RELIGION AND PSYCHOLOGY RESEARCH PROGRESS
No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.
RELIGION AND PSYCHOLOGY RESEARCH PROGRESS
JOAN C. UPTON EDITOR
Nova Science Publishers, Inc. New York
Copyright © 2008 by Nova Science Publishers, Inc.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Religion and psychology : new research / Joan C. Upton, editor. p. cm. Includes index. ISBN: 978-1-61668-123-4 (E-Book) 1. Psychology and religion. I. Upton, Joan C. BF51.R445 2007 201'.615--dc22 2007016939
Published by Nova Science Publishers, Inc.
New York
CONTENTS Preface Chapter 1
Chapter 2
vii Pain, Distress, and Social Support in Relation to Spiritual Beliefs and Experiences among Persons Living with HIV/AIDS John E. Perez, Tatiana Forero-Puerta, Oxana Palesh, Sami Lubega, Carl Thoresen, Elizabeth Bowman, Cheryl Koopman, Cheryl Gore-Felton, Margaret Chesney and David Spiegel Spiritual Coping Strategies of Individuals Dually Diagnosed with HIV and Mental Illness Sarah Shelton and Lara Stepleman
Chapter 3
The Scientific Conquest of Death: An Analysis and Response Brad F. Mellon
Chapter 4
Church Religiosity and Church Attendance and Party Choice in Eight West European Countries: A Comparative Longitudinal Study, 1970-1997 Oddbjørn Knutsen
Chapter 5
Religion and Politics in Malawi Sam Mchombo
Chapter 6
“Train up a Child in the Way…”: A Qualitative Study of How the Black Church Influences Parents Cassandra Chaney, Loren D. Marks, Diane D. Sasser and Katrina Hopkins
1
27 47
63 107
127
Chapter 7
Religion and the Psychology of Gambling in China and the U.S. Henry N. Pontell and Gilbert Geis
145
Chapter 8
The Evolution of Religion and Conscious Experience Matt J. Rossano
159
Chapter 9
Religion as Adaptation: The Role of Time Preference Robert F. Mulligan
189
vi Chapter 10 Index
Contents What the Spiritual and Religious Traditions Offer Psychologists Thomas G. Plante
213 221
PREFACE The interrelationship of psychology and religion is the subject of this new and important book. The areas of health care, longevity, and terrorism and their links to psychology and religiousness form the central core of subjects approached here. Chapter 1 - This study explored the associations of pain, distress, and social support with spiritual beliefs and experiences among persons living with HIV/AIDS. The authors reviewed the scientific literature linking different dimensions of spirituality to psychosocial functioning among persons with HIV/AIDS. A growing body of research suggests that spirituality is an important and positive resource in the lives of persons with HIV/AIDS. In the present study, the authors recruited an ethnically diverse and predominantly low-income sample comprised of 158 HIV-infected participants, of whom 43% had developed AIDS. Participants completed self-report measures of pain, distress, social support, demographic characteristics, and endorsement of spiritual beliefs and experiences in three domains: embracing life’s fullness, spiritual beliefs, and spiritual growth. Experiences of embracing life’s fullness were significantly greater among HIV-infected participants who were less distressed and had better social support. Endorsement of spiritual beliefs was greater among women and those who had experienced constant pain in the past six months and lower among those who were Catholic, not religiously affiliated, and of European American ethnicity. Experiences of spiritual growth were greatest among those who were less distressed. These results suggest that positive mental and physical health outcomes are significantly associated with different dimensions of spirituality among adults living with HIV/AIDS, which has implications for clinical care. Chapter 2 - Psychological distress and related mental disorders occur at higher rates among individuals with chronic medical illness when compared to the general population. In addition to common stressors shared across many chronic illnesses, individuals with HIV/AIDS must overcome challenges unique to their disease. Specifically, factors such as stigma and shame that plague individuals living with HIV/AIDS are not typically encountered to the same degree by individuals with other types of illnesses. Spirituality is one form of coping that may serve as an effective buffer to the distress encountered by individuals living with HIV/AIDS. Spirituality is important to the majority of Americans, and many individuals utilize their spirituality as a means of coping with crises, including crises with health. This strategy has been defined as “spiritual coping” and is recognized as an effective means by which individuals can reduce psychological distress, including the psychological distress associated with medical conditions. This chapter examines the role of spiritual coping among
viii
Joan C, Upton
adults with chronic illness with an emphasis on individuals dually diagnosed with HIV/AIDS and a mental disorder. The advantages and challenges of spiritual coping as a resource in psychotherapy are discussed through case examples of individuals living with HIV/AIDS who have diverse spiritual perspectives and received psychotherapy in a faith-supportive counseling program. Chapter 3 - The Scientific Conquest of Death: Essays on Infinite Lifespans (2004) is a compendium of writings collected and published by the Immortality Institute (hereafter also the ‘Institute’), an organization dedicated to the eradication of voluntary death. This group is made up of serious and highly competent scientists and philosophers, thus its work stands squarely in the realm of science, not science fiction. The first part of the book describes in detail a number of new and anticipated technological breakthroughs that hold the promise of, at least potentially and theoretically, extending the human life span. The second part offers ethical, philosophical, and sociological perspectives on this ambitious goal. Clearly the Institute’s approach has both religious and psychological implications, as well as a number of related issues. One obvious issue is fear, specifically the fear of death and loss of control. Another is that of death as oblivion. In his book The Illusion of Immortality, Lamont (1990) wrote, “While some men surrender up their lives on behalf of their fellows feeling sure of attaining eternal bliss thereby, there are many others who do so in the full knowledge that death means their absolute end” (p. 268). The Institute website adds, “How does one come to terms with the seemingly inescapable problem of oblivion that comes after one’s own death?” This chapter examines the Institute’s scientific discussion of radical life extension and related questions about death and the afterlife. It looks into psychological approaches to these issues, and analyzes the psychology of wanting to live forever. The religious response is drawn largely from the Judeo-Christian tradition, but also includes wisdom from other world religions. Chapter 4 - In this article the impact of church religiosity (measured by frequencies of church attendance) on party choice is studied in eight West European countries from the early 1970s to the late 1990s. The author used a genuine cumulative data set based on all Eurobarometers from 1970 to 1997 to examine how church attendance influence party choice and how this has. The analysis comprises eight of the nine countries that were members of the (then) European Economic Community: Belgium, Britain, Denmark, France, (West) Germany, Ireland, Italy and the Netherlands. The development of the strength of the correlation between party choice and church attendance, and which political parties those who goes to church frequently, the more irregular churchgoers and those who never goes to church, vote for, and how this has changed over time, are the central research questions. The impact of church religiosity within the various religious denominations in the religiously mixed countries Britain, Germany and the Netherlands are also analysed. Finally, the author examined the impact of church religiosity on left-right party choice, i.e. when the various parties are grouped into left-wing and rightwing groups. Chapter 5 - The prevailing attitude about elections and power shifts in many African countries is that religion plays a minimal role in shaping the results. By and large, this seems correct. Nevertheless, religion does play a role in influencing political developments. In some cases, the pulpit has occasionally served more to articulate political aspirations than to preach the word of God. In Malawi, the transition to democracy was influenced as much by the
Preface
ix
Catholic Bishops’ public stand against the injustices of the Kamuzu Banda regime as it owed to agitation of civil society. With the end of the late President Kamuzu Banda’s autocratic rule and the rise to power of President Bakili Muluzi, a Muslim, the country has been in the grips of speculation as to whether Islam is poised to replace Christianity as the dominant religion. Charges of desire to “Islamicize” the country have had to be consistently refuted by the incumbent. Still, the rise of Islam, an erstwhile minority religion, to a position of virtual dominance through being identified with the presidency, aided by sponsorship from oil-rich nations, and the emergence of strained relations between it and Christianity, have increasingly become relevant factors in current political developments in Malawi. As the general election that will retire Bakili Muluzi from the presidency draws near, the question of the religious affiliation of the next president has acquired significance; it is relevant to prospects of maintenance of peace, calm, and stability. Further, in the current climate of global conflict, couched as it is in a policy of “war on terror,” the alignment of Christianity and Islam in these global issues is far from neutral. This paper places these two religions in historical context, comments on recent events in global politics, and examines the role Islam and Christianity are likely to play in shaping political developments in Malawi. Chapter 6 - Previous research has indicated that many African Americans receive social, economic, and other supports from their churches. However, comparatively little is known about how the Black Church supports its members’ efforts as parents. To address this weakness in the research, in-depth qualitative interviews were conducted with 50 African Americans who were actively involved in Black churches (in DE, IL, LA, MA, and OR). Participants represented several religious denominations and were from a variety of social classes and educational levels. The participants were asked questions that explored how their religion supported them as parents. The qualitative data were analyzed using a grounded theory methodology to identify themes that were mentioned repeatedly by the participants. This paper will explore three of those themes: (a) The Bible as a Guide to Parenting: “Go to the Bible to Help You”; (b) Church as a Provider of Programs, Models, and Mentors: “This [Church] Helps Me”; and (c) Parenting is a Sacred Responsibility: “My Children are God’s Gift to Me.” Narratives will be offered to support and illustrate each of these themes. Implications and applications will be discussed. Chapter 7 - Historical and contemporary writings have noted different propensities for gambling between Chinese and western culture. Much of this literature points to the notion that religion may be a major factor that accounts for such differences. This paper examines the notion that fundamental religious doctrines in China and the U.S. play a significant underlying role in the psychological attraction of gambling in each society. Using Weber’s work on the role of the Protestant ethic in the development of capitalism and social control, we argue that these forces provided strong proscriptions against gambling in the U.S., while similar controls were absent in Chinese religious doctrine. Moreover, we argue that gambling and religion have many common features making it difficult at times to easily separate them into what is usually considered to be the antithetical realms of the secular and the sacred. Our review of historical materials, ethnographic reports, and contemporary survey data, leads to the conclusion that the absence of divine commands and strictures concerning gambling are likely to play a prominent part in the relatively high rates of such behavior in China compared to those in the United States. Chapter 8 - William James argued that the mystical experience was the foundation for all religion. Globally and historically, rituals that induce altered states of consciousness have
x
Joan C, Upton
been associated with religion and religious practices. This paper reviews recent research exploring the biological and evolutionary origins of expanded conscious experience. Based on this review a four-stage model of the evolution of expanded conscious experience is proposed. (1) A general primate stage involving rituals that induce altered states for purposes of enhancing social cohesion by reducing tension. Evidence is reviewed showing that nonhuman primates engage in ritualistic behavior. This behavior induces an altered state of consciousness which reduces social tension and can occasionally produce a trancelike or hypnotized state that may have adaptive health benefits. (2) A second stage characterized by group mimesis or the use of ecstatic, group-coordinated rituals that enhanced social bonding. Archeological evidence is reviewed indicating that our hominid ancestors very likely engaged in ritual behaviors that induced altered or ecstatic mental states. These rituals would have been increasingly important as mechanisms for maintaining social stability under circumstances of expanding group sizes with increasing numbers of non-kin members. Physiological evidence is reviewed showing that group-experienced altered states can enhance social cohesion. (3) A third stage involving the emergence of shamanism and rituals of shamanistic healing. Archeological and anthropological evidence indicates that shamanism is (most likely) the oldest form of religion. Shamanism necessarily involves the attainment of altered states of consciousness. Evidence exists that these altered states may have provided health benefits that gave a selective advantage to those who engaged in rituals and were susceptible to their suggestive aspects. (4) A final stage where shamanism is joined by human narrative capacity allowing for the construction of religious myths and stories. These stories would have been essential for maintaining group cohesion in spite of increasingly complex and stratified societies. Archeological evidence from the Upper Paleolithic provides evidence of ancestor worship, exclusive “elite” rituals, and fertility concerns all of which are consistent with increasingly complex societies with divergent forms of religious expression. The narratives that emerged from this period provided the foundation for the religions of first civilizations. Chapter 9 - This paper argues that religion confers survival benefits on societies and individuals because it allows a general lowering of time preference. Time preference is one of the most basic economic concepts and a fundamental category of human action. Theories of interest, term structure, and opportunity cost all depend on time preference, which is also the basis for capital budgeting in modern finance. This paper establishes how and why the emergence of religious belief supported a reduction of time preference, allowing for employment of capital in time-consuming roundabout means of production. The economic concept of time preference explains why belief in God conferred survival value as we evolved, and why it no longer does so. Time preference is the desire to enjoy immediate gratification. Though considered a universal determinant of human action, it has been observed to vary greatly in intensity across individuals. For example, time preference is especially high in children who lack experience and maturity, and in individuals with low life expectancy. Time preference is also high for criminals, and the general lowering of time preference both facilitates and is facilitated by the development of civilization and the increase in complexity of social relationships. The essence of low time preference is planning for the future, a willingness to delay gratification, and patience to wait for future benefits. Once religious belief emerged among our distant ancestors, to be transmitted as a successful adaptation, it must have contributed to the reproductive success of the believers. Primitive humans experienced an appalling life expectancy. Homo sapiens evolved in an
Preface
xi
environment where infant mortality approached 100% and life expectancy for those surviving infancy was certainly below 20 years. Our remote ancestors had little reason not to consume all their seed corn at once, and deistic belief mitigated their natural tendency to enjoy whatever gratification they could immediately control. Religious belief enhanced the survival prospects of both individuals and communities by conditioning them to engage in longerrange planning through such beliefs as life-after-death, spirit survival, and reincarnation. The survival benefit of religious belief is mostly lost once life expectancy lengthens to the point where, in and of itself, it results in lowered time preference and more responsible, more forward-looking behavior from the majority of agents in the community. Chapter 10 - There has been a remarkable amount of popular and professional interest in the relationship between spirituality, religion, psychology, and health in recent years. Contemporary interest in spirituality and religion is popular among not only the general population but also among many psychology professionals as well. While most people believe in God and consider themselves to be spiritual, religious, or both, most psychologists do not and have no training in religion and spirituality. Psychologists can learn much from the spiritual and religious traditions that offer principles and tools that are productive to use even if one does not share the same religious or spiritual interests. The purpose of this brief commentary is to offer thirteen spiritual and religious tools common among all of the major religious and spiritual traditions that can be utilized by contemporary professional psychologists in clinical practice and elsewhere in their professional work to enhance their already high quality professional services that they provide. In addition to the thirteen tools, relevant ethical issues are briefly discussed as well.
In: Religion and Psychology: New Research Editor: Joan C. Upton
ISBN: 1-60021-672-2 © 2008 Nova Science Publishers, Inc.
Chapter 1
PAIN, DISTRESS, AND SOCIAL SUPPORT IN RELATION TO SPIRITUAL BELIEFS AND EXPERIENCES AMONG PERSONS LIVING WITH HIV/AIDS John E. Perez, 1 Tatiana Forero-Puerta,2 Oxana Palesh,2 Sami Lubega,2 Carl Thoresen,2 Elizabeth Bowman,3 Cheryl Koopman,2 Cheryl Gore-Felton,2 Margaret Chesney4 and David Spiegel 2 *
1
University of Massachusetts, Boston, MA, USA 2 Stanford University, Palo Alto, CA, USA 3 Indiana University, Bloomington, IN, USA 4 National Center for Complementary and Alternative Medicine, National Institues of Health, Bethesda, MD, USA
ABSTRACT This study explored the associations of pain, distress, and social support with spiritual beliefs and experiences among persons living with HIV/AIDS. We reviewed the scientific literature linking different dimensions of spirituality to psychosocial functioning among persons with HIV/AIDS. A growing body of research suggests that spirituality is an important and positive resource in the lives of persons with HIV/AIDS. In the present study, we recruited an ethnically diverse and predominantly low-income sample comprised of 158 HIV-infected participants, of whom 43% had developed AIDS. Participants completed self-report measures of pain, distress, social support, demographic characteristics, and endorsement of spiritual beliefs and experiences in three domains: embracing life’s fullness, spiritual beliefs, and spiritual growth. Experiences of embracing life’s fullness were significantly greater among HIV-infected participants who were less distressed and had better social support. Endorsement of spiritual beliefs was greater among women and those who had experienced constant pain in the past six *
Address correspondence to John E. Perez, Department of Psychology, University of Massachusetts, Boston, 100 Morrissey Blvd., Boston, MA 02125. E-mail:
[email protected] 2
John E. Perez, Tatiana Forero-Puerta, Oxana Palesh et al. months and lower among those who were Catholic, not religiously affiliated, and of European American ethnicity. Experiences of spiritual growth were greatest among those who were less distressed. These results suggest that positive mental and physical health outcomes are significantly associated with different dimensions of spirituality among adults living with HIV/AIDS, which has implications for clinical care. The belief in God has often been advanced as not only the greatest, but the most complete of all the distinctions between man and the lower animals. It is however impossible, as we have seen, to maintain that this belief is innate or instinctive in man. On the other hand a belief in all-pervading spiritual agencies seems to be universal; and apparently follows from a considerable advance in the reasoning powers of man, and from a still greater advance in his faculties of imagination, curiosity and wonder. – Charles Darwin, The Descent of Man Religion and medicine intersect where it is most important--at the juncture between life and death, at the door to final separation. – Fricchione
Religion and spirituality have long been identified as widely used resources for coping with serious adversity. Moreover, research indicates that spiritual well-being is related to physical and psychological well-being among chronically ill patients, and spirituality may be particularly salient when facing death (Ellison and Smith, 1991; Paragament, 1997; Rousseau, 2000; Spilka, Hood, Hunsberger, and Gorsuch, 2003). Illnesses such as HIV/AIDS that pose a threat to a person’s life present an intimate challenge that often leads to spiritual questions and spiritual concerns that are reflected in the ways persons cope with their illness (Carson, Soeken, Shanty, and Terry, 1990; Fryback and Reinert, 1999; Kendall, 1994; Landis, 1996; Peri, 1995; Cotton, Tsevat, et al., 2006). Increasingly, researchers and practitioners are embracing a broader health perspective that encompasses bio-psychosocial-spiritual components associated with illness (Dossey, 1995; Wiedenfeld et al., 1990). Religion and spirituality can be traced back to the first evidence of abstract human thought (Momen, 1999). Indeed, any discussion of human development would be incomplete without acknowledging religion or spirituality as important sociological and historical factors. Within the history of medicine, spirituality has long been recognized as a core dimension of well-being. For much of our cultural record, spirituality and medicine were not two distinct fields, but one system. Traditionally, the role of the physician has been twofold: healer and religious leader (Barnard, 1985; Momen, 1999). Religious references have not completely disappeared from medicine. Even the Hippocratic Oath, still recited by physicians today, contains religious allusions (Arras and Steinbock, 1999). In addition, spiritual beliefs and practices continue to be pervasive in modern society. In recent surveys, for example, approximately 90-95% of Americans acknowledged belief in God or a higher power; 9 out of 10 people also said that they pray, most of whom (67%-75%) pray on a daily basis; and a majority of Americans (about 6 in 10) said religion is a “very important” part of their lives (Gallup Poll, 2004; Gallup and Lindsay, 1999). Twentieth century Western contemporary medicine became dominated by positivistic and naturalistic viewpoints, but modern research seems to be reestablishing links between spirituality and medicine, particularly within the context of life-threatening illnesses. With a growing body of empirical research, modern social and health scientists are demonstrating that spirituality can be and should be studied scientifically in the life of patients (Emmons and Paloutzian, 2003; Koenig, McCullough, and
Pain, Distress, and Social Support in Relation to Spiritual Beliefs…
3
Larson, 2001; Miller and Thoresen, 2003), as well as in the work of health care professionals (Wasner, Longaker, Fegg, and Borasio, 2005). While spirituality and religion are multidimensional and overlapping constructs, and are often used interchangeably in the social and health sciences, the terms spirituality and religion do contain some important distinctions. Spirituality is difficult to define operationally, but it is usually distinguished by what it is not—material reality as experienced by the physical senses (Miller and Thoresen, 2003). Spirituality is often described in terms that highlight its transcendent, metaphysical qualities. In essence, it can be described as a life philosophy that involves seeing beyond physical, intellectual, and ethical realms into a more expansive truth or awareness of something sacred that permeates the world in different ways. When actualized, a spiritual philosophy is used as a guide for personal conduct (Dombeck, and Karl, 1987; Ellerhorst-Ryan, 1985; Heriot, 1992; Lipsey, 1988). Spirituality is a broader term that encompasses religion. Religion describes a more formalized expression of a spiritual perspective via beliefs, rituals, and conduct that are often organized by institutions (Heriot, 1992; Mickley, Soeken, and Belcher, 1992). For the purpose of this chapter, we use the broader term spirituality to encompass both spiritual and religious phenomena.1
THE IMPORTANCE OF SPIRITUALITY AMONG PERSONS LIVING WITH HIV/AIDS A growing number of studies demonstrate that persons living with HIV/AIDS use their spirituality as a source of strength and utilize it as a core coping strategy. Spirituality appears to play a significant role in the lives of persons with HIV/AIDS, both on a subjective level (e.g., subjective well-being) (Somlai and Heckman, 2000), as well as on an objective level (e.g., observable in reports of improved health outcomes) (Woods, Antoni, Ironson, and Kling, 1999). Researchers have hypothesized that spiritual beliefs provide a variety of resources (e.g., institutional, social, emotional) that create a buffer against the psychological impact of uncontrollable life events (Paragament et al., 1988; Spilka, Shaver, and Kirkpatrik, 1985). Furthermore, the use of spirituality as a coping strategy seems to be salient among persons facing illness, disability, and death (Bearson and Koenig, 1990; Jenkins and Pargament, 1995). Several studies indicate not only high levels of self-reported spiritual beliefs and practices among persons dealing with HIV/AIDS, but also the utilization of such beliefs as coping methods that can provide meaning in the face of existential challenges. In one study that recruited 450 patients from four clinical sites, most patients belonged to an organized religion and used their religion to cope with their illness. From this group, patients who tended to be more spiritual and religious also had (among other measures) greater self-esteem and greater life satisfaction (Cotton, Puchalski, et al., 2006). A study of 142 Puerto Rican women living with HIV/AIDS in New York City also revealed high levels of spiritual practice among these women (Simoni and Ortiz, 2003). Ninety-four percent of the correspondents associated themselves with a particular religious denomination, 49% had attended some type of religious services in the past three months, and 29% were members of a church or place of worship. In 1
For a more comprehensive discussion on the use of the terms spirituality and religion in the behavioral sciences, see Miller and Thoresen (2003).
4
John E. Perez, Tatiana Forero-Puerta, Oxana Palesh et al.
addition, interview-based qualitative studies have revealed specific perceived benefits of spirituality. For instance, in interviews with 63 older HIV infected adults who self-identified as religious or spiritual, nearly all reported that these beliefs and practices had been significant in coping with their illness (Siegel and Schrimshaw, 2002). The types of benefits that the participants reported included but were not limited to feelings of: 1) peace and tranquility; 2) empowerment and control; and 3) self-acceptance and reduced self-blame. One study reported that approximately one third of a sample of 450 HIV/AIDS patients felt their life was better now than it was before being diagnosed with HIV/AIDS. These patients named an increase in spirituality/religion as the leading association (68.5%) with feeling life had changed for the better (Szaflarski et al., 2006). Spiritual and religious practice generally involves a variety of activities, including church attendance, prayer, and meditation. Several studies suggest that religious service attendance is associated with better cardiovascular health (Colantonio, Kasl, and Ostfeld, 1992; Hummer, Rogers, Nam, and Ellison, 1999; Oman, Kurata, Strawbridge, and Cohen, 2002) and lower mortality rates (McCullough, Hoyt, Larson, Koenig, and Thoresen, 2000; Oman et al., 2002; Pargament, Koenig, Tarakeshwar, and Hahn, 2001). Prayer has also been shown to produce positive health outcomes. For example, people who believe in God and pray during an illness have been reported to have better health outcomes than people who do not (Koenig et al., 1992; Koenig et al., 1998; Oxman, Freeman, and Manheimer, 1995). According to a recent survey of more than 30,000 adults in the U.S., prayer specifically for health reasons was the most commonly used form of complementary and alternative medicine (CAM) therapy (Barnes, Powell-Griner, McFann, and Nahin, 2004). Moreover, prayer is among the most utilized coping strategies among terminally ill persons (Guillory, Sowell, Moneyham, and Seals, 1997). A study of patients dealing with the advanced stages of cancer reported that faith and prayer were ranked first in coping with fear, and third in general coping (Gotay, 1984). In relation to HIV/AIDS, long-term survivors of the illness perceive both prayer and meditation to be intrinsically linked to their well-being (Carson, Soeken, Shanty, and Terry, 1990). A study of alternative therapies in a sample of over 1,000 HIV/AIDS patients found that the most common activities influencing mental health were prayer, meditation, breathing exercises, and spiritual activities (Greene, Berger, and Reeves, 1999). There is some evidence suggesting that spiritual practices are associated with improved physical and mental conditions. A link between better immune functioning and greater spirituality and religious involvement has been demonstrated in diverse populations, including women with metastatic breast cancer (Sephton, Koopman, Schaal, Thoresen, and Spiegel, 2001) and elderly in the general population (Koenig et al., 1998). In research with HIV-positive gay men, religious behavior (e.g., prayer, attendance at religious services) was associated with higher T helper/inducer cell (CD4+) counts and percentages (Woods et al., 1999). Moreover, spirituality was associated with longer-term survival among HIV-positive men, and this association was partially mediated by lower cortisol levels (Ironson et al., 2002). While these results provide initial support for an association between spirituality and physical/mental functioning, more research is needed to clarify the physiological and psychosocial mechanisms that link spirituality to physical health outcomes among persons with HIV/AIDS. One recent study aimed at determining the changes in spirituality and religiousness in HIV patients after their diagnosis, and investigated a potential link between this change and disease progression. The findings indicated that 45% of the sample of 100 individuals
Pain, Distress, and Social Support in Relation to Spiritual Beliefs…
5
surveyed through a 4-year period reported an increase in religiousness and/or spirituality after being diagnosed with HIV. Furthermore, the study reports that these individuals also had significantly greater preservation of CD4 cells and better control of viral load over the time of the study. The results hence suggest that an increase in spirituality/religiousness following HIV diagnosis could predict disease progression (Ironson, Stuetzle, and Fletcher, 2006). In summary, an examination of the existing literature illustrates that substantial research, both quantitative and qualitative, has demonstrated the importance of spiritual beliefs among terminally-ill individuals, particularly those living with HIV/AIDS. Data generally suggest that spiritual beliefs and practices are frequently employed as a coping mechanism in this group and may be associated with improvements in the emotional and physical well-being of chronically ill individuals.
THREE DIMENSIONS OF SPIRITUALITY IN RELATION TO LIVING WITH HIV/AIDS Current scientific research in behavioral and health sciences suggests that religion and spirituality are multidimensional constructs. Specific dimensions have included religious affiliation, organizational religious practice (e.g., attending services), private religious practice (e.g., prayer, meditation), daily spiritual experiences, religious beliefs and values, religious community support, religious coping styles, forgiveness, and altruism among others (Miller and Thoresen, 2003; Seybold and Hill, 2001). Thoresen et al. (1996) have identified and operationalized three dimensions of spirituality that may have particular salience among persons with HIV/AIDS: Embracing life’s fullness, spiritual beliefs, and spiritual growth. In regard to embracing life’s fullness, numerous studies in a variety of patient populations have found positive associations between spiritual variables and diverse indicators of adjustment and well-being, including life satisfaction (Reed, 1987; Swensen, Fuller, and Clements, 1993). An appreciation for life is intrinsic to the search for higher meaning, particularly within the context of a terminal illness such as HIV/AIDS. Individuals faced with this diagnosis must find ways to integrate their illness into the framework of their lives, and in so doing, find a sense of meaning in the disease (Barroso, 1999; O’Neil and Kenny, 1998; Soeken and Carson, 1987). Some studies have found that such meaning may be provided by spirituality in the face of threat to one’s existence (Jenkins, 1995; Schwartzberg, 1993). Spiritual beliefs, such as a belief in God or a higher power, may provide a sense of interpersonal connection for persons living with HIV/AIDS. In one study, persons coping with HIV/AIDS reported that their spiritual beliefs and practices offered support through a relationship with God or higher power (Siegel and Schrimshaw, 2002). For many of these persons, God played the role of a supportive entity, particularly for those who were unable to speak openly about their illness to other people. Many participants shared a common sentiment that God would be always accepting and loving, even when they were faced by rejection and estrangement from others, including religious communities. One study demonstrated the importance of religion in the lives of HIV/AIDS patients, while simultaneously reporting that many participants felt alienated by religious groups. Although 1 in 10 participants in this study reported changing their place of religious worship due to alienation by their religious communities, the change did not undermine the importance
6
John E. Perez, Tatiana Forero-Puerta, Oxana Palesh et al.
religion and spirituality played in the lives of the participants (Cotton, Tsevant, et al., 2006). A relationship with God or a higher power is not only abstractly important for many patients; practical decisions also play a role in belief and faith. In a longitudinal study that surveyed 2,266 patients who received care for HIV, 65% reported that religion was “somewhat” or “very” important to them, and 85% asserted the same of spirituality. Furthermore, 72% of the participants reported relying either “sometimes” or “often” on spiritual or religious means to make decisions, including health-related decisions (Lorenz et al., 2005). In another study, placing trust in God was associated with lower anxiety and depression in HIV/AIDS patients (Woods et al., 1999). For many persons with HIV/AIDS, their experience of illness may lead to spiritual growth. In an interview-based study of 19 HIV-positive men, Schwartzberg (1993) found that 42% viewed their illness as a means for such growth. Belcher, Dettmore and Holzemer (1989) found that spirituality changed among respondents after the onset of AIDS, while in a more recent study of 347 adults diagnosed with HIV/AIDS, 66% of participants reported becoming either “more religious” or “more spiritual” since their diagnosis (Cotton, Tsevat, et al., 2006). For these persons, spirituality served as a resource for personal control, comfort, and a means of ordering and making sense of their experience with the illness. Participants in another interview-based study considered spirituality to aid in transforming hopelessness to meaningfulness; indeed, some participants even reported having a better quality of life after their diagnosis than prior to it (Fryback and Reinert, 1999). In a related domain, Folkman and her colleagues studied the experience of positive emotion under stress in a longitudinal study of AIDS caregivers (Folkman, Moskowitz, Ozer, and Park, 1997; Moskowitz, Folkman, Collette, and Vittinghoff, 1996). They identified three kinds of coping related to the occurrence and maintenance of positive affect: positive reappraisal, goal-directed problemfocused coping, and the infusion of ordinary events with positive meaning. Spirituality provides a context that allows the reframing of life experiences with HIV/AIDS into a positive light. Moreover, spiritual beliefs may help caretakers of persons with HIV/AIDS to create, note, or remember positive events under stressful conditions (Folkman and Moskowitz, 2000). Embracing life’s fullness, spiritual beliefs, and spiritual growth are often associated constructs. A qualitative study consisting of interviews with 34 women living with various stages of HIV illustrates the interconnectedness of these experiences (Dunbar, Mueller, Medina and Wolf, 1998). Eighty-two percent of the participants reported unexpected positive outcomes as a result of their illness. Several components were found to be important to both their psychological and spiritual growth, including: 1) acknowledging their own mortality; 2) affirming a desire to live with better values; 3) finding a deeper meaning and purpose in life through greater spiritual involvement; and 4) gaining a more positive sense of self. These findings suggest the possibility for broad psychological and spiritual growth among persons with HIV, and that their spirituality helps them to confront and deal with the inevitable existential concerns associated with the disease. As a result, the researchers in this study as well as others support implementation of methods that encourage group or personal spiritual development in persons facing their own mortality (Dunbar et al., 1998; Smith, 1995).
Pain, Distress, and Social Support in Relation to Spiritual Beliefs…
7
PSYCHOSOCIAL LINKS BETWEEN HIV/AIDS AND SPIRITUALITY: PAIN, DISTRESS, AND SOCIAL SUPPORT Pain and distress often accompany the personal experience of HIV/AIDS, and social support is an important moderator of pain and distress. From a social cognitive perspective (Bandura, 1986, 2001), spirituality and health may have a reciprocal influence. Suffering due to physical pain and negative affect can influence the development of spirituality, and health outcomes can be influenced by spiritual beliefs and practices. Similarly, a religious community may provide social support, and persons seeking social support may more actively participate in religious communities to elicit such support. Indeed, social support may be an important mechanism by which spirituality leads to better mental and physical outcomes among persons with HIV/AIDS. As a growing body of research is establishing a positive link between spirituality and health, it is important to understand the potential mechanisms that underlie this connection. Several studies found positive associations between spiritual variables and diverse indicators of adjustment and well-being, such as pain management, in a variety of patient populations (Acklin, Brown, and Mauger, 1983). Among patients with advanced cancer, religious participants reported significantly lower levels of pain compared to their nonreligious counterparts even though both groups were equally likely to report the presence of pain (Yates, Chalmer, St. James, Follansbee, and McKegney, 1981). Moreover, although subjective experiences of pain often create significant suffering for individuals with HIV/AIDS, pain is sometimes capable of providing spiritual meaning. In a qualitative study of pain in a sample of AIDS patients, participants said that pain made them stronger and more capable of facing death; moreover, no one from this group perceived AIDS-related pain to be associated with punishment (Newshan, 1998). Learning to cope, understand, and see pain as a challenge or gift rather than a punishment demonstrates spiritual work, according to Levine (1982), who noted that individuals are conditioned to hate and fear pain. Humans also have the capacity to accept pain and seek meaning or significance in it, rather than struggling against it (Frankl, 1959). Ultimately, the individual coping with pain within a spiritual context may not be a victim to the pain, but instead can become an active participant by adopting a transcendent attitude or spiritual perspective (Levine, 1982). With regard to both physical and emotional pain, Eastern spiritual traditions such as Buddhism promote mindfulness and acceptance, skills that are being effectively integrated into Western psychotherapies (Hayes, Strosahl, and Wilson, 1999; Linehan, 1993). Mindfulness skills may facilitate pain management in a way similar to hypnosis, which is highly effective in managing pain (Holyroyd, 1996; Patterson and Jensen, 2003; Spiegel and Spiegel, 2004). Distress and depression can be major aspects of the HIV/AIDS experience, particularly in relation to handling the illness and facing death. Like pain, it also can be associated with a spiritual component. A study on factors of death distress among patients facing lifethreatening illnesses, including cancer and HIV/AIDS, suggested that the experience of such distress is associated with the psychosocial spiritual dimensions in the patient’s life (Chinbnal, Videen, Duckroo, and Miller, 2002). According to some researchers, this indicates that spirituality can help alleviate fear and dread of death in such patients (Chinbnal et al., 2002; Hall, 1994). A link between depression and both mortality and immune function has been found in chronically ill populations (Kilbourne and Rollman, et al., 2002; Ickovics,
8
John E. Perez, Tatiana Forero-Puerta, Oxana Palesh et al.
Hamburger, and Viahov, et al., 2001). Other studies support a negative association between spirituality and depressive symptoms, both in the general population and in samples of individuals with HIV/AIDS (Simoni and Ortiz, 2003; Smith, McCullough, and Poll, 2003; Woods et al., 1999). Qualitative studies on the perceived benefits of spirituality also offer findings that are relevant to patient distress. Spirituality was seen as helpful in easing the emotional weight of illness in many patients with HIV/AIDS (Siegel, and Schrimshaw, 2002). Placing fate in the hands of God reduced the struggle to control the illness. Many patients also described that surrendering this control to an entity higher than themselves lifted a great burden off them. In addition, spirituality facilitated meaning and acceptance of the illness. Participants came to see the illness as part of a larger plan, in which their contribution was important (e.g., to teach others important lessons, live healthier lives). Spirituality can relieve fear and uncertainty of death, particularly through a belief in an afterlife or another form of continuation after death (Gibbs and Achterberg-Lawlis, 1978). It can also decrease discomfort and loneliness and increase emotional adjustment and positive death perspectives (Reed, 1987). Additionally, spiritual activities can greatly enhance one’s sense of well-being, reduce emotional distress, and enhance quality of life among persons living with HIV (Sowell et al., 2000). Social support is another important factor in the experience of living with HIV/AIDS. Interpersonal relationships have the potential to ease negative aspects of dealing with the illness and to provide positive reinforcement. Spirituality has previously been identified as facilitating this type of positive experience in the lives of HIV/AIDS patients (Dunbar et al., 1998). Social support not only involves meaningful interactions between persons, but at its essence, it consists of a feeling of connectedness between persons (Kendall, 1994; McCormick, Holder, Wetsel, and Cawthon, 2001). Religious communities have been known to provide this sort of resource, imparting meaning to the daily challenges of living with HIV/AIDS (Barroso, 1999; Carson, Soeken, Shanty, and Terry, 1990). Spirituality reportedly provides benefits within social support networks by promoting feelings of acceptance and belonging and reducing feelings of isolation and marginality (Siegel and Schrimshaw, 2002). Researchers theorize that the type of support offered by spirituality is more than simply social; it is unique because it involves a relationship with a higher power or greater reality (Simoni, Martone, and Kerwin, 2002). Achieving a connection with an entity or reality that is perceived to operate in a higher realm than oneself may offer hope of a greater plan or purpose that transcends human understanding or capacities. It may also provide relief in the face of death. One study suggests that there may be special benefits of religious support above and beyond secular social support. In a nationally representative sample of African Americans, the relationship between church attendance and lower levels of emotional distress was mediated by religious support from members of their congregation rather than by secular social support (Ellison, Musick, Levin, Taylor, and Chatters, 1997). However, it remains an empirical question whether religious support (i.e., social support provided by religious or spiritual communities) leads to quantitatively different health outcomes among persons with HIV/AIDS. In summary, a growing body of research suggests that spirituality is an important resource in the lives of persons with HIV/AIDS. Positive associations between spirituality and well-being among persons with HIV/AIDS have emerged in the medical, psychological, and sociological literature. Different components of spiritual experience are associated with beneficial outcomes for persons living with HIV/AIDS, including prayer, meditation, and
Pain, Distress, and Social Support in Relation to Spiritual Beliefs…
9
church attendance. Various aspects of the experience of living with HIV/AIDS, including pain, distress, and the effects of social support, have been discussed within a spiritual framework throughout the HIV/AIDS literature. Pain and distress may be moderated by spiritual beliefs and practices, and social support may be an important mechanism in the link between spirituality and well-being among persons with HIV/AIDS.
THE PRESENT STUDY In the present study, we examine the associations of pain, distress, and social support with spiritual beliefs and experiences among persons living with HIV/AIDS. To examine these associations, we used social cognitive theory (Bandura, 2001) to guide our hypotheses. According to this theory, human functioning is the product of a dynamic interplay of personal, behavioral, and environmental influences. In particular, this theory posits reciprocal causation between an individual’s personal factors (cognitive, affective, and biological), the individual’s behavior, and the environment (Bandura, 1986). Thus, environmental factors such as social support and personal factors such as pain and emotional distress can influence spiritual behaviors, and vice versa. Religious and spiritual variables have often been examined as predictors of psychological and health outcomes; however, there is little research that focuses on different domains that can characterize spirituality. Given that spirituality predicts positive health outcomes, it is important to understand aspects of personal and social factors that may foster spirituality. Consistent with social cognitive theory and our multidimensional conceptualization of spirituality, we conducted a study with HIV-seropositive men and women to examine the associations of distress, pain, and social support with experiences of embracing life’s fullness, of endorsing spiritual beliefs, and of spiritual growth. Guided by previous research, we hypothesized that endorsing these three aspects of spirituality would be positively associated with social support and negatively associated with distress. We also hypothesized that pain would be negatively associated with embracing life’s fullness, because the experience of pain tends to focus one’s attention on the pain itself; therefore, pain would be expected to reduce the sense of life’s fullness. Also, we explored the relationship of pain to the other two aspects of spirituality that were examined—endorsing spiritual beliefs and spiritual growth—without making a directional hypothesis about how these aspects of spirituality might be related to pain. On one hand, being in pain could motivate people to seek spiritual growth and to focus on spiritual beliefs; on the other hand, being in pain could interfere with individuals being able to focus on these aspects of spirituality. Furthermore, this study explored the relationship of demographic characteristics (i.e., ethnicity, gender, sexual orientation, religious affiliation, income) and AIDS status with embracing life’s fullness, spiritual beliefs, and spiritual growth. We were particularly interested in the relationship of psychosocial factors to these aspects of spirituality. However, given previous findings from the 1998 General Social Survey that showed stronger endorsement by women than men of various aspects of spirituality and religiousness (Fetzer Institute/National Institute on Aging Working Group, 2003), this study explored demographic factors as well.
10
John E. Perez, Tatiana Forero-Puerta, Oxana Palesh et al.
METHOD Participants Ninety-two men and 66 women living with HIV infection participated in the study. Fortythree percent (n = 69) of our participants met T cell count for AIDS (Centers for Disease Control, 1992). The majority of our participants were in their early 40s (M = 40.2, SD = 7.6), and they had on average 13.7 years of education. Sixty-five percent (n = 102) of our participants were unemployed, 22.2% (n = 35) were working full-time and 13.3% (n = 21) were working part-time. Of those who were unemployed, more than half (53%, n = 54) were permanently disabled. The majority of our participants were earning less than $20,000. The most common ethnic background of participants was Caucasian/European American (57.6%, n = 91). Half of our participants identified themselves as gay or lesbian (50%, n = 79), 43.7% (n = 69) identified themselves as heterosexual, and 5.7% (n = 9) identified themselves as bisexual. The majority of men in this study were gay (77%, n = 71), and 12% (n = 8) of women were lesbian. Participants who were married or living with someone accounted for 27.8% (n = 44) of the sample, 49.4% (n = 78) were single, 7.6% (n = 12) were separated, 7.6% (n =12) were divorced, 4.4% (n = 7) were widowed, and 3.2% (n = 5) described the status of their relationship as “other”. Complete demographic information is presented in table 1. Table 1. Descriptive Statistics for Demographic Variables (N = 158) Demographics Age Years of education Employment status Not employed Part time (less than 30 hours per week) Full time (more than 30 hours per week) Religious affiliation Catholic Protestant Jewish Muslim Other None Racial/Ethnic background American Native/Alaskan Native Asian or Asian-American Black or African-American Latino/Hispanic Non-Hispanic White Filipino Other
Frequency or mean 40.2 13.7
Percent or SD 7.6 3.0
102 21 35
64.6% 13.3% 22.2%
31 19 5 2 54 51
19.6% 12.0% 3.2% 1.3% 34.2% 32.3%
8 3 50 15 91 2 9
5.1% 1.9% 31.6% 9.5% 57.6% 1.3% 5.7%
Pain, Distress, and Social Support in Relation to Spiritual Beliefs…
11
Table 1. (Continued). Demographics Sexual Identity Heterosexual Lesbian/Gay Bi-Sexual Transsexual Relationship status Single Married/Living as married Separated Divorced Widowed Other Total household income Less than $ 20,000 $20,000-39,999 $40,000-$59,999 $60,000-$79,999 $80,000-$99,999 $100,000 or above
Frequency or mean
Percent or SD
69 79 9 1
43.7% 50.0% 5.7% 0.6%
78 44 12 12 7 5
49.4% 27.8% 7.6% 7.6% 4.4% 3.2%
102 23 11 9 6 7
64.6% 14.6% 7.0% 5.7% 3.8% 4.4%
Measures Demographic Questionnaire and Medical Status A brief self-report measure assessed participants’ age, ethnicity, marital status, income, sexual orientation, education, religious affiliation and employment. We requested written documentation from physicians to verify HIV infection status. Via chart review, AIDS status was determined based on the CD4+ T cell count (those below 200 met criteria for having AIDS) (Centers for Disease Control, 1992). Social Support UCLA Social Support Inventory (Schwarzer et al., 1994). Perceived social support was assessed using a 24-item version of the UCLA Social Support Inventory. The participants were asked to report on social support received from four sources, including family, friends, partners, and groups in four domains (advice, assistance, reassurance, and listening). The total social support score summed these responses. If the respondent did not have a partner, then his/her total score was extrapolated from his/her responses to the items for the other three sources, as the purpose of this measure was to assess the quality of social support from sources available to each participant. In this study, the internal consistency coefficient (Cronbach’s alpha) for the Social Support Inventory was .92.
12
John E. Perez, Tatiana Forero-Puerta, Oxana Palesh et al.
Pain Rating of Chronic Pain (adapted from Spiegel and Bloom, 1983). Participants’ level of chronic pain was measured by the following question: "If you have had pain in the last six months, it typically lasted: a) constant pain for entire six months, b) If one day or more: Days__, and c) if less than one day: Hours (up to 24).” Participants were considered to suffer from chronic pain if they endorsed having constant pain for the entire six months. We also assessed whether participants were taking pain medications in the last six months. Previous research showed that self-report measures of pain are accurate (Hilgard and Hilgard, 1975; Lagana` et al., 2002). Distress Profile of Mood States (POMS) (McNair, Lorr, and Droppleman, 1992) is a 65-item scale designed to measure mood disturbances. It yields a total mood disturbance score and scores for the each of the following six scales: 1) tension-anxiety, 2) depression-dejection, 3) angerhostility, 4) confusion-bewilderment, 5) fatigue-inertia, and 6) vigor-activity. The total score is calculated by adding five subscales and subtracting one subscale (vigoractivity). Participants are asked to rate how they felt in the past week by rating each word on a 5-point Likert-type scale, with 1 representing “not at all” and 5 representing “extremely”. The measure has demonstrated good internal consistency, reliability, and validity across different population samples (McNair et al., 1992). In this study, the Cronbach’s alpha for the POMS-total score was .72. Life Meaning Principles of Living Survey (Thoresen, Bowman, Koopman, Durán, Gill, Yang, and Spiegel, 1996). This measure was developed for the parent study to assess respondents’ use of each of three strategies for experiencing life meaning. The three strategies are: 1) embracing life’s fullness, 2) spiritual beliefs, and 3) spiritual growth, and were derived from literature on spirituality and physical/mental health. Thirteen items used a 6-point Likert-type scale, from 1 = “completely disagree” to 6 = “completely agree,” and four items used a 5-point scale (e.g., for the frequency of praying to God/Higher Power/Universal Energy) from 1 = “never” to 5 = “several times a week (or more).” The three subscales are computed using mean percentile rank-ordered scores. The Cronbach’s alpha for the subscales ranged from fair to excellent: Embracing Life’s Fullness (4 items) = .72, Spiritual Beliefs (8 items) = .91, and Spiritual Growth (5 items) = .67.
Procedure This study was part of an ongoing randomized clinical trial designed to examine the effect of supportive-expressive group psychotherapy (Belanoff et al., 2005) on quality of life and health behavior in men and women living with HIV/AIDS. HIV-positive men and women were recruited through newspaper advertisements and through county hospitals and medical clinics. The recruitment efforts were bolstered by the assistance of the AIDS Community Research Consortium (ACRC), a non-profit organization in Redwood City, California devoted to community based clinical trials. Participants provided informed consent for participating in the screening interview, in which they were assessed using the Structured
Pain, Distress, and Social Support in Relation to Spiritual Beliefs…
13
Clinical Interview for DSM-IV Axis I Disorders - Non-patient Edition (SCID-I/NP, Version 2.0; First et al. 1996). Based on the results of this initial evaluation, participants were screened using eligibility criteria for inclusion and exclusion that have been previously described in detail (Koopman et al., 2000). After being screened to determine eligibility for this study, participants provided informed consent for involvement in the main part of the study. Each participant completed the baseline questionnaires prior to being randomized to treatment condition. These assessments were conducted using pencil and paper measures, with a research assistant available to answer questions. Participants were reimbursed $25 for completion of the baseline assessment. In this study, we report data collected at baseline on a subsample of 158 HIV-positive participants (92 men and 66 women) who were drawn from a larger sample of 186 participants in this study. We dropped the additional 28 participants (12 men and 16 women) from this analysis due to missing data on measures of the variables examined in this study, using listwise deletion. The demographic and medical characteristics of this sample are summarized in Table 1.
Data Analyses Three sets of multiple regression analyses were conducted to determine which independent variables (ethnicity, marital status, sexual orientation, religious affiliation, gender, age, income, AIDS status, taking pain medication, level of distress, level of pain, and social support) would be significantly associated with Embracing Life’s Fullness, Spiritual Beliefs, and Spiritual Growth in the present sample. Because we wanted to explore several independent variables in a relatively small sample size, we used statistical (stepwise) regression with a cut-off of p < .10 for demographic variables to remain in the model (Tabachnick and Fidell, 2001). Analyses of residuals were conducted to verify that multiple regression analyses assumptions were met. Dummy coding was conducted for the categorical variables such as gender (male or female) and marital status (married/living as if married or unmarried). The use of dummy variables in multiple regression analysis requires using at least one less than the actual number of categories in the analysis. For the ethnic group membership, religious affiliation, and sexual orientation, which were comprised of multiple categories, as shown in table 1, we chose the most frequently endorsed specific categories for each to serve as the dummy variables. For each dummy variable, such as “African American,” participants received a score of “1” if that category described them, and a “0” if that category did not describe them. In this way, all participants were included in the comparison for each dummy variable, even though this kind of analysis omits differentiation of some categories represented in the sample. Dummy variables for the ethnic group membership were Non-Hispanic White, African American, or Latino/Hispanic. For religious affiliation, the dummy variables selected as the most frequently endorsed specific affiliations were Catholic, Protestant, or no religious affiliation. For sexual orientation, the dummy variables were gay/lesbian or heterosexual. Screening of the data via examination of residuals indicated that the dependent variables met the assumptions of normality, linearity, and homoscedasticity for multiple regression analysis. Furthermore, there were no univariate or multivariate outliers and no multicollinearity among the independent variables. Descriptive statistics, internal
14
John E. Perez, Tatiana Forero-Puerta, Oxana Palesh et al.
consistencies, and correlations among the key independent and dependent variables are provided in Table 2. Table 2. Means, Standard Deviations, Internal Consistencies, and Correlations among Key Independent and Dependent Variables Variable
Distress (POMS)
Distress (POMS) Pain Social support Embracing life’s fullness Spiritual beliefs Spiritual growth Mean Standard deviation Cronbach’s alpha
.08 -.06 -.46** -.11 -.26** 37.94 35.17 .72
Pain
.05 .09 .24** .08 .52 .50 na
Social support
Embracing life’s fullness
Spiritual beliefs
Spiritual growth
.32** .23** .12 59.91 17.55 .92
.44** .53** 50.32 20.09 .72
.54** 50.32 21.91 .91
50.23 18.40 .67
Note. **p < .01. POMS = Profile of Mood States. na = Cronbach’s alpha was not applicable because Pain was a dichotomous variable.
RESULTS Embracing Life’s Fullness A statistical (stepwise) regression analysis was performed to examine the relationships of ethnicity, marital status, sexual orientation, religious affiliation, gender, age, household income, AIDS status, taking pain medication in the last six months, level of distress, level of global pain and social support with scores on Embracing Life’s Fullness. The hierarchical regressions were conducted in two blocks. The demographic variables, AIDS status, and taking pain medications were entered in the first block using a forward entry method. Distress, global pain, and social support were entered simultaneously in the second block. The results appear in Table 3. These variables accounted for 32% of the variance (adj. R2 = .30) in Embracing Life’s Fullness, F(4, 153) = 18.07, p < .001. Embracing Life’s Fullness scores were positively associated with social support and negatively associated with distress. Table 3. Statistical Regression of Demographic and Psychosocial Variables on Embracing Life’s Fullness Variable Protestant Distress Pain Social support Constant Note. ^p < .10, ***p < .001.
B 7.28 -.25 4.61 .33 3.00
SE B 4.13 .04 2.68 .08 .21
β .12^ -.43*** .12 .28***
Pain, Distress, and Social Support in Relation to Spiritual Beliefs…
15
Spiritual Beliefs A statistical regression analysis was performed using the same approach described above, with Spiritual Beliefs serving as the dependent variable in place of Embracing Life’s Fullness (see results in Table 4). The demographic and psychosocial variables accounted for 39% of the variance (adj. R2 = .36) in Spiritual Beliefs, F(7, 150) = 13.82, p < .001. Being female and having global pain were positively associated with Spiritual Beliefs. Being Catholic, White, and not religiously affiliated each were negatively associated with Spiritual Beliefs. Table 4. Statistical Regression of Demographic and Psychosocial Variables on Spiritual Beliefs Variable Not religiously affiliated Gender Catholic Caucasian Distress Pain Social support Constant
B -19.68 6.97 -8.50 -7.40 -.08 9.11 .16 41.50
SE B 3.22 3.12 3.78 3.05 .04 2.83 .08 7.32
β -.42*** .16* -.16* -.17* -.12^ .21** .13^
Note. ^p < .10, *p < .05, **p < .01, ***p < .001.
Spiritual Growth Table 5 presents the results of performing a statistical regression analysis using the same approach described above, with Spiritual Growth serving as the dependent variable. The model accounted for 9% of the variance (adj. R2 = .07) in Spiritual Growth, F(3, 154) = 4.90, p < .01. Distress was negatively associated with Spiritual Growth, in that those participants who reported greater Spiritual Growth also reported less distress. No other factors were found to be significantly related to Spiritual Growth. Table 5. Statistical Regression of Demographic and Psychosocial Variables on Spiritual Growth Variable Distress Pain Social support Constant
B -.14 3.69 .11 46.99
SE B .04 2.84 .08 5.47
Note. **p
