SPIRITUALITY AS A MEANS OF COPING WITH CHRONIC ILLNESS

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Individuals with chronic illnesses often deal with intense physical and psychological stressors as a consequence of living with an illness. The purpose of this study was to explore the relationship between spirituality and coping ability. Participants with various chronic illnesses completed the Spiritual Involvement and Belief Scale (SIBS), the Coping Styles Scale, and a demographics questionnaire. A significant positive correlation was found between spirituality and the ability to cope. However, only one coping style, Intrusive Positive Thoughts, was found to be a significant predictor of spirituality. These results suggest that individuals who measure high in spirituality also tend to have a stronger and more diverse coping style and also tend to cope using a more positive outlook.

Holistic approaches to health care locus upon the relationships between a patient's mind, body, and spirit as necessary components or well-being. However, the spiritual dimension of this complex relationship is often left unattended (Miller, 1985). Yet, spiritual care to help patients cope with the psychosocial stress associated with illness is thought to he an important strategy among healthcare professionals, though research on the relationship between spirituality and coping ability remains relatively scarce. Consequently, it is important to explore the relationship between spirituality and the ability to cope with illness to aid healthcare professionals in developing useful interventions.

Patients with chronic illnesses often face an array of difficulties and Stressors, such as pain, feelings of uncertainty, and changes in body image, because these illnesses cannot be cured, only managed. These kinds of Stressors can lead to changes in well-being, to spiritual distress, and to the struggle with existential questions such as "what is the meaning of life?" (O'Neill & Kenny, 1998). Often these individuals search for relevant meaning and purpose in life, which may, in turn, bring out unresolved conflicts with other people and regret about certain life choices. The inability to resolve such conflicts may then lead to greater psychological distress, such as depression and anxiety.

How individuals cope with chronic illnesses is quite important to functioning and quality of life. Coping, defined as the process through which individuals try to understand and deal with significant personal or situational demands in their lives (Folkman, & Lazarus, 1988), can greatly impact ones perceptions about his/her own chronic illness. According to Folkman & Lazarus (1988), two general types of coping arc thought to be active in the coping response. Problem Solving Efforts include strategies to do something active or constructive about the situation that is perceived by the individual as threatening, harmful, or challenging. An example of this type of coping is seeking direct help from others in order to cope with illness. Emotion-focused Coping is more passive and involves strategies to gain emotional control or understanding of a stressful event. For example, individuals who focus upon acceptance of chronic illness are using emotion-focused coping.

For centuries, philosophers have examined the various dimensions of spirituality. Smith, Stefanek, Joseph, Verdieck, Zabora & Fetting (1995) have described spirituality as an underlying dimension of the conscious in which an individual strives for meaning, union with the universe and all things, and stresses the notion that spirituality extends to a power beyond us. This definition utilizes a subconscious or instinctual component to the human psyche, which drives an individual to seek meaning in his/her life. This definition also explains an individuals striving for a union with all creation and a belief in a power beyond one's control, possibly to a being or beings. In contrast, O'Neill and Kenny (1998) have proposed that when spirituality involves an individual's relationship with a higher being in connection with others, it takes on more of a 'religious' context. In this definition, a person's religion is the motivating factor in all aspects of his// her life, and spirituality emerges from religion. Hunglemann, Kenkel-Rossi, Klassen, & Stollenwerk (1996) have found spirituality to be a kind of growth process, which leads to a realization of the ultimate purpose and meaning of life. This definition is important because it suggests that spirituality is a process by which a person can grow and learn from both good and bad experiences in life.

It is important not to confuse the concept of spirituality with that of religion, because religion is a very complex variable in its own right and reflects its own distinct aspects. Religion and spirituality are said to overlap but are not conceptually the same. More specifically, religion refers to the external expression of faith, that is the inner beliefs or values that relate to God or any higher being. It is composed of beliefs, ethical codes, and worship practices that unite an individual with a moral community (Pargament & Jenkins 1995). Religion is a type of spiritual experience, which is part of an organized belief system, practices, and knowledge. These experiences are regarded as an expression of spirituality (O'Neill & Kenny, 1998). Spirituality, however, is broader than religion, and an individual can be spiritual without being religious. For example, those who participate in the Alcoholics Anonymous (AA) program participate in the spiritual aspects of the program, but are not, in many cases, religious at all (Hatch, Burg, Naberhaus, & Hellmich, 1998; Spalding, & Metz, 1997).

Some of the earlier research exploring the relationships between coping and religion, in which spirituality was a minor component, revealed mixed results because of the lack of an appropriate measure for religion. In tact, early research on religious coping is lacking because it failed to take into account all of the complex dimensions of religion (Hathaway & Pargament, 1991). Examples of these studies include those in which religiosity has been simplistically measured according to the frequency of church visits (Ventura & Boss, 1983) or the number of times per day a individual prays (Zuckerman, Kasl, & Ostfeld, 1984). While these two studies were quite important to the development of research in this area, they lack exploration of the many components of religious practice, beliefs, and behavior.

More recent research on coping and spirituality involved the combination of both spirituality and religion as interchangeable concepts. This research, for the most part, has found religion to be an important resource for coping. Aspects of religion, such as religious beliefs, practices, and relationships, are often used to assist individuals in coping with physical and psychosocial stress (Hathaway & Pargament, 1991). Pargament (1990) discussed different ways that religious coping efforts potentially assist those coping with stressful experiences. First, religion may be an element of coping through one's interpretation (e.g. a tragic situation is part of God's plan). Second, religion may affect coping by shaping the coping process (e.g. religious background may help an individual to fight addiction). Third, religion may be shaped by the coping process (e.g. a near-death experience may lead an individual to seek out organized religion). Pargament (1990) also defined three different types of religious coping. The Self-directing Style seeks to solve religious problems without God, the Collaborative Religious Coping Style involves both the individual and God solving a problem, and the Deferring Style is passive, whereas the individual waits for God to intervene in some way. Research evaluating the relationship between religion and coping in patients with cancer has identified significant correlations between religiousness and management of symptoms. Specifically, the presence of strong religious beliefs has been related to decreased levels of pain, hostility, and social isolation, as well as high levels of life satisfaction (Acklin, Brown, &: Mauger, 1983), and less depression (Bickel, Ciarrocchi, Sheers, Estadt, Powell, & Pargament, 1998).

Research on the concept of spirituality has provided evidence that it is an important coping strategy in its own right. A study by Fehring, Brennan, & Keller (1987) investigated the relationship between spirituality and psychological mood states in response to changes in life. In this study college students who were making the transition to living away from home for the first time completed the Spiritual Well-Being scale, a spiritual maturity scale, a life change scale, and a depression scale. Results suggested an inverse relationship between negative mood states and spiritual well-being, existential well-being, and spiritual outlook. Similarly, Gurklis & Menke (1988) illustrated the importance of spirituality in coping with a chronic illness. Participants completed a hemodialysis Stressor scale, a coping scale, and a general Stressor scale, and it was found that prayer, faith in God, and maintaining purpose in life were critical components of coping with illness. Further, Landis (1996) found a negative relationship between spiritual well-being and uncertainty, and a positive relationship between psychosocial adjustment and spiritual well-being. Smith, et. al. (1993) demonstrated that those who viewed death as a normal part of life also experienced less psychosocial distress. Additional research has noted the importance of spirituality in helping individuals cope with the anxiety associated with chronic illnesses. Kaczorowski (1989) found that in individuals with cancer, anxiety is lower in people who are highly spiritual.

These studies provide direct evidence of a potentially significant relationship between spirituality and an enhanced ability to cope with symptoms like anxiety, depression, and other forms of psychosocial distress associated with chronic illness. Consequently, the purpose of the present study was to explore the relationship between spirituality and coping with chronic illnesses in individuals with a variety of different chronic disorders. Results of this study may be important to assist health educators in the development and use of interventions in healthcare programs, which focus upon the stress associated with chronic illness.

METHOD
PARTICIPANTS
A total of 201 individuals served as subjects. The individuals were recruited from a variety of settings including physicians' offices, a nursing staffing company, a group of med-techs from a hospital, a Catholic prayer group, a local chapter of the Arthritis Foundation, a suburban fire company, an electrical supply company, a cancer support group, and a financial institution. This was done to recruit from a large, diverse pool of subjects.

All subjects were recruited by contacting a member from each group by phone and asking one of the members if their group would be interested in participating in a study on spirituality. Each respective member was then asked to recruit individuals at their workplace or at their monthly meetings. The recruiting was done using the same procedure for each organization. All potential subjects were asked whether or not they were living with a chronic illness. Those who answered "yes" were asked if they were interested in participating in a study on those with chronic illnesses. Employees who were interested were then given a packet containing the three questionnaires along with instructions to complete the surveys and instructions to place their responses into an envelop and seal it, which were then collected by the employee who recruited the subjects.

MEASURES/MATERIALS
The Spiritual Involvement and Beliefs Scale (SIBS) was used to assess spirituality (Hatch, et al., 1998). This instrument is a 39-item self-administered Likert scale, which assesses spirituality. It consists of 15 underlying principles of spirituality such as, purpose in life, faith, and trust (Cronbach's alpha, r = .92, test-retest, r = .92). Each respondent is asked to judge statements on a seven-point scale by circling how strongly he or she agrees with statements such as "Everything happens for a greater purpose." The authors contend that it consists of the following four factors of spirituality: External/Ritual, Internal/Ritual, Existential/Meditative, and Humility/Personal Application. The SIBS is the instrument used most frequently in research that measures spirituality as a relatively different construct from that of religion.

The Coping Style scale was included to measure the ability to cope (Nowack, 1990). This scale consists of a 20-item Likert scale format and assesses four coping styles. The first coping style, Intrusive Positive Thoughts (alpha, r=.72, test-retest, r=.62), measures one's ability to cope with a stressful situation through a positive outlook and is assessed through statements such as, "Focus my thoughts on the positive events of a situation." Intrusive negative thoughts (alpha, r =.79, test-retest, r=.66) includes looking at a situation in a negative way through such statements as, "Blame, criticize and put myself down for somehow creating the problem." Avoidance coping (alpha, r=.70, test-retest, r=.78) involves trying to ignore or escape the problem and is assessed through statements such as "Avoid thinking about it when h crosses my mind." Finally, Problem-focused coping (alpha, r=.68, test-retest, r=.70) is a method of dealing with stress through trying to do something active or constructive about the situation and is assessed through statements such as, "Develop an action plan and implement it to cope more effectively with situations in the future." On all items, each participant is asked to circle the response that best describes him/herself using choices including, "never", "rarely", "sometimes", "often" and "always." High scores on the scale indicate more positive and diverse coping.

Finally, a demographic questionnaire was also used and included questions on age, gender, religious affiliation, ethnic background, total income, type of chronic illness, and severity of the chronic illness.

PROCEDURE
All subjects were given instructions to complete the questionnaires and assured of their anonymity and confidentiality. Participants were then handed a packet containing the three questionnaires and asked to complete them. The participants were debriefed on the purpose of the study through a written debriefing statement, and thanked for their participation. The University Institutional Review Board approved this research for the Protection of Human Subjects in Research.

RESULTS
DEMOGRAPHIC CHARACTERISTICS
Frequency data were Formulated to describe the sample. Ages of the participants ranged from 18 to 86 years old (m=47.33, sd= 18.77), 67.3% were female and 32.7% were male, 82.2% were Caucasian, 15.8% were Asian American, 1% were African American, and 1% were Eastern Indian. Also, 57.4% of the participants were Catholic, 27.7% were Protestant, 3% were Jewish, 1% were Hindu, and 10.9% were "other". Relative to annual family income level, 23.8% earned less than $20,000, 30.7% earned between $20,000 and $34,999, 19.8% earned between $35,000 and $49,999, 7.9% earned between $50,000 and $74,999, 7.9% earned more than $75,000, 6.9% did not know, and 3% did not answer the question. The number of years of education ranged from 4 to 22 years (m=14.1), with 35.7% having completed between 9 and 12 years of education, 51.4% having completed between 13 and 16 years of education, and 12.9% having completed 17 or more years of education. All participants reported having a chronic illness, with 15.1% living with diabetes, 14.9% with cancer, 10.9% with chronic back pain, 9.9% with arthritis, 8.9% with hypertension, 3.7% with asthma, and 36.6% with various other conditions such as epilepsy, heart disease, and migraine headaches.

The participants also rated the severity of their illness using 4 possible choices. Forty-nine percent reported that their illness was not 'Very Debilitating', 25% reported that their illness was not 'Debilitating', 22% reported that their illness was 'Debilitating', and 4% reported their illness was 'Very Debilitating'.

INSTRUMENTATION EFFICACY
To explore the efficacy of the SIBS as a measure of spirituality, the 39 items from the scale were analyzed using unweighted least squares factor analysis. Two criteria were used to determine the number of factors to rotate, the scree test and previous research, which indicated that the items fell into a four-factor structure (Hatch et al. 1998). Four factors were rotated using a varimax rotation procedure. Results indicated that the items did not fall into a four-factor structure but instead fell into a general spirituality factor, which accounted for 52.4% of the variance (Internal consistency, r=.87). Consequently, analyses were conducted on both the scores of the overall scale and on the scores of the subscales (as recommended by the authors).

SPIRITUALITY AND COPING
To explore the relationship between spirituality (measured using the items that loaded into a general spirituality factor on the SIBS) and coping (measured by the total coping score of all four factors), the data were then analyzed using a Pearson's r correlation. A significant positive correlation was identified between scores on the SIBS scale and total scores on the Coping Styles scale (r = .382, p < .05), representing a moderate correlation.

A Stepwise Multiple Regression analysis was also conducted on the four factors of the Coping Styles scale, including Intrusive Positive Thoughts, Intrusive Negative Thoughts, Avoidance Coping, and Problem-focused Coping as predictors of spirituality. A significant prediction equation was found for Intrusive Positive Thoughts as a predictor of spirituality [F( 4,96)=36.45, MSe=566.295]. The multiple regression equation was y'=16.93+4.80 (Intrusive Positive Thoughts). The PIN value was .05 and the POUT value was .10. The slope for the predictor variable was, b=4.795, and the y-intercept was, a=16.931. The effect size was AdjR[sup2]=.26 (a small effect size), and the unpredicted variance was .74. The Intercorrelation Matrix between all of the variables can be seen in Table 1 and the Means and standard deviations of the items are reported in Table 2.

A multiple regression analysis using the Enter method was also conducted on the four factors of the Coping Styles scale, including Intrusive Positive Thoughts, Intrusive Negative Thoughts, Avoidance Coping, and Problem-focused Coping as predictors of spirituality. Again, a significant prediction equation was found (or Intrusive Position Thoughts as a predictor of spirituality [F( 4,96)= 10.293, MSc=359.168]. There were no significant relationships found for Intrusive Negative Thoughts (Beta=.04l, n.<.05), Avoidance Coping (Beta=.145, p<.05), or Problem-focused Coping (Beta=.131, p< .05) as predictors of spirituality. The multiple regression equation was y'=29.33+4.57 (Intrusive Positive Thoughts). The PIN value was .05 and the POUT value was .10. The slope for the predictor variable was, b=4.57, and the y-intercept was, a=29.33. The effect size was AdjR[sup2]=.27 (a small effect size), and the unpredicted variance was .73.

Finally, to explore the relationship between spirituality (measured using the items which loaded into a general spirituality factor on the SIBS) and the demographic variable of age the data were then analyzed using a Pearson's r correlation. A significant positive correlation was found between spirituality and age, r = .36, p < .05, representing a moderate correlation.

DISCUSSION
As predicted, a positive correlation between spirituality and the ability to cope was found. This correlation provides evidence that spirituality may be an important coping tool because it involves the use of several different coping styles. In particular, individuals who measured high in spirituality tended to show higher overall coping scores, which demonstrates more complete and diverse coping methods using all four coping styles. These findings arc consistent with previous research on spirituality as a tool for coping with stress relative to chronic illness (Gurklis & Menke, 1988; Miller, 1985; Smith et al., 1993; Kaczorowski, 1989). The results of the present study also provide evidence for the success of one particular type of coping style, Intrusive Positive Thoughts, as a significant predictor of spirituality for individuals living with a chronic illness. This method of coping involves managing a stressful situation through a positive outlook. These findings indicate that, for individuals living with a chronic illness, spirituality may be very influential to psychological well-being. Finally, the results of this study demonstrated a significant correlation between spirituality and age. This relationship may imply that spirituality increases as a function of age, possibly as a way to cope with the realization of ones own mortality (Hunglemannet al., 1996; Reed, 1991).

The results of the present study should be interpreted in light of several potential limitations. First, although all of the participants in the study reported having some sort of chronic illness, only a small percentage perceived his/her illness to be very debilitating. Future research should attempt to replicate this study using a more debilitated sample of individuals. Second, minorities were not well represented in this particular sample. Clearly, it is important to address ethnicity and culture relative to spirituality and coping with chronic illnesses. Third, the specific religions of the subjects were relatively homogeneous and it would be important to evaluate the impact of various types of religion on spirituality and coping. Finally, subjects in this sample had a fairly large range of chronic illnesses. It would be important in subsequent research to explore the relationships between spirituality and coping with individual who have the same or similar chronic illnesses.

T he results of this study are noteworthy and may have some practical implications to healthcare professionals helping individuals cope with chronic illnesses, especially for those who provide patient education and/or counseling, those who teach disease management skills, and those who conduct patient and/or family support groups. Any strategy or coping method that can help patients find a sense of purpose in life and connectedness to others has the potential to improve the quality of life and satisfaction for those who must cope regularly with chronic illnesses. Clearly, spirituality has a significant impact on coping and healthcare professionals may help patients better cope through the development of spirituality.

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED
Responsibility I — Assessing Individual and Community Needs for Health Education

Competency B — Distinguish between behaviors that foster and those that hinder well-being

Sub-competency 1 — Investigate physical, social, emotional, and intellectual factors influencing health behavior

Legend for Chart
A-
B-SPIRITUALITY
C-POSITIVE
D-NEGATIVE
E-AVOIDANCE
F-PROBLEM
Table 1. Intercorrelation Matrix for Spirituality and 4 Coping
Styles.
A B C D E F
SPIRITUALITY 1.00 .519[*] .018 .042 .383[*]
POSITIVE 1.00 .012 .333[*] .553[*]
NEGATIVE 1.00 -.218[*] .162
AVOIDANCE 1.00 .103
PROBLEM 1.00
p < .05[*]
Table 2. Means and Standard Deviations for Scores on SIBS Scale
and 4 Coping Styles.
Variables
M SD
SPIRITUALITY
101.71 27.70
INTRUSIVE POSITIVE THOUGHTS
17.68 3.00
INTRUSIVE NEGATIVE THOUGHTS
13.24 3.96
AVOIDANCE COPING
16.25 2.80
PROBLEM-FOCUSED COPING
16.01 3.12
REFERENCES
Acklin, M., Brown, E., & Mauger, P. (1983). The role of religious values in coping with cancer. Journal of Religion and Health, 22, 322-333.

Bickel, C. O., Ciarrocchi,J. W., Sheers, N.J., Estadt, B. K., Powell, D. A., & Pargament, K. I. (1998). Perceived stress, religious coping styles, and depressive affect. Journal of Psychology and Christianity, 17, 33-42.

Fehring, R.J., Brennan, P. F., Keller, M. L. (1987). Psychological and spiritual well-being in college students. Research in Nursing & Health, 10, 391-398.

Folkman, S., & Lazarus, R. S. (1988). Coping as a mediator of emotion. Journal of Personality and Social Psychology, 54, 466-475.

Gurklis, J. A., & Menke, E. M. (1988). Identification of Stressors and use of coping methods in chronic hemodialysis patients. Nursing Research, 37 (4), 236-239.

Hatch, H. L., Burg, M. A., Naberhaus, D.S. & Hellmich, L. K. (1998). The spiritual involvement and beliefs scale: development and testing of a new instrument. The Journal of Family Practice, 46 (6), 476-484.

Hathaway, W.L., & Pargament, K. I. (1991). The religious dimensions of coping: implications for prevention and promotion. Religion and Prevention in Mental Health, 64, 65-92.

Hunglemann, J., Kenkel-Rossi, E., Klassen, L., & Stollenwerk, R. (1996). Focusing on spiritual well-being: Harmonious interconnectedness of mind-body-spirit-use of the JAREL spiritual well-being scale. Geriatric Nursing, 17(6), 262-266.

Kaczorowski, J. M. (1989). Spiritual well-being and anxiety in adults diagnosed with cancer. Hospice Journal, 5(4), 105-116.

Landis, B. J. (1996). Uncertainty, spiritual well-being and psychosocial adjustment to chronic illness. Issues in Mental Health Nursing, 17 (3), 217-231.

Miller, J.F. (1985). Assessment of loneliness and spiritual well-being in chronically ill and healthy adults. Journal of Professional Nursing. 1 (2), 79-85.

Nowack, K.M. (1990). Initial development and validation of a stress and health risk factor instrument. American Journal of Health Promotion, 4, 173-180.

O'Neill, D. P., & Kenny, K. K. (1998). Spirituality and chronic illness. Image: Journal of Nursing Scholarship, 30 (3), 275-280.

Pargament, K. (1990). God help me. Toward a theoretical framework of coping for psychology of religion. Research in the Social Scientific Study of Religion. 26, 182-200.

Pargament, R. A., & Jenkins, K. I. (1995). Religion and spirituality and resources for coping with cancer. journal of Psychosocial Oncology. 13 (1), 51-75.

Reed, P.G. (1991). Self-transcendence and mental health in oldest-old adults. Nursing Research, 40 (1), 5-11.

Smith, E.D., Stefanek, M. E., Joseph, M. V., Verdicck, M. J., Zabora, J. R., & Fetting, J. H. (1993). Spiritual awareness, personal perspective on death, and psychosocial distress among cancer patients: an initial investigation. Journal of Psychosocial Oncology, 11 (3), 89-103.

Ventura, J. N., & Boss, P. G. (1983). The family coping inventory applied to parents with new babies. Journal of Marriage and the Family, 45, 867-875

Zuckerman, D., Kasl, S., & Ostfeld, A. (1984). Psychological predictors of morality among the elderly poor: The role of religion, well-being and social contacts. American journal of Epidemeology, 119, 410-423.

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By M. Michelle Rowe, Ph.D. and Richard G. Allen, M.S.

Address all correspondence to M. Michelle Rowe, Ph.D., Associate Professor and Chair, Department of Health Services, Saint Joseph's University, 5600 City Avenue, Philadelphia, PA 19131; PHONE: 610-660-1576

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