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April 2004 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Presbyterian, Philadelphia PA.


VandeCreek, L., Paget, S., Horton, R., Robbins, L. Oettinger, M. and Tai, K. "Religious and non-religious coping methods among persons with rheumatoid arthritis." Arthritis and Rheumatism 51, no. 1 (February 15, 2004): 49-55.


SUMMARY AND COMMENT: This recent descriptive study by VandeCreek, et al. focuses on rheumatoid arthritis (RA) as an illness with characteristics that "often prompt religious coping": namely, it "is chronic, can be painful, and compromises personal functioning" [p. 49]. The authors note at the outset that there has been little research in the area of RA and religious coping. Their effort here is to examine religious and non-religious coping in a sample of RA outpatients and "describe the relationship of personal characteristics and behaviors, including depressive symptoms, to...positive and negative religious coping methods" [p. 50]. Results, in brief, indicated that religious and non-religious coping methods each made "unique contributions to coping with RA," that "persons with few (or no) depressive symptoms who reported that religion was important to them tended to make positive use of their religion as they coped with the emotional stress of RA," and that "a significant number of self-reported depressive symptoms were correlated with the negative use of religion" [p. 49, abstract].

Outpatients being treated through the rheumatology division of an East Coast, urban, tertiary care hospital were contacted by mail and asked to complete questionnaires on religious coping (the RCOPE), non-religious coping (the COPE inventory), and depression (the Brief Depression Scale). The patients were promised $10 for returning a completed consent form and the questionnaires, two weeks later a second letter was sent to encourage response, and a week after that nonrespondents were sent another letter and a second copy of the questionnaires. A total of 181 questionnaires were returned, representing 40% of the total number of people approached. Central to the study was the RCOPE measure, with its five dimensions of religious coping assessed through 17 subscales. A very clear table of these dimensions and subscales is given on p. 51. Three other tables lay out well the statistical analysis of the responses in terms of the RCOPE.

The discussion section of the article is somewhat brief but highlights a number of interesting findings. For instance, religious coping (as measured by the RCOPE in relation to the COPE instrument) was found to have more of an emotional focus than a problem-solving one and that negative religious coping was found to be significantly associated not only with depressive symptoms but with increased worship attendance. On this latter point, the authors observe: "worship attendance can have diverse implications" [p. 54]. Also, "Multivariate results of RCOPE subscales associated with positive outcomes...consistently produced significant positive associations with the item, 'How important is religion/spirituality to you?' This suggests that when religion is viewed as important, it is experienced as relevant and available during coping efforts" [p. 52].

The authors have made an important contribution to the literature of religious coping by their sophisticated comparison of responses to the many subscales of the RCOPE and COPE measures. They implicitly make the case for the use of the RCOPE in future research, and indeed pastoral care researchers should read this study closely for a sense of the practical value of this measure. They also suggest that future research should "clearly examine the religious beliefs and assumptions within the RCOPE items" and should use the instrument with diverse population samples in order to "clarify the instrument's ability to gather valid and reliable comprehensive data" [p. 54] and increase confidence in the validity of results. [For more on religious coping, see the April 2003 Articles-of-the-Month page of this web site, and, specifically pertaining to the RCOPE, see: Pargament, K. I., Koenig, H. G. and Perez, L. M., "The many methods of religious coping: development and initial validation of the RCOPE," Journal of Clinical Psychology 56, no. 4 (August 13-27, 2001): 519-543.]

ADDITIONAL THOUGHTS ABOUT RA PATIENTS AS A STUDY POPULATION: According to VandeCreek, et al., RA patients contend with a disease whose characteristics "often prompt religious coping" [p. 49]: it is chronic, painful, and compromises personal functioning. Chaplains new to research should contemplate as a pragmatic strategy for selecting disease-based populations the identification of disease characteristics that may be affected by (or have an effect on) spirituality. Moreover, this descriptive study may suggest to pastoral care researchers various foci for interventional studies aimed at bolstering patients' religious coping.

There also could be on the horizon another line of spirituality research that may be brought to bear on a RA population: research that could be interventional and outcome-oriented, regarding the effect of spirituality on immune system function. At the April 1-3, 2003 conference, Integrating Research on Spirituality and Health and Well-Being into Service Delivery [described in the "Web Finds" section of the Spring 2003 Newsletter page of this web site], Bruce R. Rabin, MD, suggested that psychoneuroimmunology proffered great opportunity for the study of the relevance of spirituality to such diseases as rheumatoid arthritis that are affected by the immune system. Harold G. Koenig, Michael E. McCullough and David B. Larson, in The Handbook of Religion and Health (Oxford University Press, 2001), mention rheumatoid arthritis in their sub-section covering "Religious Involvement and Immune Function" [pp. 289-290], based upon studies that have focused on the likely immune system regulator interleukin-6. It should be noted that there appear to be no studies at present that explicitly examine the relationship between spirituality, immune function, and arthritis in particular; but chaplain researchers in hospital settings might explore the idea with rheumatologists in their institutions. Such research could look at the impact of spirituality on both psychological coping and physiological responses. Of course, other populations could be well suited for this research (e.g., HIV patients), and for a brief overview of studies that support connections between religion and enhanced immune function, see the assessment in Seeman, T. E., Dubin, L. F., and Seeman, M., "Religiosity/spirituality and health: a critical review of the evidence for biological pathways," American Psychologist 58, no. 1 (January 2003): 53-63 [listed below, in section II of Items of Related Interest].


Suggestions for the Use of the Article for Discussion in CPE: 

This month's featured article is rich enough to engage advanced researchers, but it could easily be read by students who have only a basic knowledge of research. Discussion might revolve around the characteristics of rheumatoid arthritis and how they may prompt religious coping, the concept of religious coping per se, or a number of the study's particular findings. Regarding research methodology, students should pay special attention to the paragraphs on the study's limits [p. 54], as the four limitations given here are perennial problems: the issue of whether the study population is sufficiently representative to support generalization of the findings, whether religious items in the questionnaire in any way biased responses, whether self-reporting via questionnaires is the optimum means of gathering data (and in this case not only because of concerns about subjective self-reporting but about possible physical limits of some RA patients to physically write on questionnaires), and about whether the instrument (i.e., the RCOPE) employs religious language or concepts too limited for the diversity of the respondents (pointing up the problem of creating any instrument that could work broadly across lines of religious diversity). Finally, students should be challenged by the authors' summary comment to be wary of how a complex phenomenon like religious coping can be misunderstood if it assumed to be a "simple, singular process" [p. 55].


Items of Related Interest: 

I. Articles pertaining to spirituality and rheumatoid arthritis:

Bartlett, S. J., Piedmont, R., Bilderback, A., Matsumoto, A. K. and Bathon, J. M. "Spirituality, well-being, and quality of life in people with rheumatoid arthritis." Arthritis and Rheumatism 49, no. 6 (December 15, 2003): 778-783. [This study of 77 patients found spirituality to be an independent predictor of happiness and positive health perceptions.]

Jones, P. B. B. and Faul, K. "Arthritis--a spiritual journey." Arthritis Care and Research 12, no. 6 (December 1996): 367-368. [This is not a report of original research but a brief essay on the role of spirituality in the lives of arthritis sufferers as they seek to cope with the disease.]

Keefe, F. J., Affleck, G., Lefebvre, J., Underwood, L., Caldwell, D. S., Drew, J., Egert, J., Gibson, J. and Pargament, K. "Living with rheumatoid arthritis: the role of daily spirituality and daily religious and spiritual coping." The Journal of Pain 2, no. 2 (April 2001): 101-110. [Thirty-five participants with rheumatoid arthritis were asked to keep for 30 days a structured journal that included several standardized measures. Results indicated the importance of daily spiritual experiences and daily religious/spiritual coping variables for patients with RA.]

Matthews, D. A. "Prayer and spirituality." Rheumatic Disease Clinics of North America 26, no. 1 (February 2000): 177-187. [This brief overview of spirituality and health works out of a case of a patient with rheumatoid arthritis and includes a section on the author's own study of intercessory prayer and RA.]

Potter, M. L. and Zauszniewski, J. A. "Spirituality, resourcefulness, and arthritis impact on health perceptions of elders with rheumatoid arthritis." Journal of Holistic Nursing 18, no. 4 (December 2000): 311-331. [This study of a convenience sample of 47 adults found significant correlations between spirituality and health perception and that "the social impact of arthritis was a significant independent predictor for spirituality" (--from the abstract).]


II. The following studies relating to spirituality and the immune system (but not particularly to rheumatoid arthritis) are discussed in Seeman, T. E., Dubin, L. F., and Seeman, M., "Religiosity/spirituality and health: a critical review of the evidence for biological pathways," American Psychologist 58, no. 1 (January 2003): 53-63. See especially pp. 56-57. [The article was highlighted in the May 2003 Articles-of-the-Month page.]

Ironson, G., Solomon , G. F., Balbin, E. G., O'Cleirigh, C., George, A., Kumar, M., Larson, D. and Woods, T. E. "The Ironson-Woods Spirituality/Religiousness Index is associated with long survival, health behaviors, less distress, and low cortisal in people with HIV/AIDS." Annals of Behavioral Medicine 24, no. 1 (Winter 2002): 34-48. [This article was featured in the February 2003 Articles-of-the-Month page.]

Koenig, H. G., Cohen, H. J., George, L. K., Hays, J. C., Larson, D. B., and Blazer, D. G. "Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults." International Journal of Psychiatry in Medicine 27, no. 3 (1997): 233-250.

[Added 2/10/05:] Lutgendorf, S. K., Russell, D., Ullrich, P., Harris, T. B. and Wallace, R. "Religious participation, interleukin-6, and mortality in older adults." Health Psychology 23, no. 5 (September 2004): 465-475.

Sephton, S. E., Koopman, C., Schaal, M., Thoresen, C., and Spiegel, D. "Spiritual expression and immune status in women with metastaic breast cancer: an exploratory study." The Breast Journal 7, no. 5 (September-October 2001): 345-353.

Sephton, S. E., Sapolsky, R. M., Kraemer, H. C., and Spiegel, D. "Diurnal cortisol rhythm as a predictor of breast cancer." Journal of the National Cancer Institution 92, no. 12 (June 21, 2000): 994-1000.

Woods, T. E., Antoni, M. H., Ironson, G. H., and Kling, D. W. "Religiosity is associated with affective and immune status in symptomatic HIV-infected gay men." Journal of Psychosomatic Research 46, no. 2 (February 1999): 165-176.


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