George Fitchett December 2006 Religious Struggle and Its Impact on Health: Implications for...

George FitchettDecember 2006

Religious Struggle and Its Impact on Health: Implications for Ministry

Outline• Definition • Evidence from Research

• harmful effects• prevalence• determinants

• Screening• Case Examples• Implications for Spiritual Care

Religious StruggleA 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?”

What is Religious Struggle?Religious struggle is having high spiritual

needs and low spiritual resources with which to address those needs.

Religious struggle is marked by underdeveloped, conflicted, overwhelmed, or negative spirituality.

Negative Religious Coping (Brief RCOPE)

not at all

some-what

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

Religious Struggle: Other Measures

A. Difficulty Forgiving God

1. I sometimes find it difficult to forgiveGod for things that happen.

strongly stronglyagree disagree1 2 3 4 5 6

2. At times I feel frustrated ordisappointed with God. 1 2 3 4 5 6

3. Have you ever found it difficult toforgive God for something?

never manytimes

0 1 2 3

B. Feelings of Alienation from GodTo what extent are you having each ofthese experiences?

not at all extremely0 1 2 3

1. Difficulty trusting God 0 1 2 32. Feeling that God is far away 0 1 2 33. Difficulty believing that God exists 0 1 2 34. Feeling that your faith is weak 0 1 2 35. Feeling abandoned by God 0 1 2 3

JJ Exline et al, 1999.

Religious Struggle: Early Models

• Stoddard, 1993• spiritual concern, spiritual distress, spiritual despair

• Berg, 1994, 1999• Spiritual Injury Scale

• NANDA• Spiritual distress (1978)• Potential for enhanced spiritual well-being (1994)• At risk for spiritual distress (1998)

• Other Chaplaincy Models• Derrickson, 1994-5• Hodges, 1999• Wakefield & Cox, 1999

Spiritual Injury ScaleHow often do you feel guilty over past behaviors?

Does anger or resentment block your peace of mind?

How often do you feel sad or experience grief?

Do you feel that life has no meaning or purpose?

How often do you feel despair or hopeless?

Do you feel that God/life has treated you unfairly?

Do you worry about your doubts/disbelief in God?

Do you worry about or fear death?

© Gary Berg. www.spiritualassessment.com.

How often do you feel guilty over past behaviors?

Does anger or resentment block your peace of mind?

How often do you feel sad or experience grief?

Do you feel that life has no meaning or purpose?

How often do you feel despair or hopeless?

Do you feel that God/life has treated you unfairly?

Do you worry about your doubts/disbelief in God?





Spiritual Distress: NANDADefinition

Disruption in the life principle that pervades a person's entire being and that integrates and transcends one's biological and psychosocial nature.

Related factors [etiology] Separation from religious and cultural tiesChallenged belief and value system (e.g., result of moral or ethical

implications of therapy or result of intense suffering)

Defining characteristicsExpresses concern with meaning of life and death and/or belief systemAnger toward God (as defined by the person)Questions meaning of sufferingVerbalizes inner conflict about beliefsUnable to choose or chooses not to participate in usual religious practicesRegards illness as punishmentDoes not experience that God is forgiving

Anger With God and Rehabilitation Recovery

9.2 8.9

10.7

14.5

0123456789

1011121314151617

Anger (n=6) No anger (n=89)

So

ma

tic

Au

ton

om

y (

AD

L)

Admission

Follow-up

Fitchett et al, 1999.

Religious Coping and Health Status in Hospitalized Older Adults (N= 577)

Negative Religious Coping

Depressed Mood

Quality of Life

Self-Rated Health

Punishing reappraisal

Demonic reappraisal

Reappraisal of God's Power

Passive religious deferral

Self-directed religious coping

Spiritual discontent

Interpersonal religious discontent

Pleading for direct intercession

.25***

.17***

.15***

.09*

.22***

.22***

.27***

.10*

-.17***

-.10**

-.16***

-.06

-.19***

-.18***

-.21***

-.04

-.12**

-.12**

-.12**

-.14**

Values are standardized betas from regression models that included demographic variables, and for depressed mood and quality of life, severity of illness. *p<.05, **p<.01, ***p<.001 Koenig et al., 1998, Jnl of Nervous and Mental Disorders

Any Religious Struggle At

Group Baseline 2 Year

Follow-Up Number Percent Outcome at Follow-Up*

No Struggle No No 94 39% reference group

Transitory Struggle Yes No 40 17% ns

Acute Struggle No Yes 44 18% ns

Chronic Struggle

Yes Yes 61 26% > depression > functional limitations < quality of life

Two Year Change in Religious Struggle and Its Effects on Outcomes Among Elderly Medically Ill Patients

*Models adjusted for demographic factors and baseline values.

Source: Pargament et al, Journal of Health Psychology, 2004

Religious Struggle as a Predictor of Mortality (N=567)

Pargament et al.,2001, Arch Intern Med

Model Adjusted RR 95% CI1. Religious struggle adjusted for the

effects of demographic factors, physicalhealth, mental health, and positivereligious coping

2. Model 1, plus frequency of church attendance

3. Single Religious Struggle Items

“Wondered whether God had abandoned me”

“Questioned God’s love for me.”

“Decided the devil made this happen.”

1.06

1.06

1.28

1.22

1.19

1.01-1.11

1.00-1.10

1.07-1.50

1.02-1.43

1.05-1.33

Religious Struggle and Emotional Distress

Diabetic Outpatients

CHF Outpatients

Oncology Inpatients

psychological distress (PAID) .31*

depressed mood (CMDI) .35**

emotional symptoms (LHFQ) .30*

depression (POMS) .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

Conflict About Prayer• Unanswered prayer (13/30)• Hesitancy about petitionary prayer (10/30)• Conflict about control (9/30)• Questions about the nature of God (8/30)• Questions about meaning and theodicy (8/30)• Bargaining (5/30)• Doubt about the efficacy of prayer (4/30)• Doubt about personal spirituality and worth (4/30)• Praying the “right” way (4/30)

20% of patients had four to six types of spiritual conflict associated with praying about their cancer.

Taylor, et al., 1999

Study Sample, Design Results

Peteet, 1985

n=50 cancer patients seen in psychiatric consultation, 76% with adjustment disorder with depressed or anxious mood.

64% of patients had a religious dimension to their concern, including: -recent loss of religious support; -pressure from others to adopt a different religious position; -unusual religious beliefs; -conflict between religious views and view of the illness; -preoccupation with the meaning of life and illness.

Taylor et al, 1999

n=30, 14 men, 16 women, avg age 58 years, 73% white, variety of religious backgrounds

20% of patients had four to six types of spiritual conflict associated with praying about their cancer, 33% had one to three types of spiritual conflict.

Moadel et al., 1999

n=248 out-pts in NYC, 48% white, 25% African-Am, 19% Hispanic, 58% Christian, 15% Jewish, 59% women, 50% currently receiving Rx.

75% of an ethnically diverse sample of cancer patients had one or more spiritual needs, 31% had five or more needs, including finding hope, meaning or peace of mind, or finding spiritual resources.

Gall et al, 2002 n=39 women with breast cancer.

5/39 women (13%) report ambivalent or negative relation with God.

Manning-Walsh, 2005

n=100 breast cancer patients recruited through Internet; majority Stage I/II, avg age 46 years, 93% white, 30% some graduate edu, avg 10 mnths since dx, > 50% completed tx.

In unadjusted models, negative religious coping (Brief RCOPE) inversely associated with EWB (r = -0.34**), composite QoL (r = -0.36**), and life satisfaction (LS, r = -0.31**). In models adjusted for age, the associations with QoL and LS remain significant.

Religious Struggle and Psychological Adjustment Among Cancer Patients

Boscaglia et al, 2005

n=100 women with recent dx of gyne cancer, Melbourne, avg age 52 years, 70% married, avg 22 weeks since dx.

In models adjusted for demographic, disease and other religion variables, negative religious coping was significantly associated with higher depressive symptoms (p<.001) and anxiety (p=.03).

Sherman et al, 2005

n=213 patients with multiple myeloma being evaluated for stem cell transplant, avg age 59 years, 60% male, 89% white, 84% married, avg 3 months since dx.

In unadjusted analyses, negative religious coping was associated with higher total distress, depression, and pain and with poorer mental functioning and energy. These associations remained significant after adjustment for demographic, disease, and other religion variables.

Burker et al, 2005

n=81 patients with end-stage lung disease being evaluated for lung transplant, avg age 35 years, 43% male, 93% white, 48% married, 64% dx with CF.

In models adjusted for non-religious coping and other dimensions of religious coping, punishing God reappraisals were significantly associated with greater depression, anxiety and disability.

Rippentrop et al, 2005

n=122 pain clinic patients, avg age 53 years, 44% male, 92% white, 57% married, 55% back pain, 26% disabled/retired due to illness

In unadjusted analyses negative religious coping was associated with poorer mental health (p<.001) and greater total pain (p<.01). In models adjusted for demographic factors, pain, and mental health, these associations were not longer significant.

Religious Struggle and Psychological Adjustment Among Cancer and Other Patients

Religious Struggle and Emotional Distress Down Under

10.69.4

20.0

0

5

10

15

20

25

0 (25) 1 (5) 2+ (6)

Negative Religious Coping Items (number of cases)

mea

n T

MD

S

36 medical/surgical patients, Melbourne; F (2,35) = 3.7, p = .03.

Source: Ano and Vasconcelles, Journal of Clinical Psychology, 2005.

Correlation Between Negative Religious Coping And Negative Psychological Adjustment

Number Cumulative Confidence of Studies Effect Size Interval

22 .22* .19 to .24

Meta-Analysis of Negative Religious Coping and Psychological Adjustment

Religious Struggle and Recovery from Heart Surgery (n=232)

All Cases DeathsVariable (N = 232) (N=21, 9%) Adj OR (95% CI)History of cardiac surgery no 214 14 (7%) 10.07 (2.77, 36.55) yes 18 7 (39%)ADL impairment not severe 204 13 (6%) 6.14 (1.88, 20.05) severe 28 8 (29%)Participation in social groups yes 97 4 (4%) 4.26 (1.15, 15.73) no 135 17 (13%)Age 55 - 69 122 6 (5%) 3.38 (1.08, 10.60) 70+ 110 15 (14%)Strength and comfort from religion a little or a great deal 158 9 (6%) 3.25 (1.09, 9.72) none 74 12 (16%)Oxman et al., 1995, Psychosomatic Medicine

Comfort from Religion and Religious Struggle

149 patients with diabetes or CHF

60%

28%19%

0%

25%

50%

75%

100%

none (5) a little (39) a great deal (105)

How much strength and comfort from religion? (number)

Per

cen

t w

ith

mo

der

ate

or

hig

h

reli

gio

us

stru

gg

le

Determinants of Religious StruggleVariable Standardized BetaAge -0.289***Female (vs male) -0.091

Patient Group (reference group Oncology) Diabetic 0.022 CHF 0.164*

Attend Worship (reference group Never) Rarely -0.024 Monthly -0.053 Weekly or more -0.251*

Positive Religious Coping (reference group 0-5) 6-9 0.221* 10-14 0.148 15-18 0.241** 19+ 0.280**Model adjusted for marital status, race and education.


Differences in RS by Patient Group

1.8

2.7

2.1

0

1

2

3

4

5

diabetes (71) chf (70) oncology (97)

Differences in RS by Age

1998 GSS also found an age difference in negative religious coping (2 items, p<.05); mean scores: < 65: 1.25 > 65: 1.18

4.1

2.9

2.1 2.11.7

0.3

0

1

2

3

4

5

< 40 (18) 41-50 (32) 51-60 (58) 61-70 (68) 71-80 (53) 81-90 (9)

Differences in RS by Gender

10.2

12.8

2.61.8

0

5

10

15

male female

Me

an

Re

ligio

us

Co

pin

g S

co

re

positive coping negative coping No gender differences in GSS study.

Gender difference:-negative religious coping, ns-positive religious coping, t = -3.0, p=.003

Differences in RS by Level of Worship Attendance

2.4

3.32.9

1.5

0

1

2

3

4

5

never (39) rarely (50) monthly (26) weekly or more(123)

Differences in RS by Positive Religious Coping

1.7

2.5

1.52.0

3.0

0

1

2

3

4

5

0 - 5 (44) 6 - 9 (55) 10-14 (42) 15-18 (49) 19+ (48)

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.

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%

Moderate2 items scored "quite a bit" or "a great deal" 17 7%

High3 or more items scored "quite a bit" or "a great deal" 18 8%


Prevalence of Religious Struggle

PatientsGeneral

Population

Feel abandoned by God 9% 5%

Feel punished by God 11% 5%

Responses of “quite a bit” or “a great deal.”

Prevalence of Religious StruggleStudy Sample Measure Prevalence

Gall et al, 200239 women with breastcancer

report ambivalent or negative relation withGod 13%

Taylor, et al,1999

30 men and women withcancer

express 4-6 types of spiritual conflictabout praying about their cancer 20%

Jacobson et al,2006

19 men and women withHIV/AIDS

responses indicate religious/spiritualseeking 21%

Stoddard, 199327 patients who died inthe hospital

chaplain chart note about spiritual distressor spiritual despair 40%

Moadel et al,1999

248 ethnically diversecancer out-patients inNYC

express 5 or more needs, including findhope, meaning, peace of mind, spiritualresources 31%

Oxman et al,1995

232 older elective heartsurgery patients

report no strength and comfort fromreligion 32%

Fitchett et al,1999 96 medical rehab patients high score, negative religious coping 12%

Pargament et al,2004

239 elderly medicalpatients

evidence of negative religious coping atbaseline and 2 year follow-up 26%

FetzerInstitute/NIA,1999 1,400 US adults, GSS

feel abandoned by God or punished byGod “quite a bit” or “a great deal” 5%

19931,455 persons, age 15-90,in Yukon Terr, Canada “poor” or “fair” self-rated spiritual health

men 29%women 16%

Dimensions and Course of Religious StruggleDimension Description

The Challenge of Suffering

Wondering why God permits suffering

The Challenge of Cultivating Virtue Facing our sins

The Challenge of Supernatural Evil Diabolical attributions

The Challenge of Religious Community

Experience of betrayal or injury from religious authority or others

From Exline and Rose, 2005

Screening for Religious Struggle

Screening for religious struggle is an attempt to identify patients who may be experiencing religious struggle.

Screening for religious struggle employs a few, simple questions, that can be asked by health care colleagues.

Aim of Screening: Identifying Lost Sheep (and improving patient satisfaction)

Patient Response

Lost SheepRefer for spiritual assessment

Hungry Sheep Refer for spiritual care

Happy Non-Believer No further action needed

Religious Struggle and Requests for Spiritual Care (percent who request spiritual care)

Religious Resources

low high

Potential Need

low 9% 35%

high 31% 59%

Chi-square = 21.19, p <.001From Fitchett et al, J Pastoral Care, 2000

Pilot Study Results

Dates

New Admissions Screened

Cases of Struggle Identified

Cases of Struggle Confirmed by Chaplain Assessment

Other Requests for Spiritual Care

Phase I

Jan-Mar 2006

78/159 (49%) 7/78 (9%) 7/7 (100%)

51/78 (65%) Chaplain visit

22/78 (28%) Communion

Phase II

July & August 2006 10/46 (22%) 0/10 (0%) N/A

2/10 (20%) Chaplain visit

0 Communion

Chaplain Rounds during Phase II

July & August 2006 36/46 (78%) 4/36 (11%)

4/4 (100%)

(Plus 2 additional false negative cases) N/A

Barriers to ScreeningPhase I, Patient Care Technicians

• PCTs felt overwhelmed by other tasks and couldn’t administer the protocol because of time constraints.

• Turnover of PCTs made follow through difficult.• The protocol was sometimes misunderstood and not

followed.

Phase II, Medical Residents• The heavy Resident work load was a major barrier.• Turnover of Residents made consistency difficult. • Resident’s lack of training about the importance of

spiritual struggle was a problem.

Hershey Medical Center: Questions in Admission Assessment that Trigger Pastoral Services Referral

Percent of Referrals

Oct 05 - Jan 06

1. Would you like to see Pastoral Services while in thehospital? (Yes) 25%

2. Do you have any spiritual practices/needs you wish tocontinue while hospitalized? (Yes) 8%

3. Are your resources (emotional, social, spiritual) enough todeal with the stress in your life? (No) 15%

4. Emotional support available? (No) 8%

5. Have you experiences significant loss in the past year oranticipate significant change because of your illness? (Yes) 11%

For further information contact Paul Derrickson, [email protected]

Child/Adolescent Spiritual Screening Tool (CAAST)

How often do you think that. . .

1. A good God watchesover me. Never Sometimes Often Always

2. I have to live with God’spunishment. Never Sometimes Often Always

4.My shame makes me feeldirty. Never Sometimes Often Always

Daniel Grossoehme, Cincinnati Children’s Hospital,[email protected]

Others Models for Screening• Stoddard• Derrickson• Berg• Hodges• Wakefield & Cox• GF Review, CT, 1999

Three Levels of Inquiry About Religion/Spirituality

• screening for religious struggle

• religious/spiritual history taking

• spiritual assessment

Case Example: Alienated from ReligionThe chaplain was referred to the patient who was a

candidate for a heart transplant because he appeared very discouraged. He was also receiving medication for depression.

The patient told the chaplain about a negative experience he had with a particular church and pastor. As a result of this experience, the patient was angry with God and alienated from religious institutions.

The chaplain helped the patient separate his experience with the church from his relationship with God. She helped him rebuild his relationship with God and find a new church home.

As he did these things the patient’s depression resolved and the medication was discontinued.

The Case of Mrs. FisherMrs. Fisher was a 74 year old women with a

history of toe amputation on her left foot. She had an ulcer on a toe on her right foot and had just had an operation to replace a section of the artery in her right leg.

Her doctor had recently told her that her prognosis was very good, that she would be able to do all that she had been doing prior to the surgery.

As she made a referral to the chaplain, the nurse described Mrs. Fisher as very depressed. From: Whitby, 1999

The Case of Mrs. FisherChaplain: Sounds like you’re angry with

God?Mrs. F: (Looking up sharply) Yes I am.

No one has said that to me before.Chaplain: No. Have you told Him?Mrs. F: No. Do you think He’d listen?

(Looking over her glasses challengingly.)

Chaplain: Yes. I think He would. (Mrs. F. looked intently at the

chaplain.)

Implications for Spiritual Care

For chaplains For other health

professionals For congregations

Implications for Chaplains Chaplains come to term with their own

religious struggles Finding the Lost Sheep

“I ask God to lead me to the ones who need me.” A two – step process

1. screening by healthcare colleaguesand if indicated

2. indepth spiritual assessment by a trained chaplain

Responsible screening and “intervention”

The 7 x 7 Model for Spiritual Assessment

Holistic Assessment Spiritual Assessment Medical Belief and Meaning Psychological Vocation and Obligations Family Systems Experience and Emotions PsychoSocial Courage and Growth Ethnic, Racial, or Cultural Ritual and Practice Social Issues Community Spiritual Authority and Guidance

Pastoral Responses to Religious Struggle• Assess

• sources of struggle• duration: new, transient, leading to growth,

chronic• available resources

• Giving Voice, Being Heard • muteness, lament, companionship

• Finding Meaning• creating a new narrative• creating a new future story

Implications for Chaplains: Three Questions• How did you decide which patients to see

this week?

• How did the staff you work with determine who to refer and who not to refer?

• What evidence did you generate this week that your ministry made a difference in measurable patient outcomes?

QuestionImplication for SpiritualCare

How did you decide which patients tosee this week?

Good Stewards of ScarceResources

How did the staff you work withdetermine who to refer and who not torefer?

Protocol for Screening andReferral

What evidence did you generate thisweek that your ministry made adifference in measurable patientoutcomes?

Accountability andDocumentation

Implications for Chaplains

Implications for Chaplains

Early identification and follow-up of patients with religious struggle may:

• improve their adjustment• improve their recovery• reduce their risk of mortality

Documenting the prevalence of religious struggle provides a measure of spiritual acuity and a basis for determining chaplaincy staffing levels

Implications for Spiritual Care For other health professionals

For congregations Provide narratives and models

for lament and religious struggle Follow-up with lost sheep

Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine”“Can You Measure a Sunbeam with a

Ruler?” (Lederberg and Fitchett, 1999)



“While such measurement may be possible, it cannot capture the essence of the sunbeam and in fact may distort it” (R Sloan, 2006).



“While such measurement may be possible, it cannot capture the essence of the sunbeam and in fact may distort it” (R Sloan, 2006).

“It is our hope that the contents of this special issue will help psycho-oncologists smoothly integrate religion and spirituality into their therapeutic and research pursuits without short-changing their patients with too much uncritical enthusiasm, or too much ignorance, indifference or cynicism” (Lederberg and Fitchett).

AcknowledgmentsRehabilitation Study

Bruce Rybarczyk, Gail DeMarco, John Nicholas

Three Patient Groups Study

Pat Murphy, Jo Kim, Jim Gibbons, Jacqueline Cameron, Judy Davis

Screening Pilot Study Jay Risk, Pat Murphy

Mrs. Fisher Allison Whitby

NIA K08 AG20145

George Fitchett December 2006 Religious Struggle and Its Impact on Health: Implications for...

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