The Role of Religion in Medical Rehabilitation Outcomes.doc

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Rehabilitation Psychology 1999 by the Educational Publishing Foundation

November 1999 Vol. 44, No. 4, !"For #ersonal use only!!not $or distribution.

The Role of Religion in Medical Rehabilitation Outcomes

A Longitudinal Study

George Fitchett

%e#artment o$ Religion, &ealth, and &uman Values Rush!Presbyterian!'t. (u)e*s

+edical enter

Bruce D. Rybarcy!

%e#artments o$ Psychology and Physical +edicine and Rehabilitation Rush!

Presbyterian!'t. (u)e*s +edical enter

Gail A. DeMarco

%e#artment o$ Psychology Rush!Presbyterian!'t. (u)e*s +edical enter

"ohn ". #icholas

%e#artment o$ Physical +edicine and Rehabilitation -em#le niversity 'chool o$+edicine

ABSTRA$T

Objective: -o investigate the #rotective and consolation models o$ the relationshi#

bet/een religion and health outcomes in medical rehabilitation #atients.Design:

(ongitudinal study, data collected at admission, discharge, and 4 months

#ostadmission.Measures: Religion measures /ere #ublic and #rivate religiosity,

acce#tance, #ositive and negative religious co#ing, and s#iritual in0ury. utcomes

/ere sel$!re#ort o$ activities o$ daily living 23%(, mobility, general health,

de#ression, and li$e satis$action.Participants: 95 medical rehabilitation in#atients6

diagnoses included 0oint re#lacement, am#utation, stro)e, and other conditions.

Results: -he #rotective model o$ the relationshi# bet/een religion and health /as not

su##orted6 only limited su##ort /as $ound $or the consolation model. 7n regression

analyses, negative religious co#ing accounted $or signi$icant variance in $ollo/!u#

3%( 2"8 over and above that accounted $or by admission 3%(, de#ression, social

su##ort, and demogra#hic variables. 'ubseuent item analysis indicated that anger

/ith :od e;#lained more variance 298 than the $ull negative religious co#ing scale.

Conclusions: Religion did not #romote better recovery or ad0ustment, although it may

have been a source o$ consolation $or some #atients /ho had limited recovery.

Negative religious co#ing com#romised 3%( recovery. 3lthough anger /ith :od

/as rare, it may be use$ul in screening $or #atients /ho are s#iritually at ris) $or #oorrecovery.

7n recent years, a considerable body o$ research has emerged regarding the

relationshi# bet/een religion and health 2 @arry, 199 6 +atthe/s > 'aunders, 199? . +atthe/s et al.

2199= revie/ed a number o$ studies indicating that religious belie$s and #ractices had

a #ositive e$$ect on #reventing illness, on recovery $rom surgery, on reducing mental

illness, and on co#ing /ith illness. &o/ever, #artici#ants in a recent national

con$erence concluded that more research is needed that addresses the role o$ religion

$or #ersons /ith disabilities and rehabilitation #atients 2nder/ood!:ordon, Peters,@i0ur, > Fuhrer, 199? .
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-hree di$$erent associations bet/een religion and health have been #ro#osed. Religion

may #lay a #rotective role in health, #reventing health #roblems or aiding in recovery

or ad0ustment to health #roblems, leading to #ositive associations bet/een measures

o$ religion and health. -hese e$$ects have been sho/n $or a /ide variety o$ grou#s,

including community sam#les 2 'tra/bridge, ohen, 'hema, > +anheimer, 199" , trans#lant #atients 2 &arris et al., 199" , dialysis

#atients 2 *@rien, 19=B , and general medical #atients 2


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their res#ondents believed :od /as #unishing them, and B?8 /ere losing #ur#ose in

li$e. 'alisbury et al. 219=9 re#orted that B"8 o$ their #atients /ere angry /ith :od,

and a similar #ro#ortion /ere as)ing /hy :od allo/ed them to su$$er.

3 study by Pressman, (yons, (arson, and 'train 2199G /ith G /omen /ho

under/ent hi# re#lacement surgery /as one o$ the $irst em#irical investigations o$ therole o$ religion in the recovery and ad0ustment o$ medical rehabilitation #atients. -hey

re#orted that, at discharge, more religious #atients had better ambulation and less

de#ression. 7dler 2199" studied 145 #atients at a rehabilitation clinic and $ound that

5B8 re#orted that religion hel#ed them /ith their health #roblems. onsistent /ith

the consolation model, she $ound that #atients /ith higher levels o$ disability /ere

more li)ely to re#ort see)ing hel# $rom religion. 'he also $ound that more religious

#atients had better sel$!rated health, #ointing to the im#ortant role o$ religion in

hel#ing #atients maintain a sub0ective sense o$ health and /ell!being in the midst o$ a

disability. Finally, Riley et al. 2199= recently e;amined di$$erent ty#es o$ s#iritual

/ell!being in B15 cancer and medical rehabilitation in#atients. luster analysis

identi$ied three grou#sD #atients /hose religious belie$s #rovided meaning, #atients/ith an e;istential sense o$ meaning, and a third grou# o$ #atients /ho had no sense

o$ meaning, either religious or e;istential. Patients in the third grou# had lo/er

uality o$ li$e and li$e satis$action than those in the other t/o grou#s.

-here are several im#ortant limitations in the e;isting research on religion in medical

rehabilitation #atients. ith the e;ce#tion o$Pressman et al. 2199G , the studies have

been cross!sectional, limiting tests o$ hy#otheses about the role o$ religion in recovery

$rom and ad0ustment to disability. -he studies have used limited measures o$ religion,

$ocusing mainly on sel$!re#orted levels o$ religiousness, religious belie$s, and

meaning and #ur#ose in li$e. None o$ the studies have used measures o$ religious

co#ing, /hich have been sho/n to #redict ad0ustment to a variety o$ li$e stresses over

and above measures o$ religious belie$ and #ractice and nonreligious co#ing 2

Pargament, 199? . Furthermore, and o$ #otential greatest interest $or clinicians, none

o$ the studies e;amined the #otential negative e$$ects o$ religious belie$s or #ractices

on recovery and ad0ustment $or medical rehabilitation #atients.

-he #resent study /as designed to $urther understanding o$ the role o$ religion in

medical rehabilitation #atients. 7t had three s#eci$ic aims. -he $irst aim /as to study

the religious #rotection hy#othesis, com#aring cross!sectional and longitudinal

analyses. '#eci$ically, /e hy#othesiCed that higher levels o$ s#iritual and religious

belie$s, #ractices, acce#tance, and #ositive religious co#ing and lo/er levels o$negative religious co#ing and s#iritual in0ury /ould have a #ositive im#act on the

recovery and ad0ustment o$ rehabilitation #atients. -he second aim /as to test the

religious consolation hy#othesis. '#eci$ically, /e hy#othesiCed that #atients /ho did

not sho/ im#rovement in $unctioning over the course o$ the study /ould re#ort

higher levels o$ #rivate religiosity and #ositive religious co#ing at the end o$ the

study. -he third aim /as to identi$y any religion items that #redicted #oor

rehabilitation outcomes in these #atients. -his /ould allo/ clinicians to develo# items

to screen $or s#iritual ris). 'imilar to other ris) $actors, s#iritual ris) assesses the

#otential contribution o$ religion to #oor medical outcomes.

M%T&OD
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Sam'le and (rocedure

'tudy #artici#ants /ere recruited bet/een 3#ril 199? and Hanuary 199= $rom

consecutive admissions to the in#atient medical rehabilitation units o$ a large

mid/estern medical center. nli)e other medical rehabilitation #atients, #atients

admitted to the medical rehabilitation unit /ith a diagnosis o$ Par)inson*s disease/ere generally not e;#eriencing a ma0or change in their health status and /ere

e;cluded $rom the study. Patients* cognitive im#airment /as assessed, via their

orientation to time, #lace, and #erson, by the nursing sta$$ and con$irmed by the study

intervie/er. 3##ro;imately BG8 o$ the #atients screened $or inclusion in the study

/ere eliminated on the basis o$ not being oriented in all three s#heres or not having

English as their #rimary language. Potential study #artici#ants /ere intervie/ed by a

research assistant /ho described the #ur#ose o$ the study and its #rocedures. Patients

/ho chose to #artici#ate in the study signed an in$ormed!consent $orm.

ne hundred t/enty!one #atients /ere a##roached to #artici#ate in the study, and 114

consented 2948. 'tudy #artici#ants /ere intervie/ed /ithin " days o$ admission tothe unit and as close as #ossible to discharge $rom the unit. 3 $ollo/!u# tele#hone

intervie/ /as com#leted 4 months a$ter admission. 3dditional diagnostic data /ere

obtained $rom the #atient*s medical record. -he average length o$ the #artici#ant*s

in#atient hos#italiCation /as 14."1 days 2 SD I ?.?. $ the 114 #atients /ho

com#leted admission intervie/s, 95 com#leted 4!month $ollo/!u# intervie/s 2=48.

$ the 1= #atients /ho did not com#lete $ollo/!u# surveys, 11 could not be reached,

" declined to #artici#ate, and B sho/ed signs o$ cognitive im#airment. -he average

time bet/een these t/o intervie/s /as 1." days 2 SD I 1".1?.

-he study #artici#ants ranged in age $rom B9 to =5 years 2M I 5".B years, SD I 11.5.

'i;ty!seven #ercent o$ the #artici#ants /ere $emale, 5=8 /ere aucasian, and B58

/ere 3$rican 3merican. -hirty!seven #ercent o$ the #artici#ants /ere married, and

B?8 /ere /ido/ed. -he mean educational level /as 1B.9 years. Forty!nine #ercent

o$ the #atients had a hi# or )nee 0oint re#lacement. -he remaining #atients had

various diagnoses, including stro)e 21?8, am#utation 21?8, deconditioning 258,

neuromuscular /ea)ness 28, laminectomy 28, multi#le sclerosis 2B8, s#inal

tumor 218, bro)en #elvis 218, and arm in$ection 218.

Forty!three #ercent o$ the #artici#ants identi$ied themselves as atholic6 4B8, as

Protestant6 "8, as He/ish6 and B8, as having no religious a$$iliation. Eight study

#artici#ants identi$ied other religious a$$iliationsD Hehovah*s itness 2 n I 1, +ormon2 n I 1, nitarianJniversalist 2 n I 1, +oslem 2 n I 1, rthodo; hristian 2 n I

1, and uns#eci$ied 2 n I . -he distribution o$ religious a$$iliations o$ the study

#artici#ants /as consistent /ith all admissions to the medical center and /ith the

general #o#ulation o$ the county in /hich the study /as conducted 2 @rady, :reen,

Hones, (ynn, > +cNeil, 199B .

Measures )nde* of religiosity.

-his $our!item measure consists o$ t/o B!item subscales, #ublic and #rivate

religiosity. -hese items have been /idely used in e#idemiological studies 2 7dler,

19=? 6 7dler >


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one*s #lace o$ /orshi#. Private religiosity measures the e;tent o$ the res#ondent*s

#erceived religiosity and the levels o$ strength and com$ort that come $rom religion.

-able 1 re#orts the scale #ro#erties and ronbach al#ha coe$$icients obtained $or the

religion measures used in the study.

Brief Religious $o'ing Scale +Brief R$O(%,.

-he @rie$ RPE re#resents a $urther stage in the /or) o$ Pargament and colleagues

to develo# a broad measure o$ religious co#ing 2Pargament, 199? 6 Pargament, 'mith,

PereC, 199= . -he instrument has t/o subscales that assess #ositive and

negative religious co#ing. 7ndividuals are as)ed to rate ho/ much they used these

activities to co#e /ith their disability on a 4!#oint (i)ert scale ranging $rom not at all

2G to a great deal 2. For the #resent study, /e modi$ied the original B1!item scale,

selecting 1? items that /ere a##ro#riate $or a study o$ co#ing /ith disability. 3n

e;am#le o$ an item measuring #ositive religious co#ing is 7 loo) to :od $or things

li)e strength, su##ort, and guidance in this situation. 3n e;am#le o$ an item

measuring negative religious co#ing is 7 /onder /hether :od has abandoned me. 7nthe original B1!item @rie$ RPE, the #ositive and negative co#ing scales had al#ha

coe$$icients o$ .=? and .?=, res#ectively.

S'iritual )n-ury Scale.

-he '#iritual 7n0ury 'cale 2 @erg, 1994 consists o$ eight items that assess an

individual*s sense o$ being troubled by guilt, resentment, or disbelie$ in :od. -he

items are scored /ith a 4!#oint (i)ert scale ranging $rom never 21 to very often 24. 3

sam#le item is &o/ o$ten does anger or resentment bloc) your #eace o$ mindK 7n a

sam#le o$ male veterans in a substance abuse #rogram, the al#ha coe$$icient $or the

scale /as .?9, /ith signi$icant #ositive and negative associations /ith other measures

o$ religious belie$s and activities in the e;#ected directions 2(a/son, %rebing, @erg,

Hones, > Pen), 199= . 7n the #resent study, /hich included another measure o$

de#ression, the t/o items measuring grie$ and ho#elessness /ere omitted to reduce

res#ondent burden.

Acce'tance.

-he s#iritual com#onent o$ acce#tance /as de$ined as the ability to $ind meaning in

li$e des#ite disability, or the sense that one*s value as a #erson transcended one*s

#hysical abilities. 7t /as measured /ith $ive items ta)en $rom (in)o/s)i*s3cce#tance o$ %isability 'cale 219?1 .-he items /ere chosen by $ive e;#ert 0udges

2#sychologists and cha#lains /ho com#ared all o$ the items $rom the (in)o/s)i

scale /ith the 0ust!noted de$inition o$ the s#iritual dimension o$ acce#tance. Patients

/ere as)ed to rate, on a 5!#oint (i)ert scale, ho/ much they agreed /ith statements

about meaning and satis$action in li$e. 3 sam#le item is -hough 7 am disabled or ill,

my li$e is $ull.

Selfrated health.

Previous research has sho/n that one!item measures o$ sel$!rated health are highly

#redictive o$ scores on larger sel$!re#ort measures o$ health 2 'te/art, &ays, > are,19== and mortality 2 7dler >


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o$ religion on recovery and ad0ustment to become evident. 2%ischarge data are

available $rom :eorge Fitchett.

Aero!order correlations /ere used to identi$y the religion variables that could have a

#rotective e$$ect on recovery and ad0ustment. +ultivariate regression euations, /ith

controls $or baseline measures and other signi$icant variables, /ere used to test the#rotection hy#othesis. -he consolation hy#othesis /as tested by com#aring the mean

$ollo/!u# scores on #rivate religiosity and #ositive religious co#ing $or #atients /ith

no recovery and #atients /ith recovery in mobility and somatic autonomy. Private

religiosity and #ositive religious co#ing /ere selected $or this test because they are

good measures o$ the mobiliCation o$ religious belie$s and activities in the $ace o$

stress.

R%S1LTS

$haracteristics of the Sam'le and Study Measures

-able B re#orts descri#tive statistics $or the study variables. Eighty!$ive #ercent o$ the

study #artici#ants described themselves as $airly or dee#ly religious, and ?=8

re#orted that they received a great deal o$ strength and com$ort $rom religion. -hirty!

$ive #ercent o$ the res#ondents re#orted that, in the #revious year, they usually

attended #ublic /orshi# once a /ee) or more. -he average score $or #ositive religious

co#ing 21".? $ell near the mid#oint o$ the #otential range, and the scores /ere

normally distributed. Negative religious co#ing scores ranged $rom G to 9 2#otential

rangeD G to B1, /ith a mean o$ 1.". -/o thirds o$ the #artici#ants had scores o$ G or 1,

and another BG8 had scores o$ only B or . -he mean s#iritual in0ury score 2=.? /as

also lo/ relative to the #otential range 25JB4.

3s can be seen $rom -able ,the correlations among the measures o$ religion at

admission /ere /ea) to moderate 2 r s I .BB to .5G, suggesting that these variables

measured distinct dimensions o$ religion. -he stability o$ the measures o$ s#irituality

and religiosity used in the study /as also e;amined. 3s can be seen $rom-able B ,

three o$ the measuresL#ublic religiosity, #rivate religiosity, and #ositive religious

co#ingLhad moderately high correlations bet/een baseline and the 4!month $ollo/!u#

2 r s I .? to .=4. For the other three measuresLnegative religious co#ing, s#iritual

in0ury, and acce#tanceLthere /as more change bet/een baseline and $ollo/!u#

scores, as can be seen in the lo/er correlations ranging $rom .4= to .55.

3t baseline, the #artici#ants in the study had moderate somatic autonomy 2 M I =.9

and lo/ mobility control 2M I 1.= scores. nly 158 could not /al) at all, but a

large ma0ority needed assistance /ith bathing 2?58, and many needed assistance

/ith getting dressed 24?8. 3t the 4!month $ollo/!u#, most o$ the #artici#ants had

achieved a high level o$ somatic autonomy 2M I 14., but the overall level o$

mobility control /as still uite lo/ 2M I 4.4. 3t admission, nearly hal$ 24"8 o$ the

#artici#ants rated their general health as #oor or $air6 at the 4!month $ollo/!u#, this

#ro#ortion had decreased to B=8. Paired t tests indicated that the change in all three

o$ these measures /as signi$icant.

&i# and )nee 0oint re#lacement #atients had higher levels o$ $ollo/!u# somaticautonomy than stro)e #atients and #atients /ith other diagnoses 2M s I 1".?, 11.=,
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and 11.4, res#ectively,F 24, 9G I ".=9,p M .GG1. Hoint re#lacement #atients 2M I

"., #atients /ith deconditioning 2M I 5.G, and #atients /ith am#utations 2M I 4.4

all had better $ollo/!u# mobility control than stro)e #atients 2M I 1.B,F 24, 91 I

".5=,p M .GG1. 3t the 4!month $ollo/!u#, education /as #ositively associated /ith

mobility control 2 r I .BB,p I .G. Race /as associated /ith somatic autonomy,F 2,

91 I .1,p I .GB6 hite #atients had higher levels than @lac) #atients 2M I 1".Gvs. 1B.". 3ge, gender, and marital status /ere not associated /ith any di$$erences in

recovery or ad0ustment.

-he recommended threshold score o$ /as used $or a diagnosis o$ de#ression 2

estlund, 199B 6 at admission, 4?8 o$ the

#artici#ants in the study re#orted three or more sym#toms o$ de#ression. -his /as

slightly higher than the rates that have been re#orted in other rehabilitation

#o#ulations 2Nanna, (ichtenberg, @uda!3bela, > @arth, 199? 6RybarcCy) et al.,

199" 6 RybarcCy), inemiller, (aCarus, &aut, > &artman, 1995 . 3t the 4!month

$ollo/!u#, the #ro#ortion o$ #artici#ants /ith three or more sym#toms o$ de#ression

dro##ed to ?8. 3 #aired t test revealed that this change /as not signi$icant. Hointre#lacement #atients had lo/er levels o$ de#ression than stro)e #atients and #atients

/ith other diagnoses 2M s I 1.4, .B, and .?, res#ectively,F 24, =? I ".15,p M .

GG1.

Religion as a $orrelate and (redictor of Reco0ery and Ad-ustment

-able 4#resents the correlations bet/een religion and recovery and ad0ustment at

$ollo/!u#. -able "#resents the correlations bet/een admission religion measures and

$ollo/!u# recovery and ad0ustment.

7n those cases in /hich there /ere signi$icant correlations bet/een admission religion

and $ollo/!u# recovery and ad0ustment, /e $ollo/ed u# /ith regression analyses,

controlling $or im#ortant covariates. ontrols $or race and diagnostic grou# /ere

included because o$ signi$icant di$$erences in somatic autonomy associated /ith these

variables. Previous research has #ointed to the im#ortance o$ controls $or de#ression 2

Nanna et al., 199? and social su##ort 2 RybarcCy) et al., 199" .

-able 5 re#orts the only signi$icant results $rom these analyses. 3$ter control $or

admission somatic autonomy, race 2recoded into t/o grou#sD @lac) and other,

diagnostic grou#, social su##ort, and admission de#ression, negative religious co#ing

at admission /as a signi$icant negative #redictor o$ $ollo/!u# somatic autonomy. -heinclusion o$ negative religious co#ing in the analysis #roduced anR B increase o$ .G" 2

p I .GB.

Religious $onsolation and (oor Reco0ery

%i$$erences bet/een admission and $ollo/!u# measures o$ somatic autonomy and

mobility control /ere used to divide the study #artici#ants into t/o grou#sD those /ho

had no change or sho/ed a decrease in $unctioning and those /ho sho/ed any

im#rovement in $unctioning. sing #aired t tests, /e com#ared the mean scores $or

$ollo/!u# #rivate religiosity and #ositive religious co#ing $or these t/o grou#s.

%i$$erences in im#rovement in somatic autonomy /ere not associated /ith anydi$$erences in the t/o religion measures. %i$$erences in im#rovement in mobility
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control /ere associated /ith a di$$erence in #ositive religious co#ing. Partici#ants

/hose mobility control had not changed or had /orsened 2 n I G had higher #ositive

religious co#ing scores than those /hose mobility control had im#roved 2M s I 1=.41

and 14."?, res#ectively, t 29B I B.1",p I .G.

Selecting Religion Screening )tems

-he signi$icant relationshi# bet/een baseline negative religious co#ing and $ollo/!u#

somatic autonomy suggested that $urther analysis be conducted to determine /hich

negative co#ing items might be #redictive o$ #oor recovery. 3 ste#/ise regression

analysis entering all seven negative religious co#ing items /as #er$ormed, /ith

baseline somatic autonomy entered $irst. nly the item 7 e;#ress anger at :od $or

letting this ha##en entered the euation 2I .B9",p I .GG. -he addition o$ this

item to a regression euation /ith baseline somatic autonomy #roduced anR B change

o$ .G9 2p I .GG. Figure 1 illustrates the minimal 3%( recovery $or the 5 #artici#ants

/ith any level o$ anger /ith :od at admission.

D)S$1SS)O#

-he correlational data o$ the #resent study are consistent /ith the #rotective model o$

religion as a resource $or medical rehabilitation #atients and #ersons /ith disabilities.

3t admission 2 -able , #ublic and #rivate religiosity and acce#tance /ere #ositively

associated /ith sel$!rated general health, and acce#tance /as inversely associated

/ith de#ression. 3t $ollo/!u# 2 -able 4 , #ublic religiosity, #rivate religiosity,

#ositive religious co#ing, and acce#tance /ere #ositively associated /ith li$e

satis$action. 3cce#tance /as also #ositively associated /ith mobility control and

general health and negatively correlated /ith de#ression. Furthermore, admissionscores on #ublic religiosity, #ositive religious co#ing, and acce#tance /ere #ositively

associated /ith $ollo/!u# li$e satis$action, and acce#tance /as inversely associated

/ith $ollo/!u# de#ression 2 -able " .

3lthough the correlational data $rom this study a##ear to lend su##ort to the

#rotective model, the results o$ the regression analyses controlling $or baseline levels

o$ each de#endent measure and other im#ortant covariates sho/ed that religion made

no #ositive contribution to recovery or ad0ustment $or this sam#le. -hat is, the #resent

study did not con$irm the #rotective model o$ the relationshi# bet/een religion and

health. 'everal $actors may have #layed a role in this result. -he longitudinal design

o$ our study and the use o$ multivariate analyses, controlling $or the e$$ects o$im#ortant covariates, #ermitted a more rigorous test o$ the #rotection hy#othesis than

$ound in most #revious studies o$ the contribution o$ religion to the recovery and

ad0ustment o$ medical #atients. ur $indings suggest that religion may be better

understood as a covariate than a cause o$ better health and ad0ustment. Furthermore,

religion may $unction di$$erently $or #ersons /ho are $acing long!term disability 2e.g.,

stro)e or am#utation than those /ho are $acing short!term im#airment but long!term

im#rovement 2e.g., #atients /ith 0oint re#lacement. -he diagnostic heterogeneity o$

our sam#le may have introduced di$$erences in the role o$ religion in recovery and

ad0ustment that yielded no signi$icant #rotective e$$ects. Further research, es#ecially

longitudinal studies, /ill be needed to clari$y religion*s #ossible #rotective role in the

recovery and ad0ustment o$ medical #atients. 'tudies that e;#lore the role o$ religion
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in homogeneous grou#s o$ #atients /ith diseases that have di$$erent courses and

outcomes /ill be es#ecially hel#$ul.

-he results o$ this study did #rovide limited su##ort $or the consolation hy#othesis.

Partici#ants /ho su$$ered a loss o$ mobility control or /ho had no recovery had

higher #ositive religious co#ing scores than those /ho had im#rovement in mobilitycontrol. &o/ever, the study design did not include a measure o$ stress or #re!illness

measures o$ religiosity. @oth /ould be reuired $or a more rigorous test o$ the

consolation hy#othesis.

-he #resent study also demonstrated that some negative $orms o$ religious co#ing,

although uncommon, can com#romise recovery. orrelational analysis revealed that

negative religious co#ing and s#iritual in0ury /ere associated /ith #oor ad0ustment

cross!sectionally and longitudinally. &o/ever, in the regression analysis, /hen

controls $or baseline values /ere included, these $indings /ere not signi$icant. 7n

contrast, in regression analyses, negative religious co#ing #redicted #oorer recovery

o$ somatic autonomy even /ith controls $or baseline values, accounting $or "8 o$ thevariance.

3lthough small, the amount o$ variance e;#lained by negative religious co#ing is

note/orthy $or several reasons. 7t e;ceeded the #redictive value o$ any other

#sychosocial variable in this study and baseline 3%( and /as nearly eual to the

variance e;#lained by diagnostic category 2 -able 5 . Furthermore, although negative

religious co#ing /as signi$icant as a #redictor o$ only one o$ the three recovery

variables 23%(, there /as less change in the other t/o recovery variables, thereby

reducing the li)elihood o$ signi$icant associations /ith any #redictor. Finally, it

should be noted that in a com#arable study t/o #sychological variables, de#ression

and cognitive status, also #redicted similar change in 3%( 2?8 but not change in

mobility 2Nanna et al., 199? .

7t is di$$icult to e;#lain /hy negative religious co#ing /ould have an im#act on

measures o$ recovery but not ad0ustment. %i$$erent $orms o$ co#ing have been sho/n

to in$luence medical outcomes through a variety o$ #ath/ays 2 'tone > Porter, 199" .

-hese in$luences can occur through both behavioral and cognitiveJa$$ective

#ath/ays. 7t may be that negative religious co#ing a$$ects outcomes through strictly

behavioral #ath/ays 2e.g., decreased com#liance, #roblem solving, or motivation or

in$luences other cognitiveJa$$ective #ath/ays not measured in this study 2e.g., ho#e,

an;iety, learned hel#lessness, or anger.

-he $inding that anger /ith :od #redicted #oorer recovery a##ears to run counter to

the idea that $eelings o$ anger, /hether anger /ith :od or other angry $eelings, are a

#otentially constructive dynamic in ad0ustment to illness or disability. &o/ever, it is

consistent /ith other recent /or) on negative religious co#ing and religious red $lags

2i.e., religious or s#iritual #roblems involving ris) $or com#romised recovery.

3mong older medically ill #atients, negative religious co#ing has been associated

/ith higher levels o$ de#ression and lo/er uality o$ li$e 2

Nielsen, 199= . 7n a study o$ church members and college students /ho had

e;#erienced negative li$e events, anger /ith :od /as one o$ the strongest #redictors

o$ #oor ad0ustment among 11 ty#es o$ ine$$ective religious co#ing 2Pargament,Ainnbauer, et al., 199= . Finally, among #rimary caregivers o$ hos#ice #atients,
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a##raisals o$ :od as #unishing un$airly or as not caring /ere in$reuent but

signi$icantly correlated /ith de#ression and an;iety 2 +ic)ley, Pargament, @rant, >

&i##, 199= .

hy did #atients /ho /ere angry /ith :od have #oorer recoveryK ne #ossibility is

that some #atients may $ocus long!standing generaliCed anger and resentment on :odat a time o$ crisis. 7n the #resent study, anger /ith :od at admission /as #ositively

associated /ith an item on generaliCed anger $rom the '#iritual 7n0ury 'caleD &o/

o$ten does anger or resentment bloc) your #eace o$ mindK 2 r I .",p M .GG1.

&o/ever, in a regression euation, generaliCed anger at admission /as not a

signi$icant #redictor o$ $ollo/!u# inde#endence in 3%( 2I G.15G,p I .?=,

/hereas anger /ith :od /as signi$icant 2I .G"5,p I .GG1, suggesting that the

negative e$$ect o$ anger /ith :od on recovery cannot be e;#lained by the e$$ects o$

generaliCed anger.

3nother #ossibility is that some #atients /ho $eel angry /ith :od are con$licted about

this $eeling and $ind it di$$icult to e;#ress or /or) through their anger 2 Pargament,

Ainnbauer, et al., 199= . 7n contrast, there may be another grou# o$ #atients /ho $eel

angry /ith :od, are able to e;#ress and resolve that emotion, and invest in their

recovery 2 Pargament, 199? 6 Pargament, 'mith, et al., 199= . %ata $rom the #resent

study ma)e it clear that anger /ith :od is not associated /ith lac) o$ interest in

religion6 all 5 #atients /ho endorsed this item described themselves as $airly or

dee#ly religious. Further research is needed to hel# determine /hether there are

di$$erent ty#es o$ anger /ith :od and identi$y those #atients $or /hom it may

com#romise recovery $rom or ad0ustment to illness or disability.

-he #resent study has several limitations. First, the sam#le included #atients /ithdiagnoses that have di$$erent #rognoses $or im#roved mobilityLs#eci$ically, 0oint

re#lacement #atients, stro)e #atients, and #ersons /ith am#utationsLbut subgrou#s

/ere not su$$iciently large to #ermit se#arate analysis. -he diversity o$ this sam#le

may have obscured some o$ the role o$ religion in ad0ustment and recovery $or these

#atients.

'econd, the signi$icant $indings $or negative religious co#ing occurred in only one o$

the $ive recovery and ad0ustment measures. -his raises uestions about /hether

negative religious co#ing has a broader im#act on outcomes. &o/ever, it should be

noted that somatic autonomy sho/ed the greatest amount o$ change among the

outcome measures over 4 months 2see -able B . 'imilarly, in theNanna et al. 2199?study, de#ression and cognitive status #redicted 3%( but not mobility outcome.

-hird, three o$ the measures o$ religion used in this study had lo/ coe$$icients o$

internal reliability 2see-able 1 . -his raises the #ossibility that the null $indings are a

conseuence o$ measurement limitations.

Finally, the main outcome variables used /ere #atients* sel$!re#orts o$ $unctional

ability and ad0ustment rather than clinician ratings /ith a standardiCed instrument

2i.e., Functional 7nde#endence +easure6 :ranger > &amilton, 199 . n$ortunately,

the rehabilitation unit /here the study /as conducted /as in the #rocess o$ ado#ting a

ne/ rehabilitation sta$$ rating scale, so clinician rating data /ere not available $or use
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in this study. linician ratings o$ $unctional status and de#ression /ould have

#rovided an im#ortant com#arison /ith #atient sel$!re#orts.

-/o $indings $rom the study should be o$ interest to #sychologists and other

clinicians /or)ing in medical rehabilitation. First, at discharge, #artici#ants /ere

as)ed /hether they had received any counseling $rom a #sychologist during theirhos#italiCation. -/enty!nine #artici#ants 2G8 re#orted that they had received

counseling. 'i; o$ these #artici#ants also re#orted that they had discussed s#iritual

issues /ith the #sychologist. 7n com#arison /ith those /ho did not discuss s#iritual

issues, #artici#ants /ho re#orted discussing s#iritual issues /ith the #sychologist

/ere more li)ely to evaluate the counseling they received as very hel#$ul 2B98 vs.

5?8. +edical rehabilitation #atients may /elcome a #sychologist*s inuiry about

their religious belie$s and #ractices as #art o$ a com#rehensive assessment.

'econd, the $inding that anger /ith :od /as #redictive o$ #oor recovery o$ $unctional

ability should be o$ interest to #sychologists, cha#lains, and other clinicians /or)ing

in medical rehabilitation. 3t #resent, there are no reliable instruments that enableclinicians to screen rehabilitation #atients to determine those /ho may have religious

red $lags. -he $inding in the #resent study suggests that consideration should be given

to including a uestion about $eeling angry /ith :od in com#rehensive initial

screening o$ medical rehabilitation #atients. Further assessment should be conducted

to determine /hether #atients /ho e;#ress anger /ith :od have long!standing

#roblems /ith anger, #ersonality disorders, or other #roblems that reuire

#sychological treatment. onsideration should also be given to re$erring such #atients

to a cha#lain or #astoral counselor $or more in!de#th s#iritual assessment 2Fitchett,

199a ,199b and $or #astoral counseling. 7nterested clinicians /ho have not

received any training in addressing the religious dimension o$ their #atients* lives can

$ind in$ormation in a variety o$ resources 2e.g., see Eiesland, 1994 6Fitchett, 199a ,

199b 6 Pargament, 199? 6 'ha$rans)e, 1995 6 see alsoJournal of Religion Disability

and !ealt" that /ill assist them in integrating an understanding o$ the religious and

s#iritual dimension o$ li$e into their clinical #ractice.

References

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Pargament,


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Pargament, +c'herry, E. 219=9. linical management re#orting

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'tra/bridge, . H., ohen, R. %., 'hema, '. H. >


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ReceivedD November 1B, 199=RevisedD Huly B, 1999

3cce#tedD Huly 5, 1999

-able 1. 'cale Pro#erties o$ 3dmission Religion +easures

-able B. +ean 'cores, 'tandard %eviations, and orrelations $or 3ll +easures at

3dmission and Follo/!#


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-able . 3dmission orrelations


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-able 4. orrelations o$ Religion +easures ith Recovery and 3d0ustment at

Follo/!#


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-able ". orrelations o$ 3dmission Religion +easures ith Follo/!# Recovery and

3d0ustment


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-able 5. &ierarchial Regression 3nalysis o$ Follo/!# 'omatic 3utonomy 23%(

Figure 1. 3nger /ith :od and recovery in activities o$ daily living 23%(.


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