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April 2013 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Exline, J. J., Prince-Paul, M., Root, B. L. and Peereboom, K. S. "The spiritual struggle of anger toward God: a study with family members of hospice patients." Journal of Palliative Medicine 16, no. 4 (April 2013): 369-375.



This month's study "...examined the frequency and correlates of anger toward God, along with preferred ways of managing such anger, among family members of hospice patients" [p. 369]. The research addresses an issue pertinent to the work of chaplains and moreover one that is "not always apparent in brief assessments" [p. 373], due to such factors as feelings of "shame or fear that can accompany feelings of anger toward God" [p. 373]. While the focus here is particularly on families of hospice patients, the data help fill out the broad picture of the dynamic of anger toward God in healthcare settings generally.

The study was part of a larger project [--see Items of Related Interest, §I, below] and analyzed data from 134 surveys (out of a total sample of 298) from a not-for-profit hospice association in the Great Lakes region of the US. Included in the survey was the Attitudes Toward God Scale-9, which our Research Network previously noted in a pre-publication form in our January 2009 Article-of-the-Month feature and which has since been formally published in "Development, refinement, and psychometric properties of the Attitudes Toward God Scale (ATGS-9)" [--see Items of Related Interest, §II, below].

The most basic finding is that 43% of participants reported some anger/disappointment toward God.* Results are organized clearly around the authors' five hypotheses [enumerated on p. 370]:

Hypothesis #1: "On average, participants will report more positive feelings than anger toward God."
SUPPORTED -- "On average, participants suggested that feelings of anger toward God were low in intensity --certainly secondary to positive feelings toward God." [p. 372]

Hypothesis #2: "Positive feelings and anger toward God will show a small but significant negative association."
SUPPORTED -- "Although positive emotions and anger toward God were negatively correlated, the association was modest (r = -.28).... This finding, especially when viewed in the context of other related work, clarifies that a person could have positive attitudes toward God along with negative feelings such as anger or disappointment; the presence of the one does not exclude the possibility of the other." [p. 372]

Hypothesis #3: "Anger toward God will correlate with low religiosity, severe pain (as reported by family members), and difficulty seeing meaning in the situation."
SUPPORTED -- "...[R]eligiosity correlated negatively with anger toward God. Participants also reported more anger to the extent that they had difficulty seeing meaning in the experience and believed that the patients were experiencing high levels of physical pain." [p. 371, and see especially the authors' speculation on possible explanations of the correlation on pp. 372-373]

Hypothesis #4: "Depressive symptoms will correlate positively with anger toward God."
SUPPORTED -- "...[D]epressive symptoms correlated positively with anger toward God in these family members.... [However], the relationship could work in either direction. Depression is associated with patterns of negative thinking that could extend to God; but anger toward God might also increase negative emotion." [p. 372]

Hypothesis #5: "When experiencing conflicts related to God, participants on average will prefer help from friends, family, or clergy over help from more distant sources (e.g., professional helpers or self-help resources)."
SUPPORTED -- "...[T]he most favored strategy was prayer. After prayer, the strategies that were most preferred involved talking with friends, family, and clergy...; handling it on one's own; or reading a sacred text. Participants reported moderate interest in speaking to hospice team members about conflicts with God, although most preferred to talk to friends or family.... Lower levels of interest were shown in talking to a counselor or therapist, joining a support group, looking up information on the internet or in a book, or using self-help tapes, CDs, or videos." [p. 372]

Further regarding the last hypothesis about strategies for handling feelings of anger toward God: "To the extent that participants reported anger toward God, they were less likely to express interest in religious/spiritual strategies for coping... [by] prayer..., talking to a member of the clergy... and (marginally) reading sacred texts" [p. 372]. For chaplains, this finding would seem to signal part of the conundrum of addressing patients' feelings of anger toward God, when combined with the related finding of the association of depressive symptoms with such feelings.

Another finding in this study that should interest chaplains is that "...anger was greater in cases involving cancer than in noncancer cases,... and anger was less intense in cases involving heart disease than in cases not involving heart disease" [p. 371]. Variations in the incidence and nature of anger in different disease contexts should be a productive area of research. Network members might recall, in connection to this, research by Scott A. Murray, et al., highlighted in November 2007, on differing trajectories of spiritual needs among cancer and heart patients. Other areas for potential study are pointed out by our authors this month: "Future research should evaluate the intensity and time course of anger toward God, the most effective strategies for managing such feelings, and whether anger toward God is best framed as a marker of a cause of depression " [p. 373].

The article offers a quite good bibliography for leads to further reading.

* Note: The article twice states that 43% of participants reported some anger/disappointment toward God (in the abstract on p. 369 and in the Discussion on p. 372), but the Results section states the figure at 44%. The latter appears to be a typographical error.


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

CPE students often focus on anger as a difficult emotion, so this article month's article should be of good interest and might be approached simply in light of how anger has already come up in the life of the peer group's previous clinical discussions. Of course, the authors offer a well-organized strategy for discussing the article via their five hypotheses. How do the findings here hit with chaplains' own observations of anger in family members? Would students want to apply the findings about family members to patients themselves? Might results be generalized beyond the hospice setting? If so, what cautions in generalization might be prudent? What do students think about the ancillary finding that anger at God tended to differ in relation to cancer and heart disease? More advanced research students might want to investigate the Attitudes Toward God Scale in particular. Finally, the authors make a comment in their introduction, referring to patients' spiritual pain/spiritual struggles in relation to Dame Cicely Saunders' four-component "total pain" model. They observe that spiritual struggles in palliative care "may be easy to overlook when facing forms of suffering that are more concrete and visible" [p. 369]. Do students believe that the pressing obviousness of a patient's physical pain can obscure from health care providers or families the patient's spiritual pain?


Related Items of Interest:

I. The larger project, of which this month's featured study/article was part, has been published as follows:

Exline, J. J., Prince-Paul, M., Root, B. L., Peereboom, K. S. and Worthington, E. L. Jr. "Forgiveness, depressive symptoms, and communication at the end of life: a study with family members of hospice patients." Journal of Palliative Medicine 15, no. 10 (October 2012): 1113-1119. [(Abstract:) INTRODUCTION: Forgiveness has begun to receive empirical attention in end-of-life contexts, but primarily among patients. This study examined forgiveness issues and communication priorities among family members of hospice patients. METHODS: Surveys were distributed to family members of home-care patients in a large not-for-profit hospice in the Great Lakes region of the United States. Family members wrote what they would like to say to patients before they died. They also rated the importance of several expressions (love, gratitude, giving and seeking forgiveness, saying farewell) and the extent to which they had already expressed these messages. Participants rated their depressive symptoms and the quantity of unresolved offenses committed by themselves and the patient. RESULTS: Of 147 surveys returned by participants, 142 were usable. In comparison with forgiveness-related communications, expressions of love, gratitude, and farewell were more consistently rated important; yet many participants rated forgiveness (giving and seeking) as extremely important. If forgiveness was rated important but had not been fully expressed, participants reported more depressive symptoms (p<0.05). Also, unresolved offenses (by participants or patients) correlated positively with depressive symptoms (p<0.05). CONCLUSION: Although not as commonly endorsed as expressions of love and gratitude, forgiveness-related communications are seen as extremely important by many family members of hospice patients. If family members see forgiveness (granting or seeking) as important but have not completed the process, these unresolved issues are associated with depressive symptoms. This study suggests that unresolved offenses and forgiveness issues warrant assessment and clinical attention within families receiving hospice care.]


II. For more on the Attitudes Toward God Scale-9, see:

Wood, B. T., Worthington, E. L. Jr., Exline, J. J., Yali, A. M., Aten, J. D. and McMinn, M. R. "Development, refinement, and psychometric properties of the Attitudes Toward God Scale (ATGS-9)." Psychology of Religion & Spirituality 2, no. 3 (August 2010): 148-167. [(Abstract:) Perceived relationships with God can be a source of comfort or struggle. To advance the study of spiritual comfort and struggle, we develop the nine-item Attitudes Toward God Scale (ATGS-9), and we describe six studies (2,992 total participants) reporting its development and psychometrics. Exploratory and confirmatory factor analyses identified two factors: (1) Positive Attitudes toward God and (2) Disappointment and Anger with God. Subscale scores showed good estimated internal consistency, 2-week temporal stability, and evidence for construct and discriminant validity. Positive Attitudes toward God correlated with measures of religiosity and conscientiousness. Disappointment and Anger with God correlated with negative religious coping, lower religious participation, more distress, higher neuroticism, and entitlement. These results support the ATGS-9 as a brief measure of attitudes toward God.] NOTE: The scale itself is given on p. 167.


III. Other studies using the Attitudes Toward God Scale:

Didyoung, J., Charles, E. and Rowland, N. J. "Non-theists are no less moral than theists: some preliminary results." Secularism and Nonreligion 2 (2013): 1-20 (online journal designation): [(Abstract:) The longstanding stereotype that non-theists are less moral than theists is not empirically supported. To test this commonplace assumption, 114 undergraduate participants were evaluated to draw comparisons about religious identity and altruism levels. Participants were placed into one of two groups, theists or non-theists. The theist group was then further divided: weakly religious, moderately religious, and highly religious. Non-theists and theists as a whole, as well as theist subgroup assessments, were compared. Data were collected through self-report surveys. Additionally, to test moral decision-making abilities, participants answered questions based on situational dilemmas. Using Kohlberg�s coding schema, scores were assigned for the participant�s global moral reasoning rather than for the content of their answers. Using independent groups t-test, ANOVA, and post-hoc tests, our findings suggest no support for the existence of the stereotype that non-theists are less moral than theists. Religious identity did not conclusively determine whether or not an individual was more moral or more altruistic.]

Exline, J. J., Kaplan, K. J. and Grubbs, J. B. "Anger, exit, and assertion: Do people see protest toward God as morally acceptable?" Psychology of Religion & Spirituality 4, no. 4 (November 2012): 264-277. [(Abstract:) Do people believe that it is morally acceptable to protest against God? This question was examined in Internet studies with two samples: undergraduates (n = 358) and a broad-based adult sample (n = 471), both from the United States. Analyses were limited to participants who reported some belief in God. As predicted, seeing protest toward God as acceptable was associated with lower religiosity and more negative views of God (e.g., harsh, distant, cruel). Participants also made moral distinctions between various forms of protest toward God: Assertive responses (questioning and complaint) were rated more acceptable than anger and associated negative feelings (frustration, disappointment). Negative feelings, in turn, were rated more acceptable than exit responses (rebellion, holding on to anger; rejecting God; questioning God's authority; terminating the relationship). To the extent that participants saw protest toward God as acceptable, they reported more anger toward God. On the surface, zero-order correlations suggested that positive emotions and attitudes regarding God were associated with seeing anger toward God as wrong; however, this association disappeared when exit and assertion were taken into account via regression. These regressions revealed that positive emotions and attitudes toward God were strongly linked with seeing exit as wrong but also (modestly but consistently) with seeing assertion as acceptable. These findings suggest a parallel between perceived relationships with God and human relationships: When such bonds are close and resilient, they often allow room for some questioning and complaint, provided that there is a clear commitment to preserve (i.e., not exit) the relationship.]

Exline, J. J., Park, C. L., Smyth, J. M. and Carey, M. P. "Anger toward God: social-cognitive predictors, prevalence, and links with adjustment to bereavement and cancer." Journal of Personality and Social Psychology 100, no. 1 (January 2011): 129-148. [(Abstract:) Many people see themselves as being in a relationship with God and see this bond as comforting. Yet, perceived relationships with God also carry the potential for experiencing anger toward God, as shown here in studies with the U.S. population (Study 1), undergraduates (Studies 2 and 3), bereaved individuals (Study 4), and cancer survivors (Study 5). These studies addressed 3 fundamental issues regarding anger toward God: perceptions and attributions that predict anger toward God, its prevalence, and its associations with adjustment. Social-cognitive predictors of anger toward God paralleled predictors of interpersonal anger and included holding God responsible for severe harm, attributions of cruelty, difficulty finding meaning, and seeing oneself as a victim. Anger toward God was frequently reported in response to negative events, although positive feelings predominated. Anger and positive feelings toward God showed moderate negative associations. Religiosity and age correlated negatively with anger toward God. Reports of anger toward God were slightly lower among Protestants and African Americans in comparison with other groups (Study 1). Some atheists and agnostics reported anger involving God, particularly on measures emphasizing past experiences (Study 2) and images of a hypothetical God (Study 3). Anger toward God was associated with poorer adjustment to bereavement (Study 4) and cancer (Study 5), particularly when anger remained unresolved over a 1-year period (Study 5). Taken together, these studies suggest that anger toward God is an important dimension of religious and spiritual experience, one that is measurable, widespread, and related to adjustment across various contexts and populations.]

Grubbs, J. B., Exline, J. J. and Campbell, W. K. "I deserve better and God knows it! Psychological entitlement as a robust predictor of anger at God." Psychology of Religion & Spirituality (2013): online ahead of print from the journal website. [(Abstract:) Anger at God has begun to receive empirical attention as a psychological construct. Studies have shown that anger at God is common, and is often associated with various indicators of psychological distress. Past research has demonstrated that multiple aspects of personality, including psychological entitlement, are related to anger at God. The goal of the present study was to evaluate whether psychological entitlement is robustly associated with anger at God, even when diverse aspects of personality are statistically controlled. We tested this hypothesis in two groups: an undergraduate sample (n = 413) and an adult web sample (n = 148). Results provided strong, consistent support for our hypothesis: psychological entitlement consistently emerged as a unique predictor of anger at God, even when controlling for the Big Five factors of personality and narcissistic entitlement. These findings strongly demonstrate that psychological entitlement is a robust predictor of anger toward God, beyond previously established predictors.]

Snow, K. N., McMinn, M. R., Bufford, R. K. and Brendlinger, I. A. "Resolving anger toward God: lament as an avenue toward attachment." Journal of Psychology and Theology 39, no. 2 (Summer 2011): 130-142. [(Abstract:) Psychologists have mostly overlooked the topic of anger toward God. The current study tested an intervention based on the biblical psalms of lament, consisting of 20 devotional readings and weekly experiential assignments, delivered electronically over a four-week period. A total of 192 college students at Christian institutions across the United States completed the study, and were randomly assigned to the experimental condition, an attention control condition, or a no-contact condition. The expected findings�that the experimental intervention would cause decreased feelings of anger and complaint toward God, as well as increased intimacy with God over time�were not confirmed. However, those participants who reported maximum compliance with the intervention showed increased ratings on Communion with God. Implications are discussed.]


IV. While not a report of research, Mel Leaman's article, "Love�s angry lament: confronting our anger with God: based on Lamentations 1-3," in the Journal of Pastoral Care and Counseling [vol. 63, nos. 1-2 (Spring-Summer 2009): 5.1-11] may be of interest to ACPE members (who have free access to the journal). The article abstract reads:

The author examines biblical characters who challenged the justice of God. He contends that these lamenters laid the foundation for the rabbinic tradition of chutzpah. They freely faced God with their disillusionment and anger. Their intimacy with the Divine is exemplary. The author acknowledges the ambiguities of God's response to despair and contextualizes lament in the case of a woman who has been sexually abused and seeks pastoral guidance. This article integrates exegesis and theology with theories of anger and intimacy.


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