A Research-Based Rationale for Sensitivity to the Religious Dimension in Treatment

1. A Research-Based Rationale for Sensitivity to the Religious Dimension in Treatment Kenneth I. Pargament Department of Psychology Bowling Green State University kpargam@bgsu.edu Presented at Florence, Italy May 4, 2011

2. Overview of the Day • A Research-Based Rationale for Sensitivity to the Religious Dimension in Treatment • A Model for Understanding and Evaluating Religion and Spirituality in the Life of the Patient • Assessing Religion and Spirituality in Patients • Addressing Religion and Spirituality in Patients

3. Albert Ellis on Religion “Obviously the sane and effective psychotherapist should not go along with the patient’s religious orientation and try to help these patients live successfully with their religions, for this is equivalent to trying to help them live successfully with their emotional illness” (p. 15; The Case against Religion).

4. Therapeutic Disinterest • Lukoff, Turner, and Lu (1992) “Mental health professionals have tended to either ignore or pathologize the religious and spiritual dimensions of life . . . [As a result] individual who bring religious and spiritual problems into their treatment are often viewed as showing signs of mental illness.”

5. Reasons for the Tension between Religion and Health • Irreligiousness among Health Professionals

6. Health Professionals are WEIRD • W – western • E - educated • I - industrialized • R - rich • D - democratic

7. Reasons for the Tension between Religion and Health • Irreligiousness among Health Professionals • Competing Religions

8. Values of Health and Religion • Empiricism • Individualism • Skepticism • Autonomy • Pragmatism • Physical and Mental Health • Faith • Love • Humility • Surrender • Transformation • Forbearance

9. Reasons for the Tension between Religion and Health • Irreligiousness among Health Professionals • Competing Religions • Lack of Knowledge

10. A Lack of Training • Only 15% of Ph. D. training programs in clinical psychology in the United States and Canada offer a course in religion and spirituality

11. Why Consider Spiritual Issues? • Patients want spiritually sensitive care

12. Rose et al (2001)Journal of Counseling Psychology • 74 clients surveyed from 9 diverse counseling centers • Only 18% say they prefer not to discuss religious or spiritual issues in counseling

13. Spiritual Needs of Clients • Lindgren and Coursey (1995) • 65% of people with serious mental illness would like to talk about spiritual concerns with therapists • 35% talk to their therapists about spiritual concerns

14. Why Consider Spiritual Issues? • Patients want spiritually sensitive care • Many people turn to spirituality in stressful times

15. Drawing on the Sacred as a Resource on Flight 232 • “The plane was moving more erratically. I knew it wasn’t good by the increase in activity of the stewardesses. . . The guy next to me at minus four minutes said, ‘We ain’t going to make it’. . . I noticed the nun across from me had been praying on her rosary. I remembered I had a cross in my pocket. I pulled it out and held it in my hand for the rest of the ride.” • “I’d done a lot of Buddhist meditation in my life, and this trained me to become one pointed in my awareness. I was totally focused on the brace position.”

16. Most Frequent Method of Coping • Conway (1985-1986) • Black and white elderly women with medical problems • Prayer was most frequent method of coping • Prayer was more common than resting, seeking information, prescription drugs, or going to a physician

17. Coping with 9/11 • Schuster et al. (2001) • 90% of national sample of Americans sought solace and support from religion

18. Spirituality among People with Serious Mental Illness • Tepper et al. (2001) • Surveyed over 400 people with serious mental illness • 80% cope with their symptoms and daily problems through religion • 65% found religious coping helpful • 30% say religion was most important resource • More religious coping over time tied to less frustration, less depression and hostility, and fewer hospitalizations

19. Why Consider Spiritual Issues? • Patients want spiritually sensitive care • Many people turn to spirituality in stressful times • Spirituality has been linked to positive health outcomes

20. Church Attendance as a Predictor of Mortality • Hummer et al. (2000) • National sample of adults • Frequent church attendance is tied to 7 year increase in life expectancy • Frequent church attendance is tied to 14 year increase in life expectancy among African-Americans

21. Spiritual Meditation among Patients with Vascular Headaches(Wachholtz & Pargament, 2005) • 83 college students with vascular headaches according to criteria of the International Headache Society (1988) • Random assignment to four groups • Spiritual Meditation (e.g., “God is peace,”“God is joy” ) • Internally Focused Secular Meditation (“I am content,”“I am joyful”) • Externally Focused Secular Meditation (“Grass is green,”“Sand is soft”) • Progressive Muscle Relaxation • Practice technique 20 minutes per day for four weeks • Assess changes in headache frequency, pain tolerance, affect, headache control efficacy

22. Headache Occurrence Prior to and during the Intervention

23. Diary Analyses of Headache Occurrence by Group and Time

24. Pain Tolerance by Group and Time

25. Negative Affect by Group and Time

26. Migraine Specific Quality of Life by Group and Time

27. Headache Management Self-Efficacy by Group and Time

28. Why Consider Spiritual Issues? • Patients want spiritually sensitive care • Many people turn to spirituality in stressful times • Spirituality has been linked to positive health outcomes • Spirituality has been linked to negative health outcomes

29. Spiritual Struggles • Divine struggles • Interpersonal spiritual struggles • Intrapsychic spiritual struggles

30. Divine Struggles • “I’m suffering, really suffering. My illness is tearing me down, and I’m angry at God for not rescuing me, I mean really setting me free from my mental bondage. I have been dealing with these issues for ten years now and I am only 24 years old. I don’t understand why he keeps lifting me up, just to let me come crashing down again” (undergraduate dealing with bipolar illness).

31. Assessing Religious Struggles:Illustrative Items from RCOPE • I wonder if God has abandoned me (Divine). • I feel angry at God (Divine). • I feel abandoned by people in my church (Interpersonal). • I disagree with family and friends about spiritual matters (Interpersonal). • I feel confused about my faith (Intrapsychic). • I act inconsistently with my religious beliefs (Intrapsychic).

32. Ano and Vasconcelles Meta-Analysis(2004, Journal of Clinical Psychology) Number of Studies Cumulative Confidence Effect Size Interval Religious Struggles with Negative Health 22 .22* .19 to .24 Outcomes

33. Spirituality and Health Study • Measures • Mental Health: Symptom Assessment-45 Questionnaire (Davison, Bershadsky, Bieber, Silversmith, Maruish, & Kane, 1997) • Anxiety • Depression • Hostility • Interpersonal Sensitivity • Religious Struggle: Negative Religious Coping Subscale of Brief RCOPE (Pargament, Koenig, & Perez, 2000) • Social Support: Six items adapted from previous research (Zimet, Dahlem, Zimet, & Farley, 1988) • Obsessive-Compulsive • Paranoid Ideation • Phobic Anxiety • Somatization

34. Spirituality and Health Study • Procedure • Sample recruited from sampling frame maintained by Survey Sampling International • Sampling frame reflects demographics of 2000 U.S. census • Contacted 8,500 individuals • 1,895 completed the survey (22% response rate) • 266 surveys excluded due to missing data

35. Spirituality and Health Study • Summary • Religious struggle positively associated with various forms of psychopathology • Relationship between religious struggle and psychopathology stronger for individuals with recent illness or injury

36. Measures (Pargament, Koenig et al. 2004) • Number of Active Diagnoses • Subjective Health • Severity of Illness Scale (ASA) • Activities of Daily Living (ADL) • Mini-Mental State Exam (MSE) • Depressed Mood • Quality of Life • Positive Religious Coping and Religious Struggle • Global Religious Measures (Church Attendance, Private Religiousness, Religious Importance) • Demographics

37. Consequences of Religious Struggles • Study of medically ill elderly patients over two years (Pargament, Koenig, Tarakeshwar, & Hahn, 2004) • Struggles with the divine predicted increases in depressed mood, declines in physical functional status, declines in quality of life after controls • Struggles with the divine predicted 22-33% greater risk of mortality after controls • Struggles also predict stress-related growth

38. Specific Religious Struggle Predictors of Mortality • “Wondered whether God had abandoned me” (RR = 1.28) • “Questioned God’s love for me” (R = 1.22) • “Decided the devil made this happen” (R = 1.19)

39. Why Consider Spiritual Issues? • Patients want spiritually sensitive care • Many people turn to spirituality in stressful times • Spirituality has been linked to positive health outcomes • Spirituality has been linked to negative health outcomes • Spirituality cannot be separated from treatment

40. A Forgiveness Intervention • Rye and Pargament (2002) • College students hurt in romantic relationship • Religious forgiveness intervention • Secular forgiveness intervention • Both groups facilitate forgiveness and well-being • No group differences in efficacy

41. Strategies for Forgiveness • Two of top three strategies for secular forgiveness group • “I asked God for help and/or support as I was trying to forgive.” • “I prayed for the person who wronged me as I was trying to forgive.”

42. The Secular Impacts the Spiritual • Theresa Tisdale et al. (1997) • Evaluation of psychiatric inpatient treatment • Individual, group, milieu, and psychotropic interventions • Patients in treatment improved in adjustment • Patients in treatment developed more positive images of God

43. Research Populations • Victims of 1993 Midwest floods • Survivors of OK City bombing • Parents of autistic children • Medically ill hospitalized elderly • Hospice care providers • Cardiac pacemaker patients • African-Americans coping with racism • People coping with 9/11

44. Stereotypes about Spirituality • Spirituality is a defense against anxiety

45. Spirituality and the Search for Comfort College student recovering from an eating disorder “He just watches over me all the time. When something good happens, God’s there. But when something bad happens, God’s there too. . . Just knowing that there’s somebody up there . . . who is paying attention. . . makes me feel more secure.”

46. Spirituality and the Search for Meaning Quadriplegic young man paralyzed by spinal cord injury: “Well, I’m put in this situation to learn certain things, ‘cause nobody else is in this situation. It’s a learning experience; I see God’s trying to put me in situations, help me learn about Him, and myself.”

47. Spirituality and the Search for Intimacy Roman Catholic priest describing mother’s funeral: “The funeral was astounding. The whole church was there. Many, many friends were there. My blind niece played the piano and my best friend gave the homily. So there were many powerful religious expressions and family expressions. It is hard to separate one from the other.”

48. Spirituality and the Search for Transformation Mormon man describing death of wife in car crash: “I knew that she was killed. There was a big gash on her wrist, and it wasn’t bleeding and I couldn’t get any pulse. And I felt that I could lay my hands on her head and bring her back. And a voice spoke to me and said: ‘Do you want her back a vegetable? She’s fine. She’s alright. And . . . to let her go.’ That [voice] was just as clear to me as though somebody spoke to me.”

49. Spirituality and the Search for the Sacred 9 year old boy: “I’d like to find God! But He wouldn’t just be there, waiting for some spaceship to land! He’s not a person, you know! He’s a spirit. He’s like the fog and the mist. . . I should remember that God is God, and we’re us. I guess I’m trying to get from me, from us, to Him with my ideas when I’m looking up at the sky!” (Coles, 1990)

50. Stereotypes about Spirituality • Spirituality is a defense against anxiety • Spirituality is a passive or avoidant way of coping