 36.7°C, and respiration 24 breaths per minute. Minor dried wounds were observed on the back of his fingers.

The patient reported feeling blamed by his family, particularly his brother, which triggered his anger. He described experiencing physical violence from his brother, including being beaten, and stated that he was deceived into believing he would be taken to Dustira Hospital but was instead brought to Mental Health Hospital. He also recalled a history of persistent physical abuse from his brother during adolescence.

The mental status assessment conducted through structured clinical observation and patient interviews, revealed signs of restlessness, including frequent glances toward the window and a desire to leave the room. The assessment included evaluations of appearance, speech, motor activity, mood, affect, perception, thought processes, insight, and judgment. The patient was observed to have appropriate personal hygiene and cooperative communication, with no apparent thought disorders or perceptual disturbances at the assessment time. However, psychosocial and environmental evaluations identified significant family conflicts and persistent arguments with his brother and mother, leading to heightened emotional distress. These conflicts contributed to episodes of emotional dysregulation, characterized by raised voices and hostile expressions rather than intentional violent acts.

2.1 Ethics Statement

The participants were provided with detailed information regarding the purpose of the study and its implementation stages. They were assured that all data collected would remain confidential and that they had the right to withdraw from the study at any time without any consequences. Additionally, they were given the option to access the research findings if they wished. Written informed consent was obtained from all participants before the study commenced. The study was conducted in accordance with ethical principles, including compliance with the Helsinki Declaration.

2.2 Forgiveness Therapy Intervention

Forgiveness therapy was implemented as part of the patient’s psychosocial treatment. This intervention was conducted by a licensed clinical psychologist with expertise in trauma therapy and lasted for one week, consisting of five structured sessions of 45-60 minutes each. The goal of the treatment was to help the patient process emotions related to past experiences of familial violence and develop healthier coping mechanisms.

Each session followed a structured protocol:

• Session 1: Introduction to forgiveness therapy, identifying sources of anger and emotional pain.
• Session 2: Exploring negative emotions, guided self-reflection on the impact of past trauma.
• Session 3: Cognitive restructuring, introducing techniques to change maladaptive thought patterns related to past abuse.
• Session 4: Practicing relaxation techniques, including breathing exercises and mindfulness strategies, to manage emotional triggers.
• Session 5: Developing personal strategies for emotional regulation and conflict resolution, followed by evaluating progress.

This intervention aimed to support the patient in reframing past traumatic experiences, reducing emotional distress, and fostering adaptive emotional regulation. Forgiveness therapy did not focus on justifying past violence but rather on enabling the patient to release emotional burdens that contributed to distress and maladaptive responses. By the end of the therapy, assessments indicated a reduction in self-reported emotional distress and an improved ability to manage conflicts without aggressive outbursts. Further follow-up was recommended to ensure long-term emotional stability and behavioral improvement.

3. Discussion

Schizophrenia is often accompanied by psychotic symptoms that affect the patient's behavior. In Mr. M's case, the results of the analysis indicated that past trauma, especially violence from his brother, as well as tension in family relationships, contributed significantly to his distress and emotional dysregulation. Previous studies have confirmed that individuals with schizophrenia with a history of trauma experience significant difficulty in managing emotions, which can exacerbate their psychotic symptoms [7,25]. This finding aligns with the analysis of Mr. M's case, where unresolved traumatic experiences contributed to heightened emotional distress and maladaptive coping strategies.

The case of Mr. M highlights the impact of emotional trauma and interpersonal tension on the psychological condition of individuals with schizophrenia. The patient exhibited psychotic symptoms, including hallucinations and heightened anxiety, which were likely triggered by ongoing interpersonal stress and previous experiences of physical violence from his brother. Prior research has shown that individuals with schizophrenia with a history of trauma, particularly familial violence, are more vulnerable to emotional dysregulation and heightened stress responses [26,27]. Previous research identified that traumatic experiences, particularly those occurring during early developmental periods, influence stress management and emotional processing, potentially exacerbating psychotic symptoms and distress-related behaviors [28]. The results of Mr. M's case analysis align with these findings, demonstrating how ongoing interpersonal stress, rather than past trauma alone, influences his psychological state and symptomatology.

Additionally, persistent interpersonal tensions within the household, such as conflicts with his mother and brother, appeared to exacerbate Mr. M’s emotional distress further. These tensions contributed to feelings of isolation and frustration, further heightening his emotional instability [16,29]. Studies have shown that adverse family dynamics, including ongoing verbal or physical conflicts, may exacerbate psychiatric symptoms in patients with schizophrenia, particularly in the context of expressed emotion (EE) within the family environment [30]. Such findings suggest that unresolved familial conflict, rather than trauma alone, plays a critical role in shaping the symptom severity and coping responses of patients with schizophrenia.

The forgiveness therapy process applied to Mr. M was conducted over one week, with each session lasting 45-60 minutes. This therapy incorporated relaxation techniques, controlled breathing exercises, and guided emotional processing to assist the patient in managing distressing emotions. The primary focus of this therapy was to help the patient reframe his experiences and reduce persistent negative emotional states such as resentment and frustration [23]. Prior studies have indicated that forgiveness-based interventions can be effective in alleviating emotional distress and improving coping mechanisms in individuals who have experienced trauma [18]. This approach was particularly relevant to Mr. M's case, as his emotional distress was significantly influenced by his perception of past and ongoing interpersonal conflicts.

Forgiveness therapy is a psychological intervention that aims to help individuals process and release emotions such as resentment, frustration, and distress associated with past traumatic experiences and interpersonal conflicts [31]. This therapy is rooted in cognitive-behavioral and emotional regulation theories, emphasizing the role of forgiveness in reducing emotional burdens, fostering self-acceptance, and improving interpersonal relationships [6,21]. Research has demonstrated the efficacy of forgiveness therapy in various populations, including individuals with PTSD and depression, by reducing symptoms of emotional hyperreactivity and promoting psychological well-being [23]. In schizophrenia, unresolved trauma and social rejection may contribute to heightened emotional distress, which, in turn, can increase the risk of aggressive reactions [22]. By fostering emotional regulation and cognitive restructuring, forgiveness therapy holds potential as a complementary approach to help individuals with schizophrenia manage distress and improve interpersonal functioning.

The psychological mechanisms through which forgiveness therapy may reduce aggressive behavior in schizophrenia involve emotional processing, cognitive restructuring, and stress reduction. Emotional processing enables individuals to acknowledge and work through past traumas, while cognitive restructuring helps in reframing maladaptive thoughts associated with anger and resentment [24]. Additionally, forgiveness therapy incorporates relaxation techniques and self-compassion exercises, which contribute to reducing physiological arousal and stress levels, factors that are often linked to aggression in individuals with schizophrenia [32,33].

Previous studies have highlighted that forgiveness therapy has the potential to reduce distress-related behaviors in individuals with severe mental health conditions, including schizophrenia [18,34]. Research suggests that forgiveness-based interventions may facilitate reductions in stress reactivity and foster healthier emotional regulation patterns, particularly in individuals with histories of trauma [6]. In Mr. M’s case, therapy aimed to support him in managing distressing memories and emotional responses related to his ongoing familial tensions. Patients with schizophrenia often struggle with emotion regulation, which can lead to heightened distress responses, particularly when faced with unresolved interpersonal conflicts [24]. This aligns with Mr. M’s presentation, wherein his distress-related responses appeared to be linked to his experiences of familial discord and emotional stress rather than simply "pent-up anger."

Studies have also demonstrated that forgiveness therapy can improve interpersonal relationships by mitigating stress responses and promoting adaptive emotional expression. In the case of Mr. M, therapy sessions emphasized the development of healthier coping mechanisms, allowing him to engage in interactions with family members in a more regulated manner [34,35]. Research indicates that forgiveness-based interventions may facilitate improved communication patterns and emotional resilience in individuals with histories of trauma [21,36]. However, it is essential to acknowledge that the outcomes observed in Mr. M’s case were inferred from qualitative observations during therapy sessions, rather than through standardized measurement tools. Future studies should incorporate validated assessment tools to objectively quantify changes in emotional regulation and interpersonal dynamics following forgiveness therapy.

Furthermore, the long-term effects of forgiveness therapy remain an area for further investigation. While initial findings suggest improvements in emotional regulation and interpersonal relationships, longitudinal studies are needed to assess whether these benefits are sustained over time. Follow-up assessments could provide valuable insights into the durability of therapy effects and inform best practices for integrating forgiveness therapy into long-term schizophrenia management.

4. Conclusions

This case study suggests that forgiveness therapy may have a potential role in supporting the management of violent behavior in individuals with schizophrenia, particularly in individuals with a history of trauma and familial tension. In the case of Mr. M, the therapy process, which involved emotional processing, relaxation, and reframing of past experiences, appeared to help reduce expressions of anger, improve stress management, and enhance interpersonal relationships. However, as this study is based on a single case, these findings should be interpreted cautiously.

Forgiveness-based therapy could be explored further as a complementary psychosocial intervention alongside conventional medical treatments for individuals with schizophrenia with violent tendencies. While this case highlights the potential benefits, further research with larger sample sizes and rigorous methodological approaches is needed to confirm the effectiveness of forgiveness therapy. Future studies should also investigate its impact on broader psychological aspects, such as anxiety and depression, and compare its efficacy with other psychosocial interventions.

Acknowledgments

All authors thank you to Universitas ‘Aisyiyah Bandung who has facilitating us to make this study.

Author Contributions

Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data: RH, IY, PSA, SFPU; Involved in drafting the manuscript or revising it critically for important intellectual content: RH, IY, PSA, SFPU; Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content: RH, PSA, SFPU; Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: RH, IY.

Funding

This research has not external funding.

Competing Interests

The authors have declared that no competing interests exist.