April 2019 Article of the Month
by John Ehman, Editor, ACPE Research Article-of-the-Month
and Manager for Pastoral Care, Penn Presbyterian Medical Center, Philadelphia PA
Leo, D., Izadikhah, Z., Fein, E. C. and Forooshani, S. A. "The effect of trauma on religious beliefs: a structured literature review and meta-analysis." Trauma, Violence, and Abuse (2019): online ahead of print, 3/12/19.
[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. References are to manuscript [MS] page numbers.]
SUMMARY and COMMENT: This is not a simple review article, nor is it a particularly easy article to read, but it revisits an important topic of how patients' religious lives may be affected by trauma, which was an Article-of-the-Month subject explored in May 2005. While "[e]mpirical research has shown that religious beliefs support people recovering from traumatic experiences,...there is relatively little research on the inversion of this dynamic, the way that trauma changes a person's religious beliefs" [MS p. 1, abstract]. The authors take a highly theoretical approach, explained in an extended introductory section, and test their hypotheses against findings in the extant literature. Their focus is psychological, with an eye toward the treatment of traumatized individuals and the study of religious beliefs. Some of their positions may strike chaplain readers as debatable, but there is a great deal here to stir thought about the phenomena involved at the intersection between trauma and religion. Chaplain researchers should have a voice in the dialogue of this literature. Advanced students and clinical chaplains should also find in this article much to discuss.
The paper addresses five research questions [MS p. 5]:
- For highly religious people, as measured by Psychometric Scales, do their religious beliefs act as cognitive schemas?
- If religious beliefs do act as cognitive schemas for highly religious people, does this increase the likelihood that their religious beliefs will be challenged when a traumatic event occurs?
- Are changes in religious beliefs following trauma correlated with a person's cognitive appraisals of the event as: (a) threatening and (b) inconsistent with pretrauma religious beliefs?
- Are religious changes following trauma consistent with the shattered assumptions hypothesis (Janoff-Bulman, 1989)?
- Do published studies support the hypothesis that a person's physiological symptoms of PTSD have effects on their cognitive processes of assimilation and accommodation, leading to greater changes in their religious beliefs?
A few of the key psychological constructs/theories that ground this review:
- Cognitive Schemas and Religious Beliefs
- --the ordering of perceived events, as part of childhood development, "into varying categories or schemas, with events in the same category sharing distinctive features." "A person's schemas give them a frame of reference with which to make meanings and predictions about their world" and meet a "psychological need to perceive our world as predictable, safe, and meaningful" [MS p. 2]. Systems of interconnected schemas form worldviews and influence adult beliefs, including religious beliefs. "Religious beliefs can act as the primary framework through which individuals construct meaning about their world" [MS p. 2].
- Assimilation and Accommodation of Schemas
- --"A person's schemas give them a frame of reference with which to make meanings and predictions about their world. In order to do this, the person attributes meanings to the causes of the events based on their preexisting schemas.... When people encounter new events and incorporate these into their preexisting schema categories, these are said to be assimilated. ...When new events cannot be assimilated, new categories are formed. This is the process of accommodation. Accommodation processes require greater cognitive resources than those of assimilation...." [MS p. 2, italics added] In the present context, the process of accommodation entails changes to religious beliefs.
- Shattered Assumptions and Religious Beliefs
- -- "[P]eople with more elaborate religious schemas are more likely to expect traumatic events to occur in the course of their life and have pretrauma beliefs that provide meaningful explanations for these events in a coherent way.... Thus, these people will be protected from many of the negative effects of 'shattered assumptions'" [MS p .4] "'Those with extremely positive beliefs may find that [a] trauma shatters their trust in themselves or the world' and experience great challenges to their positive religious beliefs" [MS p. 4].
- Cognitive Dissonance
- --"Cognitive dissonance theory...suggests that the amount of inconsistency between [their] post-trauma beliefs and their pretrauma religious beliefs influences whether or not the person will change their religious beliefs. ...The greater explanatory power of...religious belief systems decreases the dissonance between a person's beliefs and their trauma experience. Subsequently, the strength of the challenge presented by the trauma experience is reduced. [MS p. 11]
The literature search excluded articles that were not in English, not peer reviewed, not about interpersonal traumas, and not about traumas as adults. The authors recognize the importance of studying childhood traumas but hold that issues of child development and increased likelihood of abuse by attachment figures and clergy demand that the data be studied separately. In the end, only nine papers were identified as pertinent to the research questions at hand: five used quantitative methodology, two qualitative, and two mixed methods, published between 1993 and 2014 [--see Items of Related Interest, §I, below]. "Of the rated papers, none were rated as being 'excellent,' eight were rated as being 'good,' and one was rated as being 'poor'" [--regarding the latter, see Tankink (2007) in Items of Related Interest, §I, below]. The authors note that these papers may pose an "overrepresentation of Christian beliefs" [MS p. 12].
Among the results from the analysis of the selected papers:
- "Firstly, most people do not change their religious beliefs following trauma. Secondly, a proportion of people experience a decrease in their religious beliefs. Thirdly, a smaller minority of people experience an increase in their religious beliefs. And lastly, people who develop PTSD have a greater likelihood of changing their religious beliefs -- either increasing or decreasing them." [MS p. 6]
- "Our hypothesis that religious beliefs act as cognitive schemas for highly religious people is supported" [MS p. 13]. "Most authors [of the selected papers] support the hypothesis that religious beliefs are forms of cognitive schemas and that changes in religious belief are associated with shattered world assumptions...." [MS p. 10]
- Quantitative studies "supported the hypothesis that trauma challenges positive world assumptions and that the breakdown of these assumptions led to greater distress.... The reported results indicated that greater changes in religious beliefs were predicted if the person experienced a greater severity of trauma..., met the clinical diagnosis of PTSD..., or experienced stigmatization by their communities...." [MS p. 6]
- There is support for "a secondary effect of PTSD symptoms on religious change in addition to the primary effects of the trauma" [MS p. 13]. "Such an effect is expected under a shattered assumptions hypothesis. This is where the trauma creates a breakdown of the person's pretrauma assumptions and leads to an increase in the likelihood that they will both develop PTSD...and maintain it...." [MS p. 7, and see esp. the paper by Falsetti, Resick, and Davis (2003) described on MS pp. 6-7]
- "When [highly religious] people encounter a trauma, they have an increased likelihood of forming religious interpretations of the event. This increases the likelihood that they will change their religious beliefs. This pattern of religious changes is consistent with the assimilation and accommodation of cognitive schemas as inferred by the shattered assumptions hypothesis" [MS p. 13]. "A person may be more susceptible to these changes [in religious schemas] if they have rudimentary positive religious beliefs or unsophisticated theodicies." [MS p. 11]
The authors go on to suggest practical implications of their analysis for "religious leaders and counselors" [MS p. 12], saying that religious persons exposed to trauma may be helped in two ways:
Firstly, by assisting them to find meanings in these [traumatic] events that conform to their current belief systems facilitates the assimilation of these meanings and preserves their faith. Secondly, cultivating greater elaboration and sophistication in person's belief systems facilitates the accommodation of their religious schemas. Persons with exposure to trauma will most likely find this latter approach more challenging because it requires the open exploration and resolution of perceived paradoxes, as well as the modification of previously cherished beliefs. Such schema accommodation is a challenge for many fundamentalist faiths due the inflexible nature of their belief systems.... In these instances, it is beneficial to focus on interpretations of the trauma that are consistent with the person's belief system, preserve their self-worth, minimize feelings of guilt, and reduce stigmatization. Additionally, fundamentalist religious counselors and leaders can compensate for these difficulties by offering a secure source of reliable and sympathetic social supports.... [MS p. 12]
Chaplains reading this article will probably be sensitive to such language as "inflexible" and "unsophisticated," may see the recommendations of the authors as utilitarian, and could feel that the overall approach is too cognitively focused. Indeed, while the present chaplain reader followed the line of the authors' thought with interest and much appreciation overall, emphasis on the functionality of "sophisticated" belief systems seemed at times to diminish the rich nature of the full spectrum of religious beliefs and coping that chaplains see up close. Also, the section summarizing qualitative findings in light of the idea of transcendence [--see MS pp. 11-12] seemed too cursory. Nevertheless, this literature review and meta-analysis offers a "plausible mechanism that explains changes that people experience in their religious beliefs" [MS p. 12] in the wake of traumas as adults, and it should prompt chaplains to be more mindful during the clinical encounter of how a patient's religious views may be affected by trauma as well as how beliefs may be critical for coping, whether or not assimilation and accommodation seem to be at play in the patient's meaning-making, what assumptions may be at risk of shattering, and whether or how there may already be PTSD in a patient's life. While most trauma patients find in their religious beliefs a powerful resource against the effects of trauma, a minority of patients who are pressed to change their beliefs surely deserve special assessment and care.
The bibliography contains 84 references, though there is significant fall-off in citations after 2014. Supplementary materials -- ten appendices -- are available online. They include detailed tables of results and two checklists for evaluating quantitative and qualitative papers (Appendices E and F) that may be useful to chaplain researchers in general.
Note: The authors follow relatively new grammatical guidance for publications regarding the use of plural pronouns for singular personal antecedents. The pre-publication version of this article contains typographical errors, but none appear to be critical.
Suggestions for Use of the Article for Student Discussion:
This article will require some perseverance for many chaplains, but advanced students should find it filled with intriguing points. It might be feasibly assignable near the end of a residency year, if students have had some experience with patients who have suffered interpersonal trauma, and discussion could begin with some general recounting of relevant pastoral visits. The authors state: "When highly valued religious schemas are challenged, the accommodation process can lead to people experiencing periods of doubt, anxiety, and a loss of perceived social support from their religious community" [MS p. 2]. Have students witnessed this? What are some of the practical consequences for patients who change religious beliefs (e.g., translating a change of beliefs into practice may risk tensions with loved ones and alienation from their social network). The article "focuses on the presence and elaborateness of religious beliefs rather than on the extent of a person's religiosity or the strength of their faith" [MS p. 2]. Is this an angle on patients' religious beliefs that students have ever considered? What was the most surprising thing about either the authors' approach or the results? Particular attention could be paid to the sections on PTSD [MS pp. 3-4 and 11], looking at the theorized mechanisms by which coping may be complicated. Also, since each selected paper is briefly summarized, students might be asked if one of those stood out and why. And, what do they make of the suggestions for how "[r]eligious leaders and counselors can assist persons with exposure to trauma" [MS p. 11]? The guidance of the authors would seem to be more about counseling than about pastoral care per se, but might it still inform chaplaincy work? Finally, the group could be asked to comment on the broad observation that "over the course of a person's life, their schemas are changed slowly rather than quickly. However, when a person experiences a trauma, the severity and suddenness of this challenge may lead to the 'shattering' of their schemas..." [MS p. 3]. How do students understand the difference between normal schema change over time and that which may be precipitated by trauma? There could be opportunity -- with caution -- for some students to relate personal stories here.
Related Items of Interest:
I. Our authors offer descriptions of each of the nine selected papers, but below are the actual abstracts, except regarding the article by Gorst-Unsworth, et al., which as a brief report has no abstract.
Ankri, Y. L., Bachar, E. and Shalev, A. Y.
"Reactions to terror attacks in ultra-orthodox Jews: the cost of maintaining strict identity." Psychiatry 73, 2 (2010): 190-197. [(Abstract:) Traumatic events can shatter faith and beliefs. The responses of Ultra-Orthodox survivors of deadly terrorist attacks illustrate an effort to reconcile dreadful experiences with deeply embedded beliefs. Qualified clinicians prospectively evaluated self-reported and interviewer-generated posttraumatic stress disorder (PTSD) symptoms and cognitive appraisal in Ultra-Orthodox (n = 20) and non-Ultra-Orthodox (n = 33) survivors of suicide bus-bombing incidents in Jerusalem. Ultra-Orthodox survivors reported higher levels of PTSD symptoms and more personal guilt. Their narratives reflected an unshaken belief in Just Providence, within which being a victim of terror was perceived as a Just retribution for known or unknown wrongdoing. Survivors' reactions to trauma often reflect an effort to reconcile incongruous experiences with previously held beliefs. When treating strict believers, helpers should be sensitive to the identity-preserving function of posttraumatic cognitions.]
Ben-Ezra, M., Palgi, Y., Sternberg, D., Berkley, D., Eldar, H., Glidai, Y., Moshe, L. and Shrira, A. "Losing my religion: a preliminary study of changes in belief pattern after sexual assault." Traumatology 16, no. 2 (2010): 7-13. [(Abstract:) The purpose of the present study was to examine the impact of sexual trauma on changes in religious perception, subjective health, and mental health among sexual assault victims. A total of 111 Jewish women participated in the study, including 51 sexual assault victims and 60 comparisons matched on age, religion, and marital status. The study was of a retrospective, cross-sectional design. Approximately half of the women (47.5%) who suffered sexual assault changed their religious perception and belief in the direction of secularization. In addition, these women exhibited elevated psychiatric symptoms and lower well-being relative to the comparison group. The results of the preliminary study revealed changes in belief patterns due to psychological trauma. Mental health professionals should take these aspects into consideration when treating women who suffered sexual trauma.]
Davidson, J. R., Connor, K. M. and Lee, L. C.
"Beliefs in karma and reincarnation among survivors of violent trauma--a community survey." Social Psychiatry and Psychiatric Epidemiology 40, no. 2 (February 2005): 120-125. [(Abstract:) BACKGROUND: This survey was designed to examine beliefs in karma and reincarnation among survivors of violent trauma in the general US population. METHODS: Two community surveys were conducted in 2001. From a sample of 1,969 respondents, two groups were created based on level of agreement with karmic belief. This sample forms the basis of this report. Information was obtained as to mental and physical health, resilience, exposure to violent trauma, and posttraumatic stress disorder (PTSD) symptom severity, and the cohorts were compared on these variables. RESULTS: Five percent of the sample admitted strong agreement to a belief in karma and reincarnation (n=99), while 77% strongly disagreed with these beliefs (n=1,511). Characteristics associated with agreement included being non-white, unmarried, and in poor physical and mental health. Moreover, agreement was associated with more extensive traumatization, including abuse, rape, and loss of a family member through violent death, as well as more severe posttraumatic stress symptoms. CONCLUSIONS: Few people subscribe strongly to a belief in karma and reincarnation in the US population, but personal experience of trauma may be associated with greater acceptance, as well as certain demographic and health-associated variables. The importance of holding such beliefs, which may represent an important way of coping following violent trauma, deserves further study.]
Decker, L. "Beliefs, post-traumatic stress disorder, and mysticism." Journal of Humanistic Psychology 33, no. 4 (Fall 1993): 15-32. [(Abstract:) This article examines three related approaches to understanding Post-Traumatic Stress Disorder (PTSD). The idea that trauma disrupts belief systems is a current widely accepted theoretical perspective on PTSD. However, it may be that beliefs founded on the inner realizations are less disrupted by trauma than are beliefs formed from interaction with the environment. Some of the psychological attempts to interweave spiritual understanding with psychological thought are examined in relationship to traumatic experience. Finally, the mystical perspective is recommended not only as a way of understanding internally based beliefs but as an important process for all therapists working with the traumatized.]
Falsetti, S. A., Resick, P. A. and Davis, J. L.
"Changes in religious beliefs following trauma." Journal of Traumatic Stress 16, no. 4 (August 2003): 391-398. [(Abstract:) Information processing theorists propose that traumatic events can lead to disruptions in the processing of information and to changes in beliefs. This study examined the relationships among trauma, posttraumatic stress disorder (PTSD), and religious beliefs. Field Trial Study on PTSD. Results indicated that the PTSD group was more likely to report changes in religious beliefs following the first/only traumatic event, generally becoming less religious. PTSD status was not related to change in religious beliefs following the most recent event. Intrinsic religiosity was related to multiple victimization, but not PTSD. Results are discussed in terms of understanding the function of religiosity in participants' lives and future directions for research.]
Gorst-Unsworth, C., Van Velsen, C. and Turner, S.
"Prospective pilot study of survivors of torture and organized violence: examining the existential dilemma." Journal of Nervous and Mental Disease 181, no. 4 (April 1993): 263-264. [This study analyzed interviews with 31 patients referred to two psychiatrist between February 1990 and January 1992 at the Medical Foundation for the Care of Victims of Torture, a London-based Center. Fifty-eight percent reported a change in religious or political beliefs. Those who were highly religious were more affected.]
Overcash, W. S., Calhoun, L. G., Cann, A. and Tedeschi, R. G. "Coping with crises: an examination of the impact of traumatic events on religious beliefs." Journal of Genetic Psychology 157, no. 4 (December 2996): 455-464. [(Abstract:) The impact of traumatic events on empirical and metaphysical assumptions was examined, by comparing assumptions of a group of 25 persons who had recently experienced a major stressor with assumptions of a group of 25 persons who had not had such an experience. Each group was composed of 22 women and 3 men, with a mean age of 20 years.
Participants completed written measures assessing levels of adjustment, empirical world assumptions, religious motivation, and religious and spiritual experiences. Naturalistic interviews were conducted with the trauma group. The trauma group obtained significantly higher scores on symptoms of psychological distress but did not differ in evaluations of the empirical world as predictable, safe, or controllable. Interviews suggested that the metaphysical assumptions were not challenged by trauma; rather, they provided a framework for understanding and coping with trauma.]
"'The moment I became born-again the pain disappeared': the healing of devastating war memories in born-again churches in Mbarara District, Southwest Uganda." Transcultural Psychiatry 44, no. 2 (June 2007): 203-231. [(Abstract:) In southwest Uganda, many people who suffer from devastating war experiences become born-again Christians. This article describes the therapeutic functions of the churches and the experiential transformations associated with becoming born-again. The discourse of the born-again churches gives people another orientation toward the future, based on the Bible, that also provides them with a different perception of the past. Whereas people remain silent about their war experiences in everyday life, the churches offer their members a public space to express their suffering. In these churches, feelings of trust and solidarity are restored. Many aspects of the churches' activities can also be found in western trauma therapies.]
ter Kuile, H. and Ehring, T. "Predictors of changes in religiosity after trauma: trauma, religiosity, and posttraumatic stress disorder." Psychological Trauma: Theory, Research, Practice, and Policy 6, no. 4 (2014): 353-360. [After a traumatic experience, increases as well as decreases in religious beliefs and activities have been observed. The current study investigated how the direction of the changes can be predicted and whether these changes are related to posttraumatic stress disorder. Trauma survivors (N = 293) filled in questionnaires related to traumatic experiences and religiosity. Nearly half of the sample reported changes in religious beliefs and activities as a consequence of the trauma. As hypothesized, shattered assumptions and prior religiosity interacted to predict a decrease in religious beliefs and activities. Increases in religiosity were related to the use of religion as a coping mechanism and to currently living in a religious environment. In addition, a decrease in religious beliefs was related to higher levels of posttraumatic stress disorder. The findings suggest that religiosity may play an important role in posttrauma adaptation.]
II. A couple of other relevant studies published after the literature review period of this month's article.
Lee, S. Y., Park, C. L. and Hale, A. E. "Relations of trauma exposure with current religiousness and spirituality." Mental Health Religion and Culture 19, no. 6 (2016): 493-505. [(Abstract:) Many theorists posit that religiousness/spirituality (RS) may change after trauma. However, empirical findings regarding RS following trauma are inconclusive. The present study examined the relationship between potentially traumatic events (PTEs) and current RS by considering the cumulative effect of PTEs and multiple dimensions of RS. In our sample of 245 undergraduates (60% female, 79% White), there were no differences in RS between participants who did and did not have PTEs. When analysed as a continuous variable, the number of PTEs was positively correlated with many RS dimensions (i.e., daily spiritual experiences, religious strain, religious comfort, provident and challenging God images, belief in God) but not all (i.e., organised religious involvement, belief in afterlife, benevolent God image). These results suggest that PTEs relate distinctly to different aspects of RS and that examining multiple dimensions of RS may be a more informative way of studying this association.]
Zukerman, G. and Korn, L. "Post-traumatic stress and world assumptions: the effects of religious coping." Journal of Religion and Health 53, no. 6 (December 2014): 1676-1690. [(Abstract:) Religiosity has been shown to moderate the negative effects of traumatic event experiences. The current study was designed to examine the relationship between post-traumatic stress (PTS) following traumatic event exposure; world assumptions defined as basic cognitive schemas regarding the world; and self and religious coping conceptualized as drawing on religious beliefs and practices for understanding and dealing with life stressors. This study examined 777 Israeli undergraduate students who completed several questionnaires which sampled individual world assumptions and religious coping in addition to measuring PTS, as manifested by the PTSD check list. Results indicate that positive religious coping was significantly associated with more positive world assumptions, while negative religious coping was significantly associated with more negative world assumptions. Additionally, negative world assumptions were significantly associated with more avoidance symptoms, while reporting higher rates of traumatic event exposure was significantly associated with more hyper-arousal. These findings suggest that religious-related cognitive schemas directly affect world assumptions by creating protective shields that may prevent the negative effects of confronting an extreme negative experience.]
III. The effect of trauma on religion/spirituality was first explored in our May 2005 Article-of-the-Month. However, chaplains' work with trauma patients was also the topic in July 2015, in terms of patients' needs around chaplain presence. A significant focus of the 2015 study involved the critical phase of patients' meaning making, as framed by psychological theory. While it does not consider the elaborateness of patients' beliefs (as does Leo, et al.), there may be some topical overlap with the advice in the present month's article pertaining to religious leaders and counselors [MS p. 12]. Could a chaplain's presence be another interventional option for patients' struggling with assimilation or accommodation in meaning-making following trauma?
IV. Key to this month's article is the work on "shattered assumptions" by Ronnie Janoff-Bulman, Professor Emerita in Psychology at the University of Massachusetts at Amherst. See Dr. Janoff-Bulman's faculty page for a complete list of her publications. NOTE: Dr. Janoff-Bulman's work was also key to our January 2008 Article-of-the-Month.
V. Related to our featured topic is that of Moral Injury. See our October 2018 Article-of-the-Month for more on that topic, especially focusing on a military population.