Comfort and Anguish
The Complex Role of
Religion in Coping
with Illness
George Fitchett, DMin, PhD
Department of Religion, Health and
Human Values
george_fitchett@rush.edu
1
Objectives
Become aware of evidence about the
beneficial effects of religious/spiritual coping
with serious illness (eg. cancer).
Become aware of evidence about the harmful
physical and emotional effects of religious/
spiritual struggle.
Learn how clinicians can utilize findings from
this research to improve referrals to
chaplains.
Comfort & Anguish
Definitions: Spirituality, Religion
Spirituality
“a search for the sacred”
Religion
“the larger social and institutional
context in which the search for the
sacred takes place”
Pargament, Desai & McConnell, 2006, p. 122
Risk of Mortality for More
Frequent Worship Attenders
1.20
Adjusted OR for Mortality
No association
1.00
0.80
0.80
0.74
0.69
0.60
0.40
0.20
0.73
0.65
0.70
0.82
Comfort
“You know, I have a
lot of faith. And that
keeps me going.
I know that God is
there walking with
me.
Even during the bad
times I still feel
blessed because it
could be worse.”
6
Importance of Religion to Cancer Patients
Somewhat
important
20%
Not
important
12%
Very
important
68%
N=230 patients with advanced cancer.
From Balboni et al, J of Clinical Oncology, 2007
10 Most Commonly Used CAM
Therapies in Past 12 Months
1. Prayer specifically for your own health
2. Prayer by others for your health
43.0%
24.4%
3. Natural products
4. Deep breathing exercises
5. Participation in prayer group for own health
18.9%
11.6%
9.6%
6. Meditation
7. Chiropractic care
8. Yoga
9. Massage
7.6%
7.5%
5.1%
5.0%
10. Diet-based therapies
3.5%
N=31,004 adults, 2002 NHIS. From: Barnes et al. 2004.
Spiritual Well-Being and
Quality of Life in Cancer Patients
Percent who 'enjoy life very much'
Low Faith
80%
High Faith
69%
60%
40%
37%
34%
20%
8%
0%
No Pain
High Pain
From Brady, Peterman, Fitchett, Mo, Cella. Psycho-Oncology, 1999
R/S and Quality of Life in Cancer Patients
Religion
Measure
Study
Sample, Design
Brady, et al,
1999
n=1,610, diverse (medically,
racially, SES) out-patients with FACIT-SpWB
cancer (83%) and HIV (17%)
(SWB)
n=142 women with breast
cancer, avg time since dx, 14
mo, 84% white, 92% self-rated
Cotton et al, heath excellent, 65% no active
1999
religious practices.
Daugherty
et al, 2004
Convenience sample of n=162
patients in Phase I clinical
trials.
Results
SWB has a positive effect (effect size = 0.5)
on contentment with QoL, independent of
pain, fatigue, physical, emotional, and
social well-being
Spiritual Beliefs
Index (SBI),
Principles of
Living
SBI positively associated with QoL (p<.0.05)
in models adjusted for demographics,
health status, and psychological adjustment
(Mini-MAC).
FACIT-SpWB
(SWB),
Collaborative
Religious
Problem Solving
SWB positively associated with QoL (total
and subscales, unadjusted models).
Collaborative problem solving positively
associated with SFWB, EWB.
Canada et
al, 2005
n=129 women with Stage III/IV
ovarian cancer
Spiritual Beliefs
Index (SBI)
SBI scores were positively associated with
active coping and QoL. Active coping
mediated the association between SBI and
QoL.
Dapueto et
al, 2005
Convenience sample of n=309
cancer patients 4 hospitals in
Montevideo; 80% with
regional/metastatic disease,
57% income inadequate for
needs, 42% no current
religious affiliation.
FACIT-SpWB
(SWB)
SWB associated with QoL in models
adjusted for income, disease, treatment,
TMDS.
Comfort



Religious/spiritual coping is
very common.
Religious/spiritual coping
takes different forms.
Positive religious/spiritual
coping enhances emotional
well being and quality of
life.
ANGUISH
A woman in her fifties with
advanced cancer told a
chaplain,
“Why? Why me? I just can’t
figure it out.
And I get so depressed that I
just want to give up on life
altogether, you know?
And I’m so very angry at God.
So angry. I refuse to speak
to Him. You know what I
mean?”
(Fitchett & Roberts, 2003)
13
Somatic Autonomy (ADL)
Anger With God and Rehab Recovery
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Admission
14.5
4 Mnth Follow-up
10.7
9.2
Anger (n=6)
From: Fitchett, et al., Rehabilitation Psychology, 1999.
8.9
No anger (n=89)
Negative Religious Coping (Brief RCOPE)
not
at all
somewhat
quite
a bit
a
great
deal
8.
I wondered whether God had
abandoned me.
0
1
2
3
9.
I felt punished by God for my
lack of devotion.
0
1
2
3
10. I wondered what I did for God to
punish me.
0
1
2
3
11. I questioned God’s love for me.
0
1
2
3
12. I wondered whether my church
had abandoned me.
0
1
2
3
13. I decided the devil made this
happen.
0
1
2
3
14. I questioned the power of God.
0
1
2
3
Pargament et al, 1998
15
Religious Struggle and Emotional Distress
Diabetic
Outpatients
psychological distress (PAID)
.31*
depressed mood (CMDI)
.35**
emotional symptoms (LHFQ)
depression (POMS)
CHF
Outpatients
Oncology
Inpatients
.30*
.42***
.22*
anxiety (POMS)
.32*
.16
hostility (POMS)
.29*
.16
emotional well-being (FACT-G)
-.23*
*p<.05, **p<.01, ***p<.001
Values are partial correlations, adjusted for age and gender.
From Fitchett et al, 2004
16
Sample (study)
Religious/spiritual struggle
associated with
94 stem cell transplant pts, 3
mo f/u (Sherman et al., 2009)
Greater anxiety
Greater depression
Worse emotional WB
300 breast cancer pts (stage
I/II, IV), 12 mo f/u
Worse mental health (MCS)
More depressive sx (CESD)
Lower life satisfaction (SWLS)
(Herbert et al., 2009)
(Park et al., 2008)
Poorer adherence to instructions
re smoking and alcohol
101 end stage CHF pts, 3 mo
f/u (Park et al., 2011)
More hospital days
Poorer physical functioning
202 CHF pts, 6 mo f/u
17
ANGUISH
Two Year Change in Religious Struggle and Its
Effects on Outcomes Among Elderly Medically
Ill Patients
Any Religious Struggle At
Baseline
2 Year
Follow-Up
Number
No
Struggle
No
No
94
39%
reference group
Transitory
Struggle
Yes
No
40
17%
ns
Acute
Struggle
No
Yes
44
18%
ns
26%
> depression
> functional limitations
< quality of life
Group
Chronic
Struggle
Yes
Yes
61
Outcome at FollowPercent Up*
*Models adjusted for demographic factors and baseline values.
Source: Pargament et al, Journal of Health Psychology, 2004
ANGUISH
Religious Struggle as a Predictor of
Mortality (30%, 176/596)
Adjusted RR = 1.06
95% CI = 1.01 - 1.11
model adjusted for:
positive religious coping, demographic factors,
physical health, mental health
Pargament et al. 2001, Arch Intern Med
Religious Struggle and Depression
Mean of Depression-Dejection (POMS)
7
6
5
Religious Struggle
recoded into 3 groups
None (56%)
4
1-2 points (11%)
3+ points (33%)
3
0
1-2
3+
neg cope recode 3 gps
N=100 oncology in-patients
20
Prevalence of Religious Struggle
None
7 items scored "not at all"
123
52%
Low
1 item scored "quite a bit" or "a
great deal," or 1 or more items
scored "somewhat"
80
34%
Moderate
2 items scored "quite a bit" or "a
great deal"
17
7%
High
3 or more items scored "quite a
bit" or "a great deal"
18
8%
238 patients with diabetes, cancer or congestive heart failure
Fitchett et al., 2004
Prevalence of Religious Struggle
Spiritual Struggle Item
% Any
Wondered what I did for God/a Higher Power to punish me
44%
Felt punished by God/a Higher Power for my lack of devotion
41%
Questioned God’s/a Higher Power’s love for me
Decided the devil made this [asthma] happen
41%
41%
Wondered whether God/a Higher Power had abandoned me
36%
Question the power of God/a Higher Power
Wondered whether my church had abandoned me
0 items endorsed
1-2 items endorsed
3+ items endorsed
32%
20%
26%
21%
53%
151 urban adolescents with asthma
Cotton et al., 2011
Differences in RS by Patient Dx
5
4
2.7
3
2
2.1
1.8
1
0
diabetes (71)
chf (70)
oncology (97)
Differences in RS by Age
5
4.1
4
2.9
3
2.1
2.1
1.7
2
1
0.3
0
< 40 (18)
41-50 (32)
51-60 (58)
61-70 (68)
71-80 (53)
81-90 (9)
Trajectories of Religious Coping
Positive
Religious
Coping
Negative
Religious
Coping
PrePosttransplant transplant
Mean (SD) Mean (SD)*
Increase
(%, Mean
Change)
Decrease
(%, Mean
Change)
23.8 (7.9)
23.7 (7.6)
45% (4.9)
46% (4.9)
7.1 (1.7)
7.4 (2.9)
21% (3.3)
23% (2.0)
*Differences in pre and post transplant mean scores were not significant.
Average time between pre and post-transplant was 3.4 months (SD 2.9).
N=94 myeloma patients who received autologous stem cell transplant
Sherman et al, J Behav Med, 2009
ANGUISH
Isn’t religious struggle really just about
Fundamentalist beliefs about God?
Jews
Among 234 Jews
(60% Orthodox),
negative religious
coping (JCOPE) was
associated with more
worry, anxiety and
depression (Rosmarin et al
2009)
ANGUISH
Isn’t religious struggle really just about
Fundamentalist beliefs about God?
Secular Europeans & Aussies
• 53% of 202 UK women w breast cancer (Thune-Boyle et
al., 2011)
•
100 women w recent dx of gyne cancer religious
struggle significantly associated with higher
depressive symptoms (p<.001) and anxiety (p=.03)
(models adjusted for demographic, disease and other religion variables;
Boscaglia et al, 2005)
‘Atheists’
Among 15 pts w adv cancer who report R/S not
important to cancer experience, 6 (40%) reported 4
or more ‘religious concerns’ (Alcorn et al., 2012)
ANGUISH
Isn’t religious struggle really just
depression?
The size of the correlations between religious
struggle and depression in our study (r from
0.22 to 0.42) suggest religious struggle is
associated with but cannot be reduced to
depression.
Religious struggle predicts both poor recovery
and mortality in models which adjust for
depression.
ANGUISH
“I am told that
God lives in me
– and yet the
reality of
darkness and
coldness and
emptiness is so
great that
nothing touches
my soul.” Newsweek
9/3/07
ANGUISH
Religious/spiritual struggle
 compromises emotional
adjustment to illness
and quality of life
 may compromise
recovery
 may increase risk of
mortality
Further Research on R/S Struggle
Descriptive
• Conceptualization and measurement
• Screening
• Prevalence in specific populations
• Correlates
• Trajectory
Spiritual Care
• Intervention
What, if anything, helps people resolve R/S
struggle?
3 Actions:
1. Refer for spiritual
assessment re:
possible RS
struggle.
2. Spiritual care
requested, make
referral.
3. No action: no
indication of RS
struggle, no
interest in spiritual
care.
Fitchett & Risk, 2009
Results from Spiritual Struggle
Screening Protocol
Number (%) of
New
Admissions
Screened
Cases of
Spiritual
Struggle
Identified by
Screening
Cases of
Spiritual
Struggle
Confirmed by
Chaplain
Assessment
Phase I - PCTs
78 (49%)
4
4
Phase II - Medical
Residents
10 (22%)
0
Phase IIIPsychologists
85 (79%)
8
7
Total
173 (55%)
12/173 (7%)
11/12 (92%)
Study Phase and
Screener
Fitchett and Risk, Journal of Pastoral Care and Counseling, 2009
33
Prevalence of Religious
Struggle
Cancer patients
at SCCA and
Dana Farber
Maine Medical Center
ESRA-C (Electronic
Self-Report AssessmentCancer)
Group
Belief Helpful
7 (50%)
171/700 (24%)
cases were
positive for
religious struggle
Belief Not Helpful
3 (21%)
Belief in Past
1 (7%)
Number (%)
No Belief
3 (21%)
14 oncology patients, Maine Medical Center
34
Other Screening Tools
Are you at peace?
N=248 patients with cancer, COPD, CHF, ESRD
(Steinhauser et al., 2006)
Are you experiencing spiritual pain
right now?
“A pain deep in your being that is not physical”
Yes = 61%
N=57 patients with advanced cancer, prognosis < 6 months (Mako et al.,
2006)
Three Implications for Chaplains
QUESTION
IMPLICATION FOR
SPIRITUAL CARE
How did you decide which
patients to see this week?
Good stewards of
scarce resources
How did staff you work with
Protocol for screening
determine who to refer and who
and referral
not to refer?
What evidence did you generate
this week that your spiritual care Accountability and
made a difference in measurable documentation
patient outcomes?
Comfort & Anguish