# data[].attributes.attachment_link.title
Religious Coping Is Differentially Associated with Physiological and Subjective Distress Indicators: Comparing Cortisol and Self-Report Patterns. | EBSCOhost

# data[].attributes.attachment_link.description
Discover this 2024 paper in Behavioral Medicine by Haney, Alison M.; and, Lane, Sean P.

# data[].attributes.attachment_link.title
The Effects of Religious Rituals and Religious Coping Methods on the Grief Process and Posttraumatic Growth: A Qualitative Study. | EBSCOhost

# data[].attributes.attachment_link.description
Discover this 2024 paper in Journal of Faculty of Theology, Sakarya University / Sakarya Üniversitesi Ilahiyat Fakültesi Dergisi by Gökmen, Ayşe; and, Sami, Said

# data[].attributes.attachment_link.title
The Meaning of Life and Religious Coping in the Fight Against Cancer: A Study with Oncology Patients in Brazil in Light of Viktor Frankl’s Theory. | EBSCOhost

# data[].attributes.attachment_link.description
Discover this 2024 paper in Journal of Religion & Health by de Medeiros, Angelica Yolanda Bueno Bejarano Vale; Pereira, Eliane Ramos; and, Silva, Rose Mary Costa Rosa Andrade

# data[].attributes.attachment_link.readable_text
Research article

Open Access

Published:

Journal of International Humanitarian Action 6, Article number: 15 (2021) Cite this article

15k Accesses

7 Citations

23 Altmetric

Metrics

Abstract

Despite evidence that faith-based and spiritual coping supports people's mental health, stigmata prevail in the aid sector around the need for psychological support in general and around this coping mechanism in particular. This qualitative research examines female aid workers' experiences and aims to elucidate how this mechanism supports mental health in stressful, conflict, or disaster-affected living and working environments. Inductive thematic analysis of 14 semi-structured interviews reveals three themes around (a) specificities of the aid work context, (b) benefits and gains through this coping mechanism and related processes, and (c) potential downsides. Interview findings suggest a faith-based and spiritual approach helped interviewees feel grounded, calm, resilient, and present in difficult environments. Participants experienced a resolute identity, space for self-care, as well as access to community, belonging, and connection across national, faith, and spiritual boundaries. Results raise the importance of de-stigmatizing faith-based and spiritual coping and invite further discussion among practitioners.

"... look around for that goodness. Like that small flower or the treat someone brought you " (Aid worker, Iraq).

Introduction

Today's global humanitarian needs are higher, more complex, and more difficult to fulfil than ever before. Resources are under a lot of strain, and one major resource in the aid world are the people itself who deliver such aid: humanitarian and development aid workers who continue to 'stay and deliver' in the most difficult and dangerous circumstances (Jackson & Zyck, 2017; OCHA - UN Office for the Coordination of Humanitarian Affairs, 2011). Living and working as an aid worker comes with many physical and psychological challenges. This paper will discuss the implications for aid workers' mental health and their potential responses to cope with psychological difficulties. It will present two of the major challenges being a reluctance to acknowledge mental health issues and more so a reluctance to acknowledge diverse approaches to mental well-being in the aid world. This research will outline and discuss (a) the pervading reality of mental health challenges in the aid world and (b) a hesitance vis-à-vis faith and spiritual coping as a valid coping mechanism, demonstrating a lack of a holistic approach to aid workers' well-being. This is even more pertinent as this coping mechanism is widespread among staff and populations in the countries where much of the aid work is delivered (Cardozo et al. 2013; Pew Research Centre 2015). The paper aims to demystify faith-based and spiritual coping, demonstrate its mechanisms and argue for such coping not to go unnoticed or under-utilized when discussing mental well-being needs of aid workers and holistic responses. Outcomes of this research call to remove stigma regarding expression of emotion, needs, and mental health issues as well as stigma regarding faith-based and spiritual coping.

Danger and stressors for aid workers

Aid workers by nature of their work in unsafe and threatening environments are regularly exposed to situations that may have a negative and long-lasting impact on their psychological well-being (Bryant 2006; Mao et al. 2018; Musa and Hamid 2008). Practitioners publish statistics that exemplify the physical dangers: in 2016, nearly 290 aid workers were injured or killed in nearly 160 security incidents reported globally, and in 2017, this number rose to over 310 aid worker victims, including kidnappings, across 22 countries (Humanitarian Outcomes 2017, 2018). Aid workers face higher death rates than military personnel in peacekeeping operations (Stoddard et al. 2009) and are increasingly seen as legitimate targets (Sheik et al. 2000). Three kinds of stressors for aid workers have been identified (Cardozo and Salama 2002): traumatic, chronic, and organizational. Traumatic stressors include experiencing or witnessing first-hand situations that are life-threatening, direct attacks on one's own person (physical or sexual assault, rape) or on offices, accommodation, restaurants, or the incessant threat thereof; bombings, the use of improvised explosive devices, and war in the immediate vicinity, as well as indirect exposure by, for example, encountering mass graves or witnessing people die of malnutrition (Eriksson et al. 2015), and listening to the traumatic experiences of colleagues or of people in need (Connorton et al. 2011). Chronic stressors include hardship living or environmental factors, such as lack of privacy, movement, or medical care. Organizational stressors include dysfunctional management and team issues, such as constant staff turnover, an overwhelming workload, unpredictable contracts, unclear terms of reference, or under-resourcing (Antares Foundation 2012; Connorton et al. 2011). A longitudinal study shows that a typical international humanitarian aid worker experiences at least one to two traumatic events during a single field deployment (Antares Foundation 2012). Cross-sectional studies across Guatemala, Jordan, Sri Lanka, and Uganda of nearly 1200 national staff reveal that national staff, often survivors of war or disaster themselves, may suffer from additional stressors compared with international staff (Ager et al. 2012; Cardozo et al. 2013; Eriksson et al. 2013b; Putman et al. 2009).

'Occupational risks'-implications for mental health

These concrete 'occupational risks' and stressors suggest that aid workers' mental health, too, may be threatened. Various studies showed a greater prevalence of affective disorders, post-traumatic stress symptoms and disorder among aid workers than among the general population in the US or western Europe (Cardozo et al. 2005; Connorton et al. 2011; Eriksson et al. 2013a). Similarly, a Global Well-Being Survey conducted in 2015 across 11 United Nations entities worldwide showed that about half of the surveyed 17,000 staff members, aid workers, and others had mental health symptoms requiring follow-up and higher levels of depression, anxiety, or post-traumatic stress (UNS - United Nations System, Chief Executive Board for Coordination, High-Level Committee on Management 2018). A longitudinal study covering 154 staff from 17 nongovernmental organizations (Cardozo et al. 2012) demonstrated that occurrence of anxiety, depression, and psychological distress were higher after field deployment than before. Prevalence of increased depression, psychological distress, and lower life satisfaction persisted when measured 6 months after deployment, signifying longer-term impact. A phenomenological study (McCormack and Joseph 2013) of the experiences of two humanitarian aid workers post-mission emphasized the "long-term psychological distress including shame, moral doubt, betrayal and narcissistic coping" (p.147).

Do aid organizations talk about mental health?

Aid worker anecdotes and blogs note the prevailing 'cowboy' culture (Edwards 2017) which requires aid workers to overcome direct or secondary trauma "as if nothing happened" Ten years ago I was sent to DR Congo as an aid worker without security training 2017, p.4). Alternatively, the industry's culture may deem aid workers unfit for the job (Young 2015). Scientific studies, too, highlight the "'macho' culture of denial" of the psychological impact of aid work (Barron 1999; Ehrenreich and Elliot 2004, p.55). There is no evidence that aid workers receive regular, special training for secondary trauma-defined as the "natural consequential behaviours and emotions ... resulting from knowing about a traumatizing event ... and the stress resulting from helping or wanting to help a traumatized or suffering person" (Figley 1995, p.7)-despite high exposure, reported by over 60 and 80% of aid staff in Uganda and Sri Lanka, respectively (Ager et al. 2012; Cardozo et al. 2013). Pre-mission trainings usually do not include psychological first aid despite availability of training manuals (World Health Organization 2011) or the recommendation to seek psychological support before, during, and after deployment (Connorton et al. 2011; Cardozo et al. 2012). Although mental health issues are a regular occurrence and a 'normal' reaction to abnormal situations people face (Bjerneld et al. 2004), less than half of the 376 national aid workers in Uganda across 21 humanitarian aid agencies reported the existence of psychological support systems in their organizations (Ager et al. 2012). However, recent developments look promising: agencies place increased emphasis on, and enhance access to, mental health services (Antares Foundation 2012; Cardozo et al. 2005; Eriksson et al. 2009; Eriksson et al. 2013a; UNS - United Nations System, Chief Executive Board for Coordination, High-Level Committee on Management 2018; Welton-Mitchell 2013). This is in line with agencies' 'duty of care' principles that aim to attenuate predictable risks, particularly in high-risk environments that may place staff in harm's way (Creta 2018). Practically, these principles are not only expressed in the provision of armoured vehicles and bullet-proof vests but also policies on occupational safety and health. The well-established origins of the concept stem from a UN General Assembly Resolution calling to ensure fullest measures of protection for UN agents (UNGA - United Nations General Assembly 1948). While not every agency offers a psychosocial support policy or direct and immediate access to a counsellor due to resource, logistic, or security restrictions, practitioners concede that while caring for people in need, it is crucial to care for their own staff, too (IASC - Inter-Agency Standing Committee 2007).

Moderating factors and coping

Exposure to aid work risks and psychological distress can be moderated by support systems, positive attitudes towards seeking help, or other coping mechanisms to protect psychological well-being (Connorton et al. 2011). One such mechanism is religious coping which is defined as "the use of religious beliefs or behaviours to facilitate problem-solving to prevent or alleviate the negative emotional consequences of stressful life circumstances" (Koenig et al. 1998, p. 513).

For the purpose of this research, religious coping shall include aspects of faith and spirituality which are understood as a sense of meaning, purpose, and hope (Peres et al. 2007) related to a connection with God or gods, nature, or a life force. Faith-based and spiritual coping among aid workers has not been extensively researched despite the altruistic nature of aid work: in line with faith-based principles of service and altruism, 96% of 214 aid workers across 19 Nongovernmental Organizations indicated prior to their deployment to be motivated to "contribute to a better world and help those less fortunate" (Eriksson et al. 2013a, p.45). Faith and spirituality remain important across cultures, particularly in many countries where international and national aid workers operate (Pew Research Centre 2015). Despite this awareness, there is a risk that faith and spirituality are viewed unfavourably. As an example, the head of the ethics office of a major humanitarian organization claimed spiritual aspects remain explicitly excluded in day-to-day office life (personal communication, 6 March 2018).

Research into the use of faith-based or spiritual practice has yielded mixed results. Some studies do not show correlations between a faith-based or spiritual practice and better mental health outcomes (Connor et al. 2003; Ellison et al. 2014; Fitchett et al. 1999; Kirkpatrick et al. 1999; Pargament et al. 2001). However, there is a growing body of evidence that establishes the benefits of a faith-based or spiritual practice on mental and physical well-being (Koenig 2001; Moreira-Almeida et al. 2014; Seybold and Hill 2001). For example, research has found positive correlations between mental health, cognitive capacities, and physical health with the frequency of prayer (Maltby et al. 1999) and attendance of religious services, giving the comfort of a social support group (Dein et al. 2012; Ellison and Fan 2008; Ellison 1998; Hackney and Sanders 2003; Koenig et al. 1999). Hourani et al. ( 2012), analysing data collected from 24,000 randomly selected active US military personnel, demonstrated that high spirituality had a significant protective effect for depression symptoms.

In addition, aid workers self-report the use of faith-based and spiritual practices as a coping mechanism. In a study of Sri Lankan national aid workers, over 55% of 398 workers surveyed on factors affecting mental health highlighted religion as an important coping mechanism for stress (Cardozo et al. 2013). This is in line with research as whole; a meta-analysis of 49 relevant studies on religious coping and psychological adjustment to stress, including several studies with longitudinal design, such as Pargament et al. ( 1994) or Tix and Frazier ( 1998), shows that religious coping methods are reliably correlated with better psychological outcomes, hope, stress-related growth, less depression, anxiety and distress, etc. (Ano and Vasconcelles 2005). A systematic review of four qualitative and seven quantitative studies (Shaw et al. 2005) noted that religion and spirituality were usually beneficial to people dealing with the aftermath of trauma. Trauma and recovery studies recommended research to "include a focus on spiritual issues and spiritual well-being" (Park 2017, p.305). Mental health practitioners are encouraged to introduce spiritual and religious practices in psychological interventions for coping with trauma, e.g. among refugee women (Smigelsky et al. 2017). Empirical research showed such practices reduced burnout in clergy (Eriksson et al. 2009). Psychologists reported that spiritual and religious issues were relevant in their practice 83% of the time, with the majority recognizing the beneficial aspects of religiosity and spirituality for individuals (Delaney et al. 2007).

However, the intersection between potentially traumatic events, living and working conditions of aid workers, and their faith and spirituality remains very specific and empirically and qualitatively under-researched (Currier and Eriksson 2017). This study qualitatively examines the interplay of these aspects among female aid workers. The outcomes provide employers, therapeutic practitioners, and other aid workers with insights into how aid workers with a faith-based and spiritual practice cope in stressful living and working environments in conflict or disaster-affected areas. It reveals how aid workers experience the challenges of their context and how their practice contributes to their well-being and the specific mechanisms thereof. Speaking about faith and spirituality may be very intimate and not self-evident to generalize and quantify (King and Crowther 2004; Wartenweiler and Eiroa-Orosa 2016); therefore, qualitative research was selected as the most appropriate design to give voice to aid workers' experiences. This qualitative research moves beyond the realm of anecdotes and provides insights into the depth of the lives of aid workers. Through inductive thematic analysis of semi-structured interviews, this paper allows an exploration of the experiences of these female aid workers without reducing collected data to numbers (Pyett 2003; Silverman 2000). Acknowledging the importance of context in which aid work, faith, and spirituality are experienced, this design is adequate to study personal, potentially traumatizing experiences and pursue vulnerable discussions about faith, spirituality, God/gods, prayer, community, etc. with the "desire to know people's own perspectives and meanings" (Braun and Clarke 2013, p.21).

Method

Participants

Participants were recruited through personal networks and an aid worker social media forum with 19,000 members. Purposive sampling narrowly followed the inclusion criteria of being female aid workers, regardless of nationality, duty station country, or type of contract, having worked in a conflict or disaster-affected area within the last 5 years and following a faith-based or spiritual practice or life approach. The latter criterion was held deliberately wide due to the intimate, individual nature of these concepts. Faith and spirituality were defined as a sense of meaning and purpose, hope, and faith which could be an explicit belief in God, feeling connected with nature or the force of life, or a collection of clear values, transcending the self (Drescher 2006; McKay 2010). All participants with a self-reported practice or life approach were interviewed. Inclusion in this study was deliberately limited to female aid workers with the aim to support homogeneity in the data. While some research highlighted how different genders experience challenges in aid work differently (Armagan et al. 2006; Holtz et al. 2002), this was not a factor in focusing on women. Longitudinal studies (e.g. by Cardozo et al. 2012) on psychological distress, depression, anxiety, and burnout among international humanitarian aid workers, involving 59% women, did not find gender differences. Purvanova and Muros' meta-analysis on burnout ( 2010) covering 183 studies reveals that both genders suffer burnout, with women being slightly more emotionally exhausted and men slightly more withdrawn or cynical. However, the deliberate choice to limit this study to women in line with principles of homogeneity aimed to give a detailed insight into the specific phenomenon of religious coping. A focus on women enabled a detailed investigation of processes relating to the research question on religious coping (Ritchie et al. 2003); Chan and Rhodes' ( 2013) analysis of multiple studies summarized that religious coping is more common among women. Other, qualitative studies show the importance of spirituality in women for overcoming trauma, e.g. childhood abuse (Shaw et al. 2005). This study wanted to take advantage of outcomes of such prior research to achieve clear results that were not potentially modified by a gender factor. A total of 14 participants from seven countries and six faith and spiritual backgrounds were interviewed and fulfilled all criteria. The sample size is adequate and in line with criteria for qualitative research (Vasileiou et al. 2018). Participants included three women acquainted with the researchers prior to the study which required managing a dual relationship. This meant interviewers carefully balanced relationships with interviewees as colleagues/acquaintances and as independent researchers during and after interviews (Garton and Copland 2010). One participant each originated from Australia, India, Philippines, Syria, and an undisclosed Asian country; three were from the UK, and six were from the USA with varying ethnic backgrounds. Nine participants identified as Christian, and five participants identified as Christian-Buddhist, Hindu, Muslim, Muslim-Buddhist, Yogini, and Meditator, respectively. Their practices varied from daily or occasional prayer, Scripture studies to nature contemplations, yoga, and insight meditation. They ranged in age from 29 to 48 years ( M = 37). Eleven participants have worked as international aid workers (i.e. in countries other than their own), two participants have worked as national aid workers, and one participant has worked nationally and internationally. The field duty stations the aid workers have worked in and mentioned during the interviews span across the globe: Afghanistan, Armenia, Bangladesh, Bolivia, China, Democratic Republic of the Congo, Djibouti, Egypt, Ethiopia, Haiti, India, Iraq, Jordan, Kenya, Lebanon, Libya, Myanmar, Nepal, Pakistan, Palestine, Philippines, South Sudan, Sri Lanka, Syria, Tunisia, and Uganda.

Procedures

In line with ethical standards (British Psychological Society 2018), researchers provided information about the project, obtained participants' consent, and offered the option to ask questions, raise complaints, and withdraw at any point. Additional resources for mental health and psychological support specific to aid workers were shared after the interviews.

Data collection

Data were collected in semi-structured, confidential, one-to-one interviews respecting the personal nature and sensitivity of the topic and allowing for an open and flexible discussion. The interview guide covered aspects of aid and spirituality and was discussed with a mental health counsellor of a major international humanitarian organization for reality cross-checking before application (Smith 1995). The conception of open-ended questions avoided any predetermined themes (Terry et al. 2017). The interviews were audio-recorded, transcribed verbatim, anonymized, and approached with thematic qualitative analysis for prevalent and repeating themes (Braun and Clarke 2006).

Reflexivity

The research team have all had experience in aid work in both sectarian and non-sectarian settings. In an attempt to facilitate discussion, the primary researchers did disclose previous aid work experience. In addition, the data collection was completed by women researchers with the hope this would alleviate any issues around gender. Despite the research team's personal and spiritual background, specifics were not divulged during the research process to avoid the perception that only positive outcomes regarding spiritual coping were sought. This research team acknowledged that individual experiences were part of a broader social and cultural context that have shaped and validated this research interest (Lazard and McAvoy 2017). Coming from both aid work and faith-based experiences allowed for a familiarity and connection with participants. However, previous sectarian and non-sectarian experiences of the research team or experiences of spirituality as protective mechanism may not reflect the participants' experiences. Consequently, the researchers acknowledged the potential of negative effects of a faith-based and spiritual practice. This was managed by paying attention to explicit and implicit bias to encourage as much neutrality as possible.

Analysis approach

Using thematic analysis as a very flexible yet systematic approach to qualitative research allowed for identification, analysis and reporting of codes and themes within the data, independent from theory or epistemology (Braun and Clarke 2006). While the ramifications of working in aid and the model of spiritual coping are acknowledged and part of the research questions, the analysis of the participants' experience was inductive and data-driven. As per the contextualised method, this analysis made space for the reality of the participants and their meaning-making while acknowledging the wider social and political context of aid work that may influence their experience and interpretation. The digital theme map demonstrates the grouping and relationship of three themes (see Fig. 1).

Results

Three themes were identified in response to the research question how a self-reported degree of faith or spirituality may contribute to better coping in the face of stressful living and working environments in conflict or disaster-affected areas. To understand the phenomenon of faith-based and spiritual coping in aid work, the first theme outlines the overall context of working in the aid world: a demanding environment that requires non-stop full capacity of its workers ( The context: The aid 'world'). The second theme outlines the primary outcome, benefits and gains, of faith-based and spiritual practices, and the underlying supportive processes reflected in respecting one's values and needs ( 'Filling one's own cup'). The third theme outlines secondary, negative implications of such practices that might threaten one's balance ( When the cup has a crack).

Theme-The context: the aid 'world'

This theme provides a frame of reference for the experience of participants. It highlights in three subthemes their faith-based or spiritual motivations to enter the profession, its demands, dangers, and psychological impact, as well as the culture of aid work.

Subtheme: motivation and expectations

Subtheme: demands, dangers, and impact

Working in aid, particularly in humanitarian aid, participant 4 noted that "the expectations are so high... everything is an emergency...there is no such thing as personal time", and subsequently, there was not much time for reflection. Statements about "crazy hours ... crazy living conditions, ...crazy risk disaster environment" (participant 5) summarized the demands. Aid workers were expected to react with flexibility, versatility, and inventiveness in all situations: An immediate travel request for an emergency response operation was answered with "' no problem' and I basically packed my bag. The next morning, I was on a plane" (participant 11). "There were no security plans for things like ... if we were attacked, so all of us ... were constantly trying to come up with our own plans" (participant 6). While being faced with a "pile of dead bodies" (participant 5), refugees and internally displaced persons' dire living conditions (participant 1), suicide attacks on project sites and accommodation (participants 6 and 12), threats of kidnapping and sexual assaults (several participants), aid workers were exposed to both direct and secondary trauma. Participant 7 noted after a traffic accident "mobs will just hack you, and we saw a number of people killed that way". Under such conditions, aid workers were left "burnt out" (participant 3), drained of "not only physical energy but emotional and spiritual" (participant 14) and subject to "anxiety" (several participants), unprocessed grief and trauma, and the isolation of having to "manage it alone" (participant 2). After many humanitarian emergency missions without the space to reflect and release emotions or recharge spiritually (participant 14), participant 5 claimed "there's a bit of me that's dead", one potential response to secondary trauma.

Subtheme: the culture of aid

Aid workers had a reputation of being courageous and efficient, " they go in, they stitch people up, they deal with any ...emergency" (participant 11). They were known to successfully accomplish their "fast-paced work where decisions need to be made very fast" (participant 2). Part of the culture also was the never-ending nature of work and how "people become workaholics because you have to give your life to it, almost" (participant 4). Several aid workers spoke of the 'cowboy' or 'cowgirl' image of aid workers who were

Participants experienced the culture as one of bravery but also stigma where coping through potentially self-destructive behaviours seemed more accessible than sharing psychological struggles or how they coped better thanks to their faith or spirituality (participant 4). Participant 6 and others observed potentially adverse coping mechanisms such as "alcoholism, ...drugs,...indiscriminate sex...a wild lifestyle that accompany aid work especially in conflict countries because that's the way that people choose to deal with their stress".

Theme-The primary outcome: 'filling one's own cup'

A crucial thread seemed to be expressed in the theme of 'filling one's own cup': "You really have to realise I need to fill myself up so I can give to others" (participant 14). Two subthemes with four components each denote (a) what a 'full cup' meant to them and (b) what mechanisms were used to fill the cup, i.e. what aspects of their faith-based or spiritual practice specifically recharged the participants.

Subtheme: What is a 'full cup'?

Participants experienced varying states and emotions when their 'cup' was filled.

Component 1: grounded and calm amidst chaos

Confronted with suddenly losing her job, one participant noted:

Component 2: resilience

Participants' practices fed their resilience and ability to withstand (e.g. secondary trauma) (participants 11 and 14) or "bounce back" (participants 6). Faith " forces you to look around for that goodness.... When I was in a place where we saw so much darkness I really felt a lot of light" (participant 14). After "spending some time with God", participant 2 remained persistent and refused "giving up", while participants 3 and 7 noted that their "connection to God" kept them going and continue in aid work. It "made me stronger and more able to deal with the refugee stories that we'd hear every day" (participant 7).

Component 3: "I am more present"

The practice across different faith traditions, while acknowledging the temporary nature of this world, also enhanced the ability to deal with death, grief, and stories of violence and sexual assaults (participants 8, 9, 10, and 11). Recounting the strength of raped Congolese survivors, participant 7 remained hopeful despite such hardship: " God is still with us, and listening and answering... That presence is the promise". Participants felt that their practices enabled them to listen better and be "more present with the people I was interviewing in the camps" (participant 11), to be a "balm to the wound" (participant 7) and be able to "walk with people as they were suffering" (participant 3). Without her spiritual practice, participant 1 notes "I wouldn't have found my job as fulfilling. I wouldn't have been as good with refugees...and able to give them the time that they needed".

Component 4: "Give it to God" and non-attachment

Participants felt their balance was restored when they practiced in moments when they did not have control over their environment (participant 1). They conceded that "God is in control" (participant 7), and they are "powerless in the scheme of the Universe and ... release it to a Higher Power" (participant 13). Participant 11 experienced rest in a place of "complete acceptance whether it is joy or suffering". Knowing that they were not in charge of events that were beyond any human control provided a certain relief.

Participant 10 and others noted: "I could die anywhere when my time's up", and therefore felt non-attached and safe, including in challenging security contexts.

Subtheme: How is the cup filled? Values and needs

This subtheme expressed the particular mechanisms which are specific to participants' faith-based and spiritual approach and which caused the 'refill' to enable them to better cope.

Component 1: identity and belonging

Component 2: space for self-care-physical, mental, emotional

In their work context, space was not always available, be it physical space, such as living quarters and choice of housemates (participants 12 and 14), or space to process the demands, dangers and impact and to acknowledge the related emotions:

A faith-based or spiritual practice supported and facilitated the creation of metaphorical space for self-care on the physical, mental, and emotional levels. Participant 11 experienced her meditation practice as a life-guard for her physical health as it "prevented further damage that may never have been able to be repaired", and participant 1 "would have continued to engage in things that were more self-destructive than helpful to me" without her yoga practice. Participant 4 admitted she "would have drank a lot more, I would have smoked a lot more" without her faith, while participant 3 felt her centering prayer practice made her "just able to ... take steps back.... I'm not so in it and emotionally ... invested". Pursuing their practices was " carving out that bit of the day for me, but it's also a way of processing and acknowledging emotions" (participant 5). Her practice gave her "the freedom and the ability... to ... observe it neutrally and then, take action" (participant 13).

Component 3: community and belonging: virtual and in the flesh

Component 4: connection across boundaries

In line with the felt sense of community was the connection across the experienced divide between nationals and internationals, staff and other, and across faith boundaries. "So you all have your own take on it and you all come from very different backgrounds ..., all of that can be hard but if you have something in common it helps bring it together" (participant 14). A faith-based or spiritual approach and identity created an environment where national and international aid workers of different spiritual practices, beliefs, languages, and cultures could connect and discuss (participant 8). This felt connection enabled a Christian international aid worker to respond to a Muslim national aid worker to " just pray and Allah will give you a dream" and to "have those conversations about faith" (participant 5).

Most participants felt being more accepted, integrated, and respected by national colleagues for having a faith-based or spiritual practice than by international colleagues: "They were delighted that I had a faith" (participant 5), " they saw it very highly ... because all of them ... value their faith and see it as an essential part of their life and identity and so seeing me as a Westerner who actually had faith meant a lot to them" (participant 4). Participants felt connected through their shared humanity (participants 3 and 8).

Theme-Secondary outcome: when the cup has a crack

This theme covers potentially adverse consequences of a faith-based and spiritual practice.

Subtheme: Can you ever do enough for God?

A related aspect to the subtheme of motivation which increased the burden on faithful or spiritually minded aid workers was the question if you can ever "do enough for God" (participant 5). There might also be an additional burden of "representing a good, religious person ... with a responsibility for my faith" (participant 9). Participant 3 conceded " that connection with God... drove me to ... probably push myself when I needed to maybe step back and take some time ... to work out whatever I was feeling". This aspect demonstrated that some parts of a faith-based or spiritual approach might increase the chance of burnout, rather than relieving it and 'filling your cup'. In line with their motivation and the culture of aid, " often ...we expend ourselves" (participant 3) and "often ...we do get burnt out...we start thinking things are not going to work without us" (participant 12).

Subtheme: You need a crutch?!

Many participants noted that the international aid environment was less welcoming to expressions of faith-based or spiritual practices (participant 4). Participant 1 experienced lack of acknowledgment of the value and benefits of a spiritual practice: "It's kind of like 'Science vs. Spirituality'" and participant 13 experienced attitudes in the West as " sneery about the positive ...effects". Participant 7 noticed a "general sense of ambivalence or apathy towards" her faith and some even felt ridiculed:

Regarding not engaging in adverse common coping mechanisms to "let off steam" (participant 6), some also feared judgment and felt that they did not "want to be judged for my faith, saying ... I don't want to do this for this and this reason, so that's a challenge" (participant 4).

Discussion

Summary and synthesis

The study expected to find how a self-reported degree of faith or spirituality may contribute to better psychological coping in the face of stressful living and working environments in conflict or disaster-affected areas. Inductive thematic analysis of 14 semi-structured interviews revealed three related themes, " The context: The aid 'world'", the "Primary outcome: 'Filling one's own cup'", and the " Secondary outcome: When the cup has a crack". The findings reflect previous quantitative research with large and varied samples on religious coping and its multidimensional character (Pargament et al. 1998): Findings suggested that a faith-based and spiritual approach provided participant aid workers with a groundedness and calm amidst an environment of chaos and direct and secondary trauma. Participants gained a sense of enhanced resilience and ability to be present for their personal needs, work demands, and the needs of people they served. A faith-based and spiritual approach allowed participants to let go of the impulse to try and control every situation that arose in the aid context but other times also challenged them to push themselves beyond their capacities. To some degree, participants experienced ostracism due to their faith and spirituality. The identified supportive mechanisms were represented by the participants' strong identity characterized by their faith-based or spiritual beliefs, the availability of community support, and the connection experienced across cultural, national or faith-based and spiritual boundaries. An important mechanism was revealed by the creation of emotional processing space following exposure to stressors and direct and secondary trauma.

Outcomes reflected in psychological theory

Some of the supportive mechanisms and related outcomes revealed in this research are reflected in certain psychological theories, e.g., in the framework of the mindfulness-based Acceptance and Commitment Therapy (ACT) (Hayes 2004; Hayes et al. 2001; Hayes et al. 1999). Participants viewed themselves as self-as-context through a solid understanding of their identity, a 'continuous sense of self' (McLean and Follette 2016, p.145). This means their sense of self was not determined by the limiting context they lived or worked in. Rather, their sense of self determined how they viewed their context. Their aid experiences did not restrict participants' sense of personhood. Rather, their identity as faith-based or spiritual persons, in instances, supported them to continue their work in the aid world while being in line with their own values (Hayes et al. 2006).

Escaping and avoiding emotions, thoughts, and memories is "one of the most pathological processes known (as)...experiential avoidance...even when the attempt to do so causes psychological harm" (Hayes 2004, pp.649-650; Hayes et al. 1996). Accordingly, by practicing their faith and spirituality, participants gained the chance to accept and process these emotions, thoughts, and memories by taking space for self-care, instead of engaging in experiential avoidance. This could decrease the occurrence of psychological harm (Hayes et al. 2006). The more control someone has over their work, the lower their stress levels (Bond and Bunce 2003). In the aid context, participants outlined that such control was not always available, given war and conflict situations, direct or secondary traumatic events. However, they felt a groundedness and greater ability to be present for themselves and for others by accepting certain circumstances as beyond their control. They acknowledged their lack of control which, indeed, may protect from burnout (Johnson 2001; Maslach and Jackson 1981) and psychologically accepted related emotions (Bond and Hayes 2002).

Social support in community and connection

In line with social psychology research, participants' experiences reflected the need to belong (Baumeister 2012): Their practice enabled them to be part of and to create communities, both in-country and virtually, as well as building connections to the people in the countries where they worked. Participants' feelings of being 'sheltered' and supported as part of prayer or meditation communities is in line with previous research on the impact of religious communities (e.g. Nicholson et al. 2009). Social support sustains mental health through e.g. a regular joint spiritual practice (Hill and Pargament 2003), which, over time, can enhance resilience (Comoretto et al. 2015). While religiousness and social support do not necessarily correlate positively with each other in secular contexts (Kvande et al. 2015), the latter is not the contextual reality of the majority of the world population-about 90% actively pursue some form of religious or spiritual custom (Schafer 2010; Pew Research Centre 2015). This indicates that such practices may be important and beneficial to social support in most global contexts, for example for national aid workers. Feeling connected across cultural and religious boundaries was not ubiquitous but sufficiently important and rewarding for participants' well-being. The connections, thanks to their beliefs and practices, across what some of them perceived as a separation between national and international staff were particularly meaningful in the context of aid challenges and culture.

Implications for policy and practice

Aid organizations have power in removing stigma around mental health difficulties and in challenging such stigmatization which was regarded part of aid culture (McCall and Salama 1999).

Removal of stigma regarding expression of emotions, needs, and mental health

The demands in the aid world require aid workers to successfully deliver projects to save lives. The endeavour to fulfil high expectations while neglecting personal needs without adequate physical, psychological, or social organizational resources may lead to higher levels of burnout (Bakker and Costa 2014). The head of the ethics office of a major humanitarian organization noted "a gap between what some people believe and do in their personal life - mindfulness, faith-based and therapeutic interventions - versus what they bring in to their professional lives: There is no holistic approach that would include our emotions, body sensations, etc. There is an alarming 'illiteracy' in dealing with emotions and in reading one's own emotions and those of colleagues, in the work place" (personal communication, 6 March 2018). Such observations demonstrate the responsibility of aid organizations for the psychological welfare of their employees (Comoretto et al. 2015): The organizational culture is a major factor in this. Connorton et al. ( 2011, p.147) claim "there is no evidence base regarding how to prepare relief workers for occupational trauma and stress". Admittedly, humanitarian agencies' guidelines on mental health and psychosocial support with focus on beneficiaries do suggest some actions and resources on how to "prevent and manage problems in mental health and psychosocial wellbeing among staff and volunteers" (IASC - Inter-Agency Standing Committee 2007, p.87). Some organizations have demonstrated key initiative to look into staff needs (Welton-Mitchell 2013). Agencies offer access to staff counsellors at Headquarters and field duty stations, availability of internal training materials on stress management and mental health, or organizational access to commercial mindfulness training apps (personal communication with staff counsellor of major humanitarian organization, 28 March 2018). However, more is required to institute cultural change and satisfy the psychological needs of aid workers and thus enable them to better fulfil the high work demands and achieve organizational goals.

The potential impact of the aid work context on mental health requires more conversations, training, preventive interventions, continuous support, and debriefings. To illustrate, psychological therapists are exposed to secondary trauma through the recounts of their patients. The related recommendations for this occupational group are to engage in peer discussions and to obtain additional training on prevention and impact (Trippany et al. 2004). Aid workers, similarly exposed to secondary trauma, require e.g. "peer support networks ... during or after deployment" (Cardozo et al. 2012, p. 11) and additional psychological training on self-care. It remains important to continue working towards de-stigmatization of mental health difficulties. Organizations could support their staff through structured exercises to build community and enable environments where 'weakness' is redefined and having a 'crutch' is deemed helpful and essential.

Removal of stigma regarding faith-based and spiritual coping

Participants shared how difficult it is to discuss their faith-based and spiritual coping mechanisms with colleagues, indicating the lack of an inclusive approach. While organizations as the Headington Institute offer documentation and training on spirituality and humanitarian work (McKay 2010), it is difficult to advertise such a mechanism within aid agencies: Agencies' codes of conduct prohibit the promotion of a particular religious standpoint (Schafer 2010). However, it is important to differentiate between organizational programme delivery and personal welfare aspects. While respecting codes of conduct, agencies may address all available coping mechanisms, including faith-based and spiritual, in agency-internal stress-management trainings. For example, agencies could facilitate "time for the exercise of spiritual practices as part of recreational life and well-being for staff" (Eriksson et al. 2015, p.21). Psychological therapists and staff counsellors could be further sensitized on faith-based and spiritual coping, integrating it into the treatment and healing process of staff (Pargament 2012; Smith 2004). Client-driven discussions on multiple coping mechanisms should be incorporated. Agency staff counsellor teams could include interfaith chaplains to address faith-based and spiritual coping and integrate both psychological and spiritual needs of multi-cultural staff teams. As such, aid agencies would follow the examples of hospitals, mental health institutions, law enforcement agencies, and universities which offer the services of chaplains. Such steps would be particularly helpful to address the needs of national staff considering that the vast majority of aid staff are national, e.g. 95% of International Nongovernmental Organizations' staff (ALNAP 2010), and faith is an important factor for them (McCall and Salama 1999). Opening up mental health support with spiritual emphasis for aid workers would also reflect current considerations of a faith-sensitive approach among aid organizations regarding mental health and psychosocial programming in humanitarian aid IASC - Inter-Agency Standing Committee Reference Group Mental Health and Psychosocial Support in Emergency Settings 2018). With increased attention on resilience-building among aid workers and the existence of spiritual constructs in resilience, faith, and spirituality as coping mechanisms must be recognized as important factors for aid workers' well-being and thus productivity (Peres et al. 2007; Selby et al. 2009; Wartenweiler and Eiroa-Orosa 2016).

Both "social support and organizational support each remained significantly related to less" burnout (Eriksson et al. 2009, p.682) and practitioners acknowledge that staff "who feel ...psychologically secure are more likely to be productive and engaged" (Konterra Group 2017, p.2). This indicates the importance of supportive relationships, policies, and procedures at the organizational level. Such networks are important even after aid workers' deployments end, potentially supporting faster staff recovery (Cardozo et al. 2012).

Limitations

This research outlines self-selected participants' experiences and a larger, quantitative sample would be required to enable generalization. The strength of the chosen method however is the chance to glimpse into the reality of people's lives as aid workers with a faith-based or spiritual practice, their difficulties, hopes, and strengths beyond mere anecdotes. While many different faiths and expressions of spirituality were represented, most respondents were from industrialised and Christian-majority countries. However, the recruitment through social media beyond personal networks and avoiding official organizational channels allowed a neutral and independent approach to participants and thus the data.

Recommendations for future research

This research focussed on women to obtain largely homogenous data and follow up on available research about women and religious coping. Further research could hone in on participants' specific experience as women in aid. Future similar research could target male aid workers and the potential stigma around mental health issues men may face, and their access to faith and spirituality for coping. An important aspect would be the role that faith plays among national staff and how it can be integrated in mental health-related and stress management trainings targeting national aid workers. Future research should target follow-up on implementation of recommendations to test their effectiveness.

Conclusion

A faith-based and spiritual practice can be an effective coping mechanism through processes that are linked to humanity's primary needs of identity, space for self-care, community, belonging, and connection. The participant aid workers' experiences revealed the potential ongoing presence of stigma around mental health challenges and this coping mechanism. An organizational and social culture change is required to acknowledge the need for and utility of this psychological mechanism. While participants here have experienced challenges in their aid work contexts despite their faith-based and spiritual practices, they also reported that they have struggled less and coped better because of their practices which were integral to their coping. Opening up the discussion and allowing space for faith and spirituality might help reveal and remove stigma and improve aid workers' well-being and thus productivity in the field.

Availability of data and materials

The dataset that supports the findings of this study is available on request from the corresponding author. The dataset is not publicly available due to privacy and ethical restrictions.

References

Download references

Acknowledgments

The researcher wishes to express gratitude to each of the female aid workers who shared their stories with generosity and trust for their continuous courage and work in the field.

Funding

No outside funding was used to support this work.

Author information

Authors and Affiliations

Clinical Psychology, School of Health in Social Science, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK

Ozgul Ozcan, Mark Hoelterhoff & Eleanor Wylie

Contributions

The corresponding author is the principal author. The co-authors have been involved in editing and advice, and data collection, respectively. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Ozgul Ozcan.

Ethics declarations

Competing interests

The researcher declares no potential conflicts of interest with respect to the authorship and/or potential publication of this article. The views expressed herein are those of the author and do not necessarily reflect the views of the United Nations.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Reprints and Permissions

About this article

Cite this article

Ozcan, O., Hoelterhoff, M. & Wylie, E. Faith and spirituality as psychological coping mechanism among female aid workers: a qualitative study. Int J Humanitarian Action 6, 15 (2021). https://doi.org/10.1186/s41018-021-00100-z
Download citation

# data[].attributes.attachment_link.title
Faith and spirituality as psychological coping mechanism among female aid workers: a qualitative study - Journal of International Humanitarian Action

# data[].attributes.attachment_link.description
Despite evidence that faith-based and spiritual coping supports people's mental health, stigmata prevail in the aid sector around the need for psychological support in general and around this coping mechanism in particular. This qualitative research examines female aid workers' experiences and aims to elucidate how this mechanism supports mental health in stressful, conflict, or disaster-affected living and working environments.

# data[].attributes.attachment_link.readable_text
: the being perfect in power, wisdom, and goodness who is worshipped (as in Judaism, Christianity, Islam, and Hinduism) as creator and ruler of the universe

Throughout the - patristic and Jame Schaefer medieval periods, Christian theologians taught that God created the universe ...

... the Supreme Being or God, the personal form of the Ultimate Reality, is conceived by Hindus as having various aspects. - Sunita Pant Bansal

Christian Science : the incorporeal divine Principle ruling over all as eternal Spirit : infinite Mind

: a being or object that is worshipped as having more than natural attributes and powers

specifically : one controlling a particular aspect or part of reality

Greek gods of love and war

: a person or thing of supreme value

had photos of baseball's gods pinned to his bedroom wall

Examples of god in a Sentence

Word History

Noun and Verb

Middle English, from Old English; akin to Old High German got god

Noun

before the 12th century, in the meaning defined at sense 1

Verb

1595, in the meaning defined above

The first known use of god was before the 12th century

Cite this Entry

"God." Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/god. Accessed 27 Mar. 2025.

More from Merriam-Webster on god

- Updated example sentences

Subscribe to America's largest dictionary and get thousands more definitions and advanced search-ad free!

Merriam-Webster unabridged

More from Merriam-Webster

# data[].attributes.attachment_link.description
the supreme or ultimate reality: such as; the being perfect in power, wisdom, and goodness who is worshipped (as in Judaism, Christianity, Islam, and Hinduism) as creator and ruler of the universe... See the full definition

# data[].attributes.attachment_link.description
Sometimes death strikes down the living abruptly through a heart attack, a suicide, a car accident, a drowning. Loved ones can be left feeling stranded, breathless, and unprepared. In contrast…

# data[].attributes.attachment_link.readable_text
In the fourth grade, I became a Mennonite. It was 1975. I would read Bible stories every day, listened to Morning Has Broken religiously, and went to Mennonite church on Sundays. As a 9-year-old boy, I believed that if I sinned, God would punish me. I lived in fear of a lightning bolt striking me down if I said a curse word or told a lie.

Over the years, my spirituality has evolved to be more secular and science based. I believe that positive actions such as altruism, loving-kindness, forgiveness, fostering close-knit bonds, and working hard to make the world a better place all reinforce someone's state of well-being.

The health benefits of being guided by a moral compass have nothing to do with God. I believe that "doing the right thing" and living by the Golden Rule creates an upward spiral of well-being. Our universal neurobiological responses-linked to "tend-and-befriend" and "rest-and-digest"-are part of the parasympathetic nervous system and vagus nerve, which help to create better health outcomes.

On the flip side, I believe that negative actions and emotions, driven by greed, holding a grudge, hate, and bigotry create a toxic environment that lowers your immunity, increases stress hormones, blood pressure... Simply put, I believe that sustained hyperactivity of the "fight-or-flight" mechanisms of the sympathetic nervous system creates a downward health spiral.

I still adhere to many of the core values and lessons I learned in Mennonite church about magnanimity, volunteerism, nonviolence, and peace efforts. The Mennonites are one of two "Peace Churches" in the United States, the Quakers are the other. The Mennonite Disaster Service, provides both immediate and long-term responses to hurricanes, floods, and other natural disasters.
Do You Believe that a Higher Power Can Make You Healthy or Sick?
Brick Johnstone and colleagues at the University of Missouri (MU) have been conducting fascinating research on the positive and negative impact of having strong spiritual beliefs on someone's physical and mental health, as well as perceptions of pain. Johnstone is a neuropsychologist and professor of health psychology in the MU School of Health Professions.

In 2012, Johnstone et al published a paper, " Relationships Among Spirituality, Religious Practices, Personality Factors, and Health for Five Different Faiths," in the Journal of Religion and Health. This study analyzed the results of three surveys to determine if correlations existed among participants' self-reported mental and physical health, personality factors, and spirituality among: Buddhists, Muslims, Jews, Catholics, and Protestants.

Although a Christian wouldn't say that he or she was trying to achieve a state Nirvana, nor would a Buddhist monk say he had communed with Jesus Christ... each practitioner may well be referring to similar phenomena using a different vernacular. Ideally, all religous roads lead to the same place of loving-kindness and forgiveness.

The researchers found that despite differences in specific rituals and beliefs among the world's major religions, that being spiritual tended to improve someone's health, regardless of his or her actual religion. In a press release, Dan Cohen, assistant teaching professor of religious studies at MU and one of the co-authors of the study said,

In many ways, the results of our study support the idea that spirituality functions as a personality trait. With increased spirituality people reduce their sense of self and feel a greater sense of oneness and connectedness with the rest of the universe.

What was interesting was that frequency of participation in religious activities or the perceived degree of congregational support was not found to be significant in the relationships between personality, spirituality, religion and health.

Spirituality Essential Reads

Across all five faiths, a greater degree of spirituality was linked to better mental health, specifically lower levels of neuroticism and higher levels of extraversion. Interestingly, forgiveness was the only spiritual trait that predicted better mental health after all other personality variables were considered.

"Our prior research shows that the mental health of people recovering from different medical conditions, such as cancer, stroke, spinal cord injury, and traumatic brain injury, appears to be related significantly to positive spiritual beliefs and especially congregational support and spiritual interventions," said Cohen. "Spiritual beliefs may be a coping device to help individuals deal emotionally with stress."

Cohen believes spirituality may help people's mental health by reducing their self-centeredness and allowing them to develop a sense of belonging to a larger collective and something bigger than themselves. A sense of selflessness and magnanimity that can grow out of spirituality fortifies characteristics that are important for nurturing a global society based on the virtues of love, peace, and cooperation.
Believing that a Higher Power Is Punishing You Can Sabotage Health Outcomes
In September 2015, Johnstone et al published another study, " Relationships Between Negative Spiritual Beliefs and Health Outcomes for Individuals with Heterogeneous Medical Conditions," in the Journal of Spirituality in Mental Health.

The researchers found that Individuals who blame karma or a "divine curse" for their poor health tend to experience higher levels of pain and inferior physical and mental health. In a press release, Johnstone described this study saying,

In general, the more religious or spiritual you are, the healthier you are, which makes sense. But for some individuals, even if they have even the smallest degree of negative spirituality-basically, when individuals believe they're ill because they've done something wrong and God is punishing them-their health is worse.

For this study, Johnstone and his colleagues studied nearly 200 individuals to identify how their spiritual beliefs affected their health outcomes. Individuals in the study had a range of health conditions, such as cancer, traumatic brain injury or chronic pain. A control group in the study consisted of physically healthy people.

The researchers divided the individuals into two groups: a "negative spirituality group" who reported feeling abandoned or punished by a higher power, and a "not negative spirituality" group that consisted of people who didn't feel abandoned or punished by a higher power. Participants answered questions about their emotional and physical health, including physical pain.

Those in the negative spirituality group reported significantly higher perceptions of pain as well as worse physical and mental health. Those with positive spirituality reported better mental health. However, the researchers discovered that even if individuals reported general positive spiritual beliefs, having any degree of negative spiritual belief was found to contribute to poorer health outcomes.

"Previous research has shown that about 10 percent of people have negative spiritual beliefs; for example, believing that if they don't do something right, God won't love them," Johnstone said in a press release. "That's a negative aspect of religion when people believe, 'God is not supportive of me. What kind of hope do I have?' However, when people firmly believe God loves and forgives them despite their shortcomings, they had significantly better mental health."
Conclusion: Positive Spiritual Beliefs and Faith May Improve Your Well-Being
The new research from MU suggests that negative spiritual beliefs are correlated with reduced physical and mental health and increased perceptions of pain. Conversely, positive spirituality was correlated with better overall health and less pain. The researchers conclude that creating specific interventions to counteract negative spiritual beliefs could help some individuals decrease pain and improve their overall well-being.

There is one important caveat. All too often, there is a 'blame the victim' component inadvertently built into correlating good health with a person's mindset, spirituality, or having a positive attitude. Your sickness or health is not strictly linked to a belief system or explanatory style. Most deadly viruses and malignant diseases don't give a damn about your spirituality or religion.

Yes, optimists and people with positive spiritual beliefs may have a buffer against illness, but there are so many cancers, diseases, and plagues that can cause someone to get sick and die. In the 1980s, the AIDS epidemic decimated my community. In the Reagan Era, the double-whammy for any gay person with HIV/AIDS was that Christian conservatives and the homophobic religious right believed that people who contracted HIV were sinners and "deserved" to get sick and die.

On the other end of the spectrum, there was a "New Age" movement based on a spiritual belief in the power of "divine miracles" that unintentionally made some people who got and stayed sick subconsciously believe that they were spiritually inadequate or defective. There was an unspoken judgement that if you couldn't pray or meditate successfully enough to get better, that you were somehow "less than."

That said, any degree of negative spiritual belief-regardless of your positive spiritual beliefs-appears to be associated with worse health outcomes based on the latest research from MU. Therefore, developing targeted interventions that specifically address negative spiritual explanatory styles could benefit spiritual believers from all religions and those of us who have a secular faith in something universal and bigger than ourselves.

To watch my Stonewall Portraits interview about spirituality with Brian McNaught click here. I'm definitely not a poet, but I did write and publish a poem on p. 330 of The Athlete's Way (St. Martin's Press) based on my life experience and observations.
THE ATHLETE'S RECOGNITION by Christopher Bergland
Recognize that god is alive and well in every cell. Recognize that god is in us all.

Recognize this source of power-every hour, here. Recognize with strength and love there is no fear.

Recognize the light in every eye and soul. Recognize the sun lives in us all.

Recognize your thoughts and actions every day. Recognize the passion-always give your all.

Recognize One Blood, One Sun, One Hope, One Love. Recognize the collective conscience of humankind.

Recognize that god is living everywhere. Recognize that god is you and I.
If you'd like to read more on this topic, check out my Psychology Today blog posts:
© 2015 Christopher Bergland. All rights reserved.

Follow me on Twitter @ckbergland for updates on The Athlete's Way blog posts.

The Athlete's Way ® is a registered trademark of Christopher Bergland.

# data[].attributes.attachment_link.title
Negative Spiritual Beliefs Can Sabotage Your Well-Being

# data[].attributes.attachment_link.description
New research shows that people who believe that a higher power or "God" is punishing them with an illness tend to have significantly poorer health outcomes.

# data[].attributes.attachment_link.title
Religious/Spiritual Coping, Emotion Regulation, Psychological Well-Being, and Life Satisfaction among University Students - Lídia Graça, Tânia Brandão, 2024

# data[].attributes.attachment_link.description
Previous research has found that religious/spiritual coping, which is generally understood as the use of cognitive and behavioral strategies based on an individ…

# data[].attributes.attachment_link.readable_text
by * and *

Bowling Green State University, Bowling Green, Ohio 43403, USA

Authors to whom correspondence should be addressed.

1. Introduction

From its inception, religion has addressed matters of paramount importance to humanity, matters of life, suffering, and death. Major religions portray life as a sacred gift to be enjoyed and used wisely. There are countless religious injunctions for how to live life well, as well as warnings about the failure to do so. Yet, for all its attention to day-to-day issues of living, religion also speaks often and powerfully to the darker aspects of human existence. One of faith's most appealing characteristics is the promise to help humans understand and cope with pain and the prospect of life's end. People want to know how to avoid, ameliorate, and, ultimately, accept suffering and death. Throughout history, humans, individually and collectively, have implored supernatural forces to intervene on their behalf when faced with famine, human aggression, and plague. In the modern Western world, poor health remains a conspicuous threat to human well-being and many people turn to religion when they are ill. The health and social sciences have recognized this dynamic and have devoted considerable time and effort to understanding the causes and effects of religious coping with poor health.

There is already a voluminous literature concerning religious coping, so we will review some of the most recent work in the field, focusing solely on religious coping in samples of patients dealing with medical conditions. Although most of the evidence originates from North American samples, we have taken care to include findings that use European samples; there is unfortunately little recent work in this area outside of North America and Europe. We will first present a conceptual model of religious coping to assist the reader in understanding this phenomenon and associated research. In addition, we will report general findings on the prevalence and outcomes of religious coping. Beyond this preliminary overview, we will explore the functions of religious coping in greater detail, for we assume that religion serves multiple purposes in coping with illness. These purposes include promoting active coping with health problems, fostering emotional well-being, establishing and maintaining social support, and facilitating meaning making. Further, religious coping can help preserve the individual's perceived relationship with the sacred, which is often a valued outcome above and beyond whatever purely secular psychosocial benefits religious coping might have. Despite this list of positive functions, religious coping is not without drawbacks; therefore, we will also describe negative forms of religious coping that have been linked to a range of deleterious outcomes. In order to highlight the applicability of this research to clinical settings, we will then present some studies of psychospiritual interventions designed to improve patients' well-being. Finally, we will conclude with recommendations for future research and practice.

2. A Conceptual Model of Religious Coping

Coping is a universal human activity, for opportunity and adversity are universal human experiences. Psychologists use the term stressor to designate an event or situation that has some bearing on the fulfillment or frustration of human desires and that requires people to adapt in order to obtain or preserve valued ends (e.g., relationships, health, employment) [ 1, 2]. Health-related stressors often pose a risk to physical comfort, ability to function in diverse life contexts, and continued existence, among other things. Further, these stressors take many forms including the harmful physical effects of the illness itself, side effects of the treatment, the cost (in terms of both time and money) of seeking treatment, and the obstacles inherent in navigating the healthcare system. It would be easy to assume that such difficulties have a direct, straightforward effect on the individual, but theory and research stemming from Lazarus and Folkman's [ 2] account of coping have demonstrated that the individual's perception of, and response to, stressors is integral to understanding and predicting the outcomes of stress.

Lazarus and Folkman [ 2] contended that humans evaluate their circumstances to determine how they ought to respond to them. The first stage of this process, primary appraisal, entails discerning the possible consequences of the event. If it will likely lead to desirable outcomes or poses minimal risk to any of the individual's valued ends, there is no urgent need to respond to the event. If, on the other hand, the event represents a significant menace, additional evaluation is required. Primary appraisals typically classify stressors into one of three categories: challenge, threat, and loss. Challenges represent opportunities to achieve desired outcomes and are commonly considered to be positive stressors. Circumstances believed to reduce one's ability to maintain a valued object are appraised as threats and tend to create anxiety for the individual. Loss appraisals pertain to perceptions that the individual has already been deprived of something he or she values; the common reaction to loss is dysphoria. Upon deciding that an event is a stressor of significance to the individual, secondary appraisal occurs. In secondary appraisal, the person evaluates potential options for addressing the stressor and estimates the likelihood of successfully responding to it. Primary and secondary appraisal both contribute to the individual's reaction to stressors; stressors perceived as harmful and beyond the individual's ability to cope are particularly distressing [ 3].

Following the appraisal of a stressor, humans have two kinds of options for responding to the stressor [ 4]. Problem-focused coping refers to efforts to resolve the stressful situation itself. For individuals with medical conditions, this type of coping is likely to involve seeking treatment to cure the illness or alleviate its symptoms. In contrast, emotion-focused coping involves trying to mitigate the negative emotional consequences of the stressor. Patients may engage in emotion-focused coping by participating in mood-lifting activities.

Pargament [ 3] applied Lazarus and Folkman's [ 2] model to the sphere of religion. He defined religion as "the search for significance in ways related to the sacred" [ 3]. This definition of religion assumes that humans are agents who actively pursue personally significant or valued ends. Religious pursuits are those that incorporate the sacred, either as the goal toward which one strives or the means by which one hopes to reach a goal. Pargament's [ 3] definition of the sacred is not limited to deities, but includes anything the individual perceives to be divine or to have qualities of the divine-that which transcends mundane reality, possesses no natural boundaries or limitations, or is of ultimate significance. Sacred goals can take many forms, including communion with God or enlightenment about the nature of ultimate reality. Prayer is one possible sacred method to achieve the former, whereas meditation may be employed in service of the latter. It is also important to note that Pargament [ 3] does not assume that all forms of religious coping lead to positive outcomes. In concert with colleagues, he has identified harmful religious coping strategies that will be discussed further below [ 5, 6].

Religious coping occurs when a stressor related to a sacred goal arises or when people call upon a coping method they view as sacred in response to a stressor [ 3]. If life and health are sacred gifts for the individual, or if illness disrupts one's relationship with God, religious coping may be activated. Even if a sacred goal is not at stake, people may turn to religious coping methods to help them withstand and overcome stress in times of poor health. For example, they may pray for healing, guidance in health decisions, or emotional strength. They may look to faith communities for comfort and aid. Reflecting on core religious beliefs and concepts may help them gain perspective on their situation.

Central to Pargament's [ 3] theory of religious coping is the notion that it is critical to understand the functions of religious resources people call upon in stressful times; in fact, understanding the functions of religious coping is more valuable in predicting outcomes than understanding the forms of religious coping. In other words, it is not enough to know that someone prays multiple times a day or attends religious services every week or considers him or herself to be highly religious. The content of prayers, the types of support sought from faith communities, and the perspectives about what the stressor means in light of one's faith may vary dramatically across people performing the same religious behaviors or even within the same person across different stressors. For this reason, he argues that researchers should assess how patients use religious coping to deal with a particular stressor. In contrast, most researchers simply ask study participants about how much they engage in religious behaviors or consider themselves to be religious in general, assuming that these global variables capture the coping dynamic. Because these variables are more distal from the function of religious coping strategies in a particular situation, they may exhibit weaker, though similar, relationships to measures that assess the mechanisms involved in religious coping.

For the purpose of measuring religious coping in greater detail, Pargament et al. [ 5] developed the RCOPE. They generated 105 items intended to represent five theoretical functions of religious coping, including finding meaning, gaining control, gaining comfort and closeness to God, gaining intimacy with others, and achieving a life transformation. Factor analysis yielded 17 factors. For instance, the benevolent religious reappraisal factor contained items asking about the extent to which individuals viewed the stressor as having a positive, divinely ordained purpose. Other factors assessed the extent to which the individual believed he or she needed to work with God to resolve the problem or to wait passively for God to resolve it. These measures provide a more fine-tuned picture of religious coping than is afforded by more general measures. In addition, a 14-item version, the Brief RCOPE, was derived to give researchers a broader view of the extent to which individuals engage in positive and negative forms of religious coping [ 6]. The Positive Religious Coping subscale assesses efforts to maintain a positive connection with God, collaborate with God, find positive meaning in the stressor, and let go of negative emotions. The Negative Religious Coping subscale assesses perceptions of a disrupted or conflictual relationship with God and one's faith community, as well as loss of faith in God's power and belief that the devil caused the stressor.

In recent years, researchers have become more aware of the complex, multivalent nature of religious coping and have consequently included more specific measures of religious coping. Nevertheless, many continue to rely on global markers of religiousness, as will be seen in the following review.

3. Prevalence of Religious Coping

The majority of studies of religious coping in samples with medical conditions have taken place in the United States, which is well known for its citizens' reportedly high levels of religiousness. As one might expect, these studies tend to find that substantial proportions of patients engage in religious activities that may be construed as religious coping methods. In spite of the challenges people with health problems face in participating in public religious activities, sizable proportions of American samples make efforts to do so. For example, with respect to attendance at religious services, between 39% and 51% of HIV/AIDS and cancer patients reported attending services at least once per month [ 7, 8, 9]. Religious practices that may take place in private, such as prayer, meditation, or reading sacred texts, offer an option that is perhaps more accessible for those with health problems. Over a quarter of a sample of male and female patients with HIV/AIDS reported engaging in private religious activities between a few times a month and two or more times a week, while another third reported daily private religious activities [ 9]. In a study of cancer patients, 75% said they spent time in private religious activities at least once a month [ 8]. Although most studies using the Brief RCOPE do not provide prevalence rates of positive and negative religious coping, they generally suggest that patient samples make use of positive religious coping strategies more frequently than negative religious coping [ 8, 10, 11, 12, 13]. Tarakeshwar et al. [ 8] noted percentages of cancer patients who endorsed any use of negative religious coping strategies, breaking the results down by ethnicity and gender. Slightly over half of whites and a little over a quarter of non-whites reported engaging in any negative religious coping; 32% of males and 42% of females endorsed one or more negative religious coping items.

Other studies suggest that religious coping is not uncommon among European patients. Büssing, Fischer, Ostermann, and Matthiessen [ 14] presented nearly 1,700 patients in German hospitals with five items related to religion and religious coping, assessing the extent to which their faith was a stronghold even in hard times, their trust in a higher power, their belief that God would help them, their effort to live in accordance with religious convictions, and their use of prayer to become healthy. Approximately half of the patients endorsed each of the items. In a study of Swedish chronic pain patients, Andersson [ 15] noted that 37% of patients completely denied praying for an end to their pain or relying on faith in God or a higher power; he did not provide details about the degree to which the other 73%, engaged in these forms of coping, but it seems that they must have indicated at least minimal use of religious coping. Although Soothill et al. [ 16] did not measure actual use of religious coping resources, their study provides useful information on patients' perceived importance of religious coping. Of 189 cancer patients in England, 35%, 31%, and 18% described opportunities for personal prayer, support from people of their faith, and support from a spiritual adviser as important needs, respectively. Finally, over three fifths of hospitalized children between the ages of eight and 16 in Switzerland said they asked God for help or prayed to God for comfort [ 17].

Pargament [ 3] has argued that stress can trigger increases in religious coping. This process, termed the stress mobilization effect, may be responsible for contradictory findings across cross-sectional religious coping studies. That is, some studies find positive relationships between religious coping and distress, whereas others find negative relationships. Among studies of the former type, it may be that the tendency of people to turn to their faith in times of stress yields positive correlations between coping and distress; in contrast, the ability of religious coping efforts to ameliorate distress may produce the negative correlations seen in the former type of study.

We have selected two studies that demonstrate the stress mobilization effect. Balboni et al. [ 18] asked advanced cancer patients to report their religiousness (retrospectively) prior to and after being diagnosed with cancer. Reported church attendance significantly decreased, but private religious practices increased. Further, religiousness was positively associated with distress. Another illustrative case is a prospective longitudinal study of women being tested for breast cancer that assessed the women prior to diagnosis, one week prior to surgery to remove the cancer, and at multiple follow-up assessments up to two years after the surgery [ 19]. Women diagnosed with breast cancer showed an increase in seeking spiritual support (reassurance and comfort from God's love) from pre-diagnosis to around the time of their surgery, after which this form of religious coping declined. The strategies of providing spiritual support to others, focusing on religion to distract oneself from the cancer, and seeking spiritual transformation and new meaning in life increased in use following diagnosis and remained at elevated levels 14 months post-diagnosis. All in all, health-related stressors appear to predict increases in religious coping.

4. Religious Coping and Health-Related Outcomes

Having established that religious coping is a common response to health problems, researchers seek to determine whether religious coping is associated with any outcomes of interest. There is a sizable body of work intended to answer this question, and the general picture appears to be that religious coping is often related to important outcomes. We will present a brief survey of the correlates of religious coping in samples of patients.

Although the studies discussed above offer much evidence supporting the existence of correlations between religious coping and beneficial outcomes, they do little to further our understanding of the mechanisms through which religious coping is related to well being in people with medical conditions. Fortunately, there are many other studies that have attempted to elucidate this matter by testing associations between religious coping and variables that may promote health (e.g., active coping, emotional well-being, social support, meaning making). We review research that illustrates these relationships below.

5. Religious Coping and Active Coping

A common charge against religion has been that it prevents individuals from actively coping with their stressors because they wait for supernatural intervention that may never materialize [ 35]. Some of the most striking examples of this phenomenon are seriously ill people who refuse medical care due to their religious beliefs [ 36]. On the other hand, religious teachings that the body is a temple and that life is a divine gift may instill a sense of responsibility to care for one's body and maintain good health status. A study of college students found that those who viewed their bodies as linked to God or possessing divine qualities reported higher levels of health protective behaviors and general exercise and lower levels of unhealthy dieting practices and substance use [ 37]. The following studies suggest that the contribution of faith to attitudes and behaviors that foster health extends to people with medical conditions.

Religious coping has been linked to a variety of attitudes that might promote medical care. For instance, chronic cardiac patients in Crete who reported higher levels of intrinsic religiousness (i.e., valuing religion for its own sake rather than for the secular benefits it may provide) also indicated lower levels of helplessness [ 38]. In a sample of cancer patients, those who endorsed having more daily spiritual experiences indicated greater self-assurance [ 39]. Because perceived helplessness and lack of self-assurance may inhibit seeking medical care, religious coping may indirectly encourage actual help-seeking behavior by obviating these obstacles to treatment. In a sample of Latina breast cancer patients, a composite measure of spiritual beliefs, practices, and support was linked to greater perceived positivity of one's relationship with one's physician [ 40]. It seems reasonable to presume that people with positive relationships with their physicians would be more likely to seek medical care and cooperate with the medical advice they receive.

Beyond health-related attitudes, studies have demonstrated a range of ways in which religious coping may be related to actual health behaviors and active coping. Composite measures of religious beliefs and practices, as well as self-reported spiritual transformation, were related to more reports of making plans and taking action to resolve health problems in studies of cancer and HIV patients [ 21, 26, 41]. Other studies identify more specific health behaviors related to religious coping. Religious well-being has shown a positive association with knowledge about AIDS among African American men with HIV [ 42]. According to Friedman et al. [ 43], self-rated spirituality was related to less delay in reporting cancer symptoms to a medical professional after noticing the symptoms. Büssing et al. [ 14] reported that German patients who reported relying on God for help also reported higher levels of searching for health-related information, adhering to medical advice, and engaging in preventative health behaviors (e.g., exercise, healthy diet). Similar results were found in samples of cancer patients and individuals with congestive heart failure [ 39, 44]. A few studies have addressed medication adherence in HIV-positive samples. Two of them found better medication adherence among patients who had experienced a spiritual transformation or who believed that spirituality helped them cope with the side effects of medication [ 26, 45]; a third found no relationship between religious coping and adherence, but patients who said they used religious coping reported fewer reasons for failing to take their medication [ 46].

Religious coping is not always associated with an active approach to dealing with health problems, however. Multiple studies have not found relationships between religious coping and active coping [ 49, 50, 51]. Further, some studies indicate that religious coping may be negatively related to desirable responses to ill health. Among cancer patients in England, claiming to have a faith was linked to less perceived importance of health information [ 16]; if patients do not value health information, they may not obtain it and may therefore be less able to engage in health-protective behaviors. Over a quarter of a sample of African American women with breast cancer said they had only told God about their symptoms; these women reported greater delays in seeking medical care [ 52]. Samuel-Hodge et al. [ 50] likewise noted that in African Americans with diabetes, church attendance was related to taking less action to address the illness. HIV patients who said they believed God or a Higher Power controls their health were more likely to refuse antiretroviral medication [ 45]. These results are disconcerting and suggest religious coping may have a negative impact on cooperation with medical care.

To sum up, the evidence often suggests religious coping is a catalyst for active coping with health problems. However, there are also quite a few studies with contrary findings. It may be that there are moderator variables (e.g., the type of religious coping measure used, the demographic characteristics of the sample, the type of active coping assessed) that vary across studies and give rise to the differences in observed relationships between religious coping and active coping. More specifically, the main theme that emerges from the studies that find negative effects of religious coping on active coping is that some individuals believe they have no need of medical care if they have faith; they may passively defer any responsibility for protecting their own health, waiting for divine intervention. Pargament, Koenig, and Perez [ 5] included a subscale assessing this deferring style of religious coping in their RCOPE measure. Future studies of the deferring coping style may provide valuable insight into why this style develops and how to overcome it as an obstacle to medical care.

Our discussion of religious coping and health-related choices would be incomplete without a comment on end-of-life care. End-of-life care presents especially complex and significant issues for the medical field involving the financial cost of intensive measures, the ethical implications of choosing not to prolong life, and the designation of the appropriate person or group to make end-of-life decisions. Balboni et al. [ 18] reported that religiousness was associated with a desire to preserve life by any means necessary in a sample of advanced cancer patients. More recently, Phelps et al. [ 53] conducted a prospective, longitudinal study of advanced cancer patients to investigate the relationship of religious coping to end-of-life preferences, advance care planning, and the actual care received in the last week of life. Positive religious coping was related to active coping and acknowledgement of having terminal illness. Patients higher in positive religious coping were more likely to prefer heroic measures (doing anything necessary to prolong life, even if the patient will die within a few days) and less likely to engage in advance care planning (establishing Do Not Resuscitate Order, living will, or healthcare proxy). They were also more likely to receive mechanical ventilation and intensive life-prolonging care. One way of interpreting these results would be that patients who use religious coping maintain an active approach to handling their illness, or a "fighting spirit," all the way to the end of life. Alternatively, one could argue that these individuals are in denial of the inevitability of their demise. Considering the conflicting motivations to preserve life and contain healthcare costs, the influence of religious coping on end-of-life care will likely receive more attention in future research and public policy debates.

6. Religious Coping, Emotion, and Health

Religion has long been believed to have an effect on individuals' emotional well-being, and theories abound concerning the origins and mechanisms underlying this effect. Terror Management Theory asserts that one function of religion is to help individuals cope with the recognition of their mortality [ 54]. According to the theory, such recognition threatens to overwhelm the individual with terror, but religion offers people a chance to escape mortality by offering them some form of eternal existence. If mortality is more salient to people suffering from a medical condition, it stands to reason that religious coping could be a valuable asset in staving off noxious emotions for these individuals. Others have suggested that, in addition to reducing negative emotion, religious coping creates positive emotion by helping individuals believe they are connected to and valued by a divine presence [ 55].

The ability of religion to regulate emotion may be valuable in and of itself, but it takes on a special significance with respect to health. Psychoneuroimmunological research, the study of how psychological factors are interconnected with the nervous and immune systems, has indicated that emotions are linked to physical health. In fact, there is evidence that high levels of negative emotions create deleterious physical effects, whereas high levels of positive emotions cause beneficial physiological changes. Kiecolt-Glaser, McGuire, Robles, and Glaser [ 56] cited studies demonstrating that negative mood was related to lower levels of salivary antibodies and reduced activity of natural killer cells that may attack tumors and virus-infected cells. They also noted studies in which psychological interventions were associated with both lower levels of distress and better immune function. In their review of research on positive emotions and health, Cohen and Pressman [ 57] stated that there was some evidence (though not conclusive) that positive affect was related to lower morbidity and patient reports of fewer symptoms and less pain. If religious coping indeed impacts emotional states, emotion may therefore serve as a pathway for additional effects on health outcomes.

One common finding in research on religious coping is a negative relationship with depression. Studies that test the link between depression and measures of well-being, comfort, and strength derived from religion and spirituality and report that patients with greater levels of spiritual well-being indicate less severe symptoms of depression [ 28, 58]. Similarly, a longitudinal study tested the association between measures of spiritual striving, which included items about feeling alive and joyful, and depression among individuals with HIV/AIDS [ 32]. Participants who stated that they were striving to grow spiritually indicated being less depressed at a six month follow-up. However, studies such as these contain a significant limitation. Because they use measures of spiritual well-being that represent inherently positive emotional states, it is possible that they actually function as measures of the absence of depression and therefore have a built-in negative correlation with explicit measures of depression.

Much of the research on religious coping and emotional outcomes has been concentrated on the negative side of the equation, devoting comparatively little space to positive emotions and attitudes. Recent studies that do assess positive affect tend to support the existence of a positive relationship with religious coping. For example, a measure combining religious beliefs and practices was positively related to emotional well-being among cancer patients [ 21]. In a similar vein, Simoni, Martone, and Kerwin [ 7] found that a measure assessing prayer and spiritual activities, meditation and visualization, and finding new faith was associated with greater levels of psychological adaptation (i.e., high mastery, high self-esteem, low depression, and low distress). Belgian chronic pain patients who possessed a positive God image reported being happier [ 63], and a sample of German patients mainly suffering from chronic pain were more likely to be satisfied with themselves, their future prospects, and their overall life if they indicated trusting in God to help them [ 64].

Optimism, the expectation of positive outcomes rather than negative outcomes, is often tied to religious coping. Cardiac patients reporting strong, traditional religious beliefs tend to be more optimistic [ 25]. In a study by Cotton et al. [ 12] involving persons with HIV/AIDS, optimism was related to public, organized religious behaviors; private, nonorganized religious behaviors; and intrinsic religiousness. Other predictors of optimism and positive attitudes include self-reported increase in religiousness/spirituality [ 29], positive image of God [ 65], as well as private prayer and self-rated importance and degree of religious faith [ 66]. Religious coping may also have indirect effects on other outcomes by way of its relationship with optimism. In a sample of HIV/AIDS patients, optimism partially mediated the positive relationship between a composite measure of religiousness/spirituality and the belief that one's life had improved since being diagnosed with HIV/AIDS [ 67].

Despite the considerable amount of research supporting the contribution of religious coping to emotional well-being, a substantial subset of studies fails to find such relationships. Attendance at religious services, prayer, spiritual experiences, and self-rated importance of religion were unrelated to depression in coronary artery bypass patients [ 24]. Likewise, positive God image and a composite measure of religiousness were unrelated to distress among cancer patients [ 65], and general religious coping was unrelated to mental health outcomes in congestive heart failure patients [ 30]. Some studies of positive religious coping reported no relationship with depression or distress [ 13, 31], while other studies found positive relationships with depression, anxiety, and worry [ 23, 68]. Moreover, negative emotional and mental health outcomes have been associated with prayer [ 15, 69] and intrinsic religiousness [ 49]. As noted earlier, the stress mobilization effect is one possible explanation for these findings. If emotional distress triggers religious coping, a positive relationship between these two variables would be observed. In other samples, the opposing tendencies of distress to activate religious coping and of religious coping to reduce distress may cancel each other out, producing no observable relationship.

7. Religious Coping, Social Support, and Health

Social interaction is a ubiquitous facet of human life, and people typically place high value on and seek out positive interactions with others. More to the point, humans rely on each other for the fulfillment of basic needs; this exchange of assistance is called social support. Social support has been divided into four subtypes: instrumental, informational, appraisal, and emotional [ 70]. Instrumental support is intended to facilitate the achievement of a tangible goal and might consist of providing someone with necessary resources or actively working with the individual [ 71]. Informational and appraisal support are less direct means of assistance; the former involves sharing knowledge, whereas the latter entails guidance in decision making [ 71]. Emotional support refers to the positive interpersonal emotions of love, sympathy, understanding, and esteem [ 72]. Berkman et al. [ 71] detailed a comprehensive conceptual model of the ways in which social networks produce social support, which then impacts health through behavioral, psychological, and physiological pathways.

Religion has long been recognized as a social phenomenon, and religious organizations have the potential to be a major source of social support. Yet, a study by Balboni et al. [ 18] suggests there may be a discrepancy between the extent to which patients value social support from religious sources and their satisfaction with the amount of support they receive. The majority of advanced cancer patients in their sample said that receiving visits from chaplains or clergy was comforting, but 47% noted that their religious communities had not provided adequate support. Below, we review more studies to shed light on the relationship between religious coping and social support, as well as the effects of social support from religious sources.

Research often finds that religious coping is related to higher levels of social support. Composite measures of public and private religious activities, traditional religious beliefs, and positive religious coping have been positively related to social support in samples with cancer, HIV/AIDS, and heart conditions [ 7, 8, 25, 40]. In a study of Turkish women with breast cancer, seeking assistance from supernatural forces was related to better social functioning [ 73]. Striving for spiritual growth predicted greater social support six months after the initial assessment [ 32]. Cancer patients in England who endorsed having a faith perceived less need for help with loneliness and housework, which might imply that they receive more emotional and instrumental support than those without a faith [ 16]. On the whole, the evidence suggests religious coping and social support go hand in hand, though there are some studies that contradict this conclusion [ 20, 65].

There are several possible explanations for the link between religious coping and social support. One explanation might be that attending religious services may expand and strengthen the individual's social network such that there are more people who are willing and able to provide the individual with support in times of need. Further, groups that hold altruistic religious beliefs and values might be more willing to help ill members. For their part, patients who adhere to religious ideals might be more socially appealing and hence garner more favor from their acquaintances. An alternative explanation is that illness interferes with religious coping, especially public religious activities, thereby weakening the individual's social network. Participants in a qualitative study of Alzheimer's disease stated that their symptoms did make it more difficult to go to church [ 74]. On the other hand, patients may receive social support to help them maintain their religious lifestyles.

Whereas the studies discussed above utilized general measures of social support, others assess support specifically provided by religious communities. When religious communities as well as medical professionals assist patients with their spiritual needs, these patients report greater quality of life [ 18]. Congregational support has also shown positive relationships with general mental health and maintaining a healthy diet, as well as a negative relationship with substance use [ 44, 77]. Sometimes, religious social support can even be a life-saving resource. Military veterans with traumatic brain injury stated that the support they received from their religious communities helped them resist their desire to commit suicide [ 78]. Social support is not always related to positive outcomes, however. Johnstone and Yoon [ 79] found that congregational support was unrelated to health status in patients with stroke or traumatic brain injury. For Greek cancer patients, there was no relationship between social support received from one's faith community and any quality of life outcomes [ 20].

8. Religious Coping, Meaning, and Health

Meaning making has emerged as a prominent construct in the field of psychology. Park and Folkman's [ 80] seminal article explained the significance of meaning making and its relevance to coping. According to Park and Folkman, humans orchestrate their lives based on systems of global meaning, overarching theories about the way the world works and the individual's place in it. One typical feature of global meaning is the assumption that events generally unfold in the world in an orderly, predictable manner. Moreover, people usually expect positive outcomes to occur more than negative ones and that the nature of a person's circumstances corresponds to his or her quality of character - that is, bad things happen to bad, incompetent people, and good things happen to good, competent people; of course, most people believe themselves to be in the latter camp. Another component of global meaning is the sense that one is purposefully pursuing worthwhile ends. Park and Folkman asserted that religion is a prime example of a belief system that affords the individual with global meaning.

Park and Folkman [ 80] further explained that, occasionally, stressors threaten to undermine the global meaning system by contradicting core assumptions. Something unexpected or beyond human control happens, like an injury or an illness, and people's certainty about the "just world" in which they live, the loving God in whom they believe, or their own personal morality and competence on which they depend is shaken. Changing one's global meaning system may entail the significant costs of emotional upheaval, investment of personal resources in the search for plausible and functional new beliefs, and lifestyle adaptation. Hence, Park and Folkman contended, individuals prefer seeking situational meaning that resolves apparent incongruities between their experiences and their existing global meaning systems. They may try to identify the cause of the stressor so that they can retain belief in an orderly world and their own ability to control what happens to them. Another option is to reappraise the stressor as a source of positive changes or perceived benefits (e.g., spiritual growth, improved relationships). Just as religion contributes to global meaning, it also specifies strategies for finding situational meaning; religion's role in meaning making will be described in greater detail below.

Empirical evidence supports the theoretical relationship between religious coping and global meaning in patient samples. Tarakeshwar et al. [ 8] found that engaging in positive religious coping was related to believing that one is living a meaningful life, even after controlling for self-efficacy, depression, and demographic variables. Prostate cancer patients who reported that they valued religion for its own sake scored higher on the meaning/peace subscale of the FACIT Spiritual Well-Being scale; in contrast, valuing religion for the psychosocial benefits it confers (e.g., social recognition, comfort) was not related to greater reports of meaning/peace [ 58]. This may mean that in order to derive meaning from one's faith, one must be truly devoted to the substantive content of that faith. Experiencing spiritual transformation may also promote higher levels of perceived meaning and purpose in life, goal seeking, and acceptance of responsibility for one's choices [ 26]. In a longitudinal study of congestive heart failure patients, those who indicated using religious coping at baseline showed an increase in meaning in life six months later [ 30].

Beyond providing a sense of global meaning in life, religious coping may help patients reframe their illness in a larger spiritual context, which is a form of situational meaning making. For example, Pakistani and Iranian Muslim patients stated that they believed their medical conditions were gifts from God intended to strengthen their faith, absolve them of their sin, and foreshadow divine blessings in this life or the next [ 83, 84]. HIV patients who had reportedly experienced a spiritual transformation also endorsed higher levels of benefit finding and said they believed they had a meaningful reason for contracting their disease [ 26].

Further, there is evidence that the situational meaning that religious coping facilitates may in turn lead to additional positive outcomes. In a sample of people with HIV, a mixed measure of religious/spiritual variables was positively related to the tendency to reappraise HIV in a positive light and benefit finding [ 27]. Positive reappraisal and benefit finding mediated the negative relationship between religion/spirituality and depression; benefit finding also mediated the negative relationship between religion/spirituality and urinary cortisol, which has been linked to depressive symptoms and HIV disease progression.

9. Spiritual Struggle: The Dark Side of Religious Coping

Religious coping, especially among religious populations, is often assumed to be a powerful and valuable resource for well-being. Images of people calling upon a benevolent higher power for strength and comfort, finding solace in their faith communities, and serenely reminding themselves of a transcendent purpose for their experience of illness may readily come to mind. Indeed, we have presented research on the religious coping response to health problems that may be adduced as evidence for the power of religious coping to ameliorate suffering. To stop here, however, would be to overlook the reality of spiritual struggle, or negative religious coping. Instead of patiently turning to God, people with medical conditions may view their illness as an indication that God has abandoned or is punishing them; they might even experience distressing doubts about their faith. People who contract an illness through a behavior their religion classifies as sinful, such as drug use or sexual activity, may find themselves in conflict with or shunned by their religious community. These are just a few examples of the kinds of spiritual struggles that illness can occasion.

In terms of physical well-being, negative religious coping appears to be a liability. Scores on general measures of physical well-being and health were negatively related to spiritual struggle in a sample of patients with a life-threatening illness [ 31], as well as another sample of patients with traumatic brain injury, spinal cord injury, or stroke [ 79]. Cancer patients who were struggling spiritually reported greater pain and less energy [ 13]. Viral load and HIV symptoms were positively related to negative religious coping, whereas CD4 levels and quality of life were negatively related to it among HIV/AIDS patients [ 9]. Even more striking, negative religious coping predicted greater mortality risk over a two-year, prospective longitudinal study of medically ill older adults [ 88]. Although the mechanisms underlying the relationships described above have not been firmly established, one possibility is that negative religious coping may impair physical well-being by reducing patients' efforts to preserve their health and serving as a trigger for risk behaviors intended to distract them from their illness. In support of this hypothesis, Park et al. [ 39] noted that negative religious coping was associated with reduced adherence to medical advice and medication adherence, as well as higher levels of alcohol use among cancer patients.

Negative religious coping is associated with a variety of negative emotional outcomes and psychopathology. Zwingmann et al. [ 51] found that it was related to higher levels of depression and anxiety in German breast cancer patients. Studies of patients with HIV/AIDS [ 9] and other life-threatening illnesses [ 31] also reported positive relationships between negative religious coping and depression, and spiritually struggling cardiac patients indicated greater anxiety [ 10]. In the same sample of cardiac patients, negative religious coping was a risk factor for hostility and anger coping [ 10]. In addition, negative religious coping has been linked to posttraumatic stress symptoms in burn patients [ 11].

This brief review indicates that negative religious coping may have a variety of negative effects on outcomes in medical patients. Indeed, negative religious coping appears to be at least as potent of a predictor of undesirable outcomes as its positive counterpart is of beneficial outcomes. In light of these findings, this phenomenon likely warrants continued attention in future research.

10. Psychospiritual Interventions

Researchers have sought to capitalize on the evidence that religious coping has implications for people with medical conditions by designing interventions that incorporate religious or spiritual elements for the purpose of improving outcomes for patients. This area of work is still in the early stages of development, but it has significant potential for health care. We present findings from three different kinds of interventions to illustrate possible means of translating basic research on religious coping into practice.

Meditation has gained recognition as a potential intervention to foster physical and mental health. Despite the tendency of researchers and clinicians to portray meditation as a secular practice, it has roots in major religious traditions and may produce powerful spiritual experiences. Bormann et al. [ 92] preserved the spiritual aspect of meditation in a study of its effects on health outcomes. Ninety-three HIV-positive adults were randomly assigned either to a 10-week meditation group or to an attention control group [ 92]. The meditation group was received a collection of mantras (spiritual words or phrases) from a variety of religious traditions (i.e., Buddhism, Hinduism, Judaism, Islam, Christianity, and Native American traditions). They were then taught how repeat their mantra and focus on it during weekly sessions with group facilitators. Compared to the control group, the meditation group showed significantly greater reductions in non-HIV intrusive thoughts and trait anger over time, in addition to a marginally significant reduction in depression. Frequency of mantra repetition was positively correlated with quality of life.

A third approach to psychospiritual treatment is spiritually integrated psychotherapy [ 93]. In this approach, a mental health professional uses established psychological interventions while addressing religious/spiritual concerns and helping clients make use of religious/spiritual resources. Cole [ 94] developed a group therapy program consisting of eight weekly two-hour sessions for people diagnosed with cancer. The intervention deals with the themes of control, identity, meaning, and relationships. The therapist works with clients to identify and resolve spiritual struggle with each of these themes and promotes spiritual coping. In the pilot study of this program, nine cancer patients chose to participate in the therapy group and seven patients volunteered to receive no treatment [ 94]. Both groups were assessed before the treatment was initiated, shortly after the end of treatment, and two months post-treatment. The control group showed a marginally significant increase in pain severity from pre-treatment to post-treatment and a significant increase in depression from pre-treatment to the two-month follow-up. The levels of pain severity and depression remained stable in the treatment group. Therefore, the spiritually integrated psychotherapy intervention appeared to prevent cancer patients' physical and emotional well-being from deteriorating.

Conclusion

Based on our review of recent studies of religious coping, we believe there is ample evidence to conclude that religious coping is an important predictor of health-related outcomes among patients with medical conditions. It is a complex collection of beliefs, attitudes, and behaviors that may operate through an array of mechanisms, promoting active coping behaviors, emotional well-being, social support, and meaning making. Nevertheless, it may be a double-edged sword with the power to harm as well as to heal. Having surveyed the landscape of this field of inquiry, we hope that researchers will use this overview as a guide for their own exploration of the numerous questions that remain and that clinicians will find it helpful in their efforts to assist patients on the road to wellness.

Other aspects of research design deserve notice, as well. For instance, the field would benefit from more empirical studies of complex theoretical models specifying mediators and moderators of the relationships between particular religious coping strategies and outcomes. In order to make a stronger case for causal effects of religious coping on health, we need additional prospective longitudinal studies and, to the extent possible, randomized controlled trials of religious coping interventions. Studies of all kinds should statistically control for potential confounding variables, such as demographic variables and the severity of the participant's health condition. Last, greater attention should be devoted to the impact of religious and cultural differences on the religious coping-health relationship. Most studies have been conducted with Christian samples in the United States, whose inhabitants report moderate to high levels of religiousness. Investigations of Muslim, Jewish, Hindu, and Buddhist groups may reveal new forms and effects of religious coping. Similarly, studies conducted in the more secularized culture of European countries may yield results that differ from those obtained in the United States. For instance, a team of Dutch researchers [ 99] created a measure assessing individuals' trust that they will find meaning in and solutions to life's problems; in contrast to similar American measures that assume belief in an active, personal God, this measure does not specify the agent that will provide the individual with meaning and solutions. This measure was negatively related to anxiety in Dutch and Belgian samples, whereas a more theistic measure did not demonstrate such a relationship. Ideally, researchers will carry out comparative studies of representative samples from different religious groups and cultures so as to shed light on these important questions.

As for the practical implications of the findings reviewed above, the main point is that health professionals must not dismiss religious coping as irrelevant to their work. Like it or not, patients bring their own religious resources and struggles with them into the medical center. Religious coping may work in conjunction with medical treatment to promote health, or it may interfere with treatment goals, so it behooves practitioners to address these issues. We recommend handling religious coping with sensitivity, initiating conversation with each patient to determine whether the patient engages in religious coping or perceives personal spiritual needs. Health professionals should review published guidelines for assessing patients' spirituality [ 100]. In cases where religious coping is clearly relevant for the patient, one may encourage the patient's use of positive religious coping techniques, such as interacting with a faith community or participating in private religious activities. Lo et al. [ 101] suggested that a physician may choose to comply with a patient's request for prayer or for an accommodation for a religious ritual if the request is consistent with the physician's ethical, religious, and professional values. However, they added that health professionals should not feel obligated to do so, especially if the request disrupts medical care or conflicts with other patients' rights. Declining patients' requests must be done politely and in such a way that the patient feels his or her beliefs are respected [ 101]. Finally, it is important to gauge the patient's interest in services designed to promote positive religious coping and resolve spiritual struggle, referring interested clients to a chaplain, minister, or mental health professional who has developed competency in addressing spiritual issues [ 100]. We recommend reading Koenig's [ 102] book, Spirituality in Patient Care, for more in-depth guidelines about how health professionals might work with spirituality in their clinical practice. To achieve the best physical, psychological, and spiritual outcomes for patients, professionals from various disciplines will have to address religious coping cooperatively and with a solid understanding of the research on this topic.

AMA Style

Cummings JP, Pargament KI. Medicine for the Spirit: Religious Coping in Individuals with Medical Conditions. Religions. 2010; 1(1):28-53. https://doi.org/10.3390/rel1010028

Chicago/Turabian Style

Cummings, Jeremy P., and Kenneth I. Pargament. 2010. "Medicine for the Spirit: Religious Coping in Individuals with Medical Conditions" Religions 1, no. 1: 28-53. https://doi.org/10.3390/rel1010028

APA Style

Cummings, J. P., & Pargament, K. I. (2010). Medicine for the Spirit: Religious Coping in Individuals with Medical Conditions. Religions, 1(1), 28-53. https://doi.org/10.3390/rel1010028

# data[].attributes.attachment_link.title
Medicine for the Spirit: Religious Coping in Individuals with Medical Conditions

# data[].attributes.attachment_link.description
Religious coping now represents a key variable of interest in research on health outcomes, not only because many individuals turn to their faith in times of illness, but also because studies have frequently found that religious coping is associated with desirable health outcomes.

# data[].attributes.body
"Religion, as a buffer against psychological stress, has also been found to impact physiological indicators of stress, such as heart rate, blood pressure, and cor-tisol levels.1 In a sample of individuals with HIV/ AIDS, higher levels of religiosity, a sense of peace from religion, and faith in God, specifically, were associated with lower levels of urinary cortisol and lower levels of psychological distress and mental health problems.7 The association between religiosity and long-term survival in this sample was mediated by optimism, altruistic behaviors, and cortisol concentration."

"Involvement in religion is associated with enhanced positive psychological states, stress-buffering, and pro-tection against negative psychological states.1 Turning to religion as a form of distress tolerance is an adap-tive strategy that may support overall well-being and buffer against maladaptive behaviors and mental health difficulties"

# data[].attributes.body
"Several studies (Breitbart et al., 2010, 2015; Fraguell et al. 2018) have found that
the search for the meaning of life is fundamental in the experience with cancer. It
contributes to psychological and spiritual well-being, promotes mental adjustment
and feelings of satisfaction with life, improves emotional balance in the face
of disease, encourages transcendence and resilience, helping the psychological
adaptation to the disease and treatment process, thus improving quality of life."

Focus on life: Big Picture

“My family.”
“My children, my nephew, my God.”
“My daughters, right, I have a married daughter, grandchildren, and another
younger daughter, single, so they are the meaning of my life, ok ...”
“My children, family and niece.”
“God in the heart, communion with Him, family, neighbors.”
“Having God in my life.”

# data[].attributes.body
"Religious forms of coping may be particularly relevant and compelling for persons with schizophrenia (5,6), recurrent major depression (7), and other forms of severe mental illness because of the overall loss of hope, control, and purpose that these illnesses may engender. In fact, Lindenthal and associates (8) found that more internal or personal forms of religious expression, such as prayer, may come to the foreground as coping strategies precisely when psychological impairment and life crises increase. Sullivan (9) found that almost half of a group of 40 psychiatric outpatients perceived their spiritual beliefs and practices as crucial to their psychiatric improvement."

# data[].attributes.body
"A common report from those with schizophrenia is some type of religious belief that many medical practitioners consider to be delusional—such as the belief that they are possessed by demons, that a god is talking to them, that they themselves are divine beings, or that they are prophets.[5][6][7] Active and adaptive coping skills in subjects with residual schizophrenia are associated with a sound spiritual, religious, or personal belief system."

"These symptoms may cause violent behavior, either toward others or themselves.[22] In some instances, they may also experience distressing symptoms if they believe a god is inducing illness as punishment. The patient may refuse treatment based on religious speculation."

# data[].attributes.body
"The researchers divided the individuals into two groups: a "negative spirituality group" who reported feeling abandoned or punished by a higher power, and a "not negative spirituality" group that consisted of people who didn't feel abandoned or punished by a higher power. Participants answered questions about their emotional and physical health, including physical pain."

"The new research from MU suggests that negative spiritual beliefs are correlated with reduced physical and mental health and increased perceptions of pain."

# data[].attributes.body
Journal of Sakarya University Faculty of Theology was written by ____ and Said Sami, and I took a section of this journal and used the study as evidence. Throughout this section, there was a study done by an unknown research team (assumed to be associated with the authors), and it had over 10 participants who were diagnosed with PTSD. They asked religious related questions to see how during a traumatic time for them affected them. The article is #26 and was last updated in 2024. The article is based in Turkey, and there is little information on publishing because of the small section being used from a Turkish research book.

The intentions the author had with writing this piece were to examine the participants and their relationships with God (religion) after the Earthquake that had taken the lives of many. The author chose the formatting of charts, showing a P(#) next to everything that was said in the study, and overall showed how many participants related to each other and many had very similar responses. The intended audience is people who are most likely researching as well, and overall, reading the charts and understanding the reasons for the study. The document overall explains what religious coping is and how it affects humans. The author goes into rituals with religion and how they affect people the hardest when dealing with loss/mourning. There is an entire section about what trauma means, and how there can be growth from it with different coping mechanisms, and then it goes into religion as one.

This study was conducted in 2023, and overall has the most up-to-date research and no restrictions as you would if made any earlier. The author gives a neutral opinion about the positive and negative effects of religious coping, but shows an informational point of view. The only slightly controversial idea in this study is religion, and the author found a way to show religion without disrespecting either side of such. There was a loss before this study, and that was the main reason it was conducted.

The part of this article we don't get much information on is what the periods were exactly, besides the earthquake happening in early 2023? The content of the piece seems reasonably true because of the masses of evidence given after the study. The time period of this study matches up with common day knowledge, and overall the author covered every bit of the study with definitions before, then explanations after.

# data[].attributes.body
This article is a secondary source, speaks frequently about a specific person and theories. "The Meaning of Life and Religious Coping in the Fight
Against Cancer: A Study with Oncology Patients in Braziln Light of Viktor Frankl’s Theory" was written by authors from Springer Science and Business Media. 2023

This article was written to show the meaning of life and how this can be interpreted from different views, and it shows a religious sense as well. There are 19 participants. The intended audience is most likely researchers, and the formatting of the article is based on a study (ie charts, statistics). The document Viktor Frankl’s views and outlook on life, and how his studies apply to how many people feel internally. Overall the article is more philosophy-based rather then religion and the participants aren't based off only a specific illness.

The author speaks very highly of Viktor Frankl’s idealogies, and shows how this can apply to religion. The author doesn't show a bias, but throughout the entire artlcle there is no bias to be taken. The author shows a wide range perspective, since the study was very open and didn't stick a specific ideas (besides religion). While being written in 2023 the author's timelines add up with current research.

Since this article is study based, there is no room to see if theres anything specific being left out. We can verify the content of this piece because the study has been conducted by an actual company and journaling workforce.

# data[].attributes.body
'Religious Coping Is Differentially Associated with Physiological and
Subjective Distress Indicators: Comparing Cortisol and Self-Report Patterns" was written by Alison M. Haney and Sean P. Lane. This article consists of studies along with information based on cortisol and subjective stress, and overall, the mental toll life takes when dealing with trauma. The article was last updated in October 2023 and was written in September 2022.

This document exists because the study that had been done showed that religious coping improves mental health and overall physical health as well. This article intends to share how the participants' lives had changed for the better, and life became lighter since going into religion. I believe the intended audience is people who are researching and following charts and statistics. The article goes over the participants of different races and genders, and proves how, as a whole religion, it can change a person's mentality.

The author comes off neutral, but is fighting to show how religion can positively affect someone. The timeline of this piece is fairly recent and lines up with modern research. The only controversial show is speaking of religion, and the author remains completely neutral throughout the article.

We do not know if there is any part of the study being left out, but there are only positive results from the tests. We are unable to see the negative side of the story, but I don't believe it was purposely unaddressed. I believe the author was using the study to only show positive outcomes, not negative.

# data[].attributes.body
"Negative Spiritual Beliefs Can Sabotage Your Well-Being" was written by Christopher Bergland and was posted in late 2015. The article counts as a secondary source, referencing a college book article multiple times throughout.

This document was made for people to read, since its a public website and can even be considered a daily "news" source (not politically based, just stories). I believe the author wrote this to give an educated opinion on a topic. The document goes over why the author believes religious coping can affect the mind of people very negatively, and overall is passionate about that.

We can tell the author has came from a background of religion (mentions it). Even being written in 2015, I would assume it was written in the past year or two. The author seems to hold a stronger bias towards the negative, and hardly addresses the positive sides. The article can come off slightly contreversial, but any strong opinions are.

We aren't shown the positive side, and it is hard to verify the truth about this piece. There is negative affects from certain actions of course, but there is no verification of positive, which leads to the source being extremely opinionated. I believe the authors past situations leads them to leaving out certain ideas.

# data[].attributes.body
"Religious/Spiritual Coping, Emotion Regulation, Psychological Well-Being, and Life Satisfaction among University Students" was written by Lídia Graça and Tânia Brandão and was published in early 2024. This article seems to be a secondary source, referencing a study.

The intended audience is researchers and anyone who is interested in reading about the ideas taken from a study. The article goes over how individuals use religious coping mechanisms and how they use them to handle stress within their lives. I believe the author intended for this article to show the inside of peoples minds and how they use religion to alleviate their states of mind.

We can tell the author doesn't show a bias, and is neutral when it comes to a bit of a contreversial topic. The time period aligns with the current research, and aligns with other articles written about the same topic.,

The author shows no bias, but there is no confirmation of a "other side" not being shown. The article is confirmed to be true, since again its a company article and they use a study to reference their ideas.

# data[].attributes.body
"The Prevalence of Religious Coping Among Persons With Persistent Mental Illness" was written by Leslie Tepper, Ph.D., Steven A. Rogers, M.A., Esther M. Coleman, Ph.D., and H. Newton Malony, Ph.D. and was published in early 2001. The article proves to be a secondary source, referencing a study throughout the discussion.

This document exists because it shows us multiple examples from a study on how people with mental illness use religion as a form of coping. The intended audience is most likely other researchers and anyone who is reading up on studies. The article discusses how religious practices play a bigger role in people's lives than they actually think. The author shows their explanations to the evidence given (study).

The author shows no bias throughout this piece and remains completely neutral. The topic overall is completely controversial and focuses on mental health and religion and the author explains this well without picking a side.

The author holds no bias, and there is no confirmation if there is any evidence sticking out that wasn't shared. The website of this article is based off a psychology book, and this is a chapter that fits my research.

# data[].attributes.body
"Religion and Schizophrenia" was written by the Wikipedia team, and overall is a secondary source. The publishing date is unknown, and there are no updates given.

This document exists to show the effects religion can have when dealing with someone having schizophrenia, specifically. Overall the intentions of this article is to share knowledge and let it be open for anyone to read.

The author(s) show no biases, but there is full evidence from both sides given. The time period of this piece is not specific, but can be based on up to information from recent studies.

The author holds no bias, but the security of this article being fully true is unknown. Wikipedia can have anyone view/edit the articles, so I plan to use this article less than others. We don't know if there is any other edits to the article that is proven false.