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August 2012 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Koenig, H. G. "Commentary: Why do research on spirituality and health, and what do the results mean?" Journal of Religion and Health 23, no. 2 (June 2012): 460-467.


SUMMARY and COMMENT: Our Articles-of-the-Month are usually reports of original research or reviews, but this month we feature a commentary by a leading figure in the field of religion/spirituality and health because it may be an excellent piece to engage new CPE students in thinking about the very idea of research at the beginning of a residency year. Harold G. Koenig, MD, addresses two questions preliminary to any student's reading of research as part of their chaplaincy program.

Koenig notes the large and increasing number of studies on religion/spirituality [R/S] and health and the concerns raised by some health professionals about the quality and clinical application of this research as well as by theological professionals about the instrumental use of religion for health purposes. The "criticism from both sides" ..."raises two important issues: the value of such research and the interpretation of what the research findings actually mean" [p. 461].

As for why the research should be conducted in the first place, he offers five reasons [--see pp. 462-463]:

  • "First, research on R/S and health might uncover certain R/S beliefs or behaviors that could be used to help identify those at higher or lower risk of disease, allowing easier identification of high-risk individuals to whom health resources could be directed so that disease could be diagnosed early or prevented entirely. ...If certain R/S beliefs or practices place persons at higher or lower risk for a particular disease or mortality in general, then doctors need to know about it."
  • "Second, information on the relationship between R/S and health might also be important in terms of planning ahead for health services needed by the public."
  • "Third, R/S involvement is common in the United States and most countries around the world. If it is related to better health, and studies show that R/S interventions improve health, then there is no reason why those interventions couldnít be used to enhance and support treatment in those who indicate religion is an important part of their daily life. Clinicians need not prescribe religion to those who are not religious (nor is there likely to be any scientific basis for doing so). However, there may be many reasons for inquiring about the role that R/S plays in a personís life and whether he/she would prefer an intervention that utilizes their R/S resources in treatment."
  • "Fourth, many patients have spiritual needs when hospitalized with serious medical illness, and they often go unmet with significant consequences in terms of quality of life, satisfaction with care, and desire for sometimes futile health care services...."
  • "Finally, the public deserves to know whether there are certain beliefs or behaviors that influence their health and well-being. ...We may or may not decide to change how we believe or live, but at least having some objective information about factors that influence our health can help us make informed decisions."
These reasons are, of course, "not exhaustive" [p. 461]. They come from a medical perspective and do not touch upon reasoning common among chaplains, like the need to participate in the research culture of health care institutions and demonstrate the value of chaplaincy by a modality that can be appreciated within that culture. Nevertheless, the five reasons given are cogent and worth the consideration of chaplains.

The second half of the article is a caution against misinterpretation of research findings, especially misrepresentation (exaggeration, hype) by popular media. Koenig offers two illustrations, relating to a study of brain anatomy and a study regarding self-control [--see pp. 463-465]. While the points here involve to some degree the author's own interpretation of others' takes on the research, the message for chaplain readers is essentially an exhortation to be wary of secondary reporting of research and to be vigilant in general that "interpretation should not go beyond what the data actually say" [p. 465]. Koenig goes a step further though in his criticism, in a way that may be of strong interest to both clinical chaplains and research chaplains: observing that the misrepresentation of findings can have harmful consequences for the public/patients who may be mislead by erroneous reporting. He gives an example of how some people may be led to a utilitarian understanding of religion, for the purpose of achieving health benefits, and how that may ultimately cause disillusionment and other unfortunate effects.

This article is brief and clear and should easily generate discussion among chaplains. Its slight weaknesses -- from this chaplain's reading -- are that the illustrations of misinterpretation are a bit esoteric, the whole area of qualitative research that is often of interest to chaplains is avoided, and the occasional language of "church" may be somewhat off-putting to non-Christians; but overall it should be thought-provoking for anyone new to the field and a reminder of important points for those already familiar with the literature and research.


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

Students could discuss the reasons given for doing research in this field and what additional reasons may be particular to chaplains' interests (e.g., the need to demonstrate chaplains' effectiveness empirically because of administrative or funding requirements, or the importance of examining topics pertinent to chaplaincy anew from outside of the traditional pastoral perspective). If this article were to be paired with another that reports original research, students could be challenged to identify precisely that study's hypothesis and findings, being sensitive to how easy it is to distort and misinterpret the subtle details of an article. [A good companion article might be selected from one of the listings from our Incorporating Research section, like the "Syllabus from Introduction to Research" or the "Ten Articles Especially Useful for Introducing CPE Students to Research." It would also be possible to have students read one of the two articles that Koenig uses to illustrate misinterpretation -- see Items of Related Interest, §II, below -- though the substance of those articles may not well engage students.] One topic that might be of special interest is the difference between research findings of correlation and claims of causation. Do students see this confusion at play in Koenig's examples? Also, can students see the value of research into religion/spirituality and health apart from utilitarianism?


Related Items of Interest:

I. Other articles in recent years that also address the basic question of "why do research?" include (noting especially the one by Koenig):

Fitchett, G. "Making our case(s)." Journal of Health Care Chaplaincy 17, nos. 1-2 (2011): 3-18. [(Abstract:) Health care chaplaincy needs to develop a body of published case studies. Chaplains need these case studies to provide a foundation for further research about the efficacy of chaplainsí spiritual care. Case studies can also play an important role in training new cha- plains and in continuing education for experienced chaplains, not to mention educating health care colleagues and the public about the work of health care chaplains. Guidelines for writing case studies are described, herein, as is a project in which three experienced oncology chaplains worked together to write case studies about their work. Steps that chaplains, and professional chaplain organizations, can take to further the writing and publishing of case studies are described.]

Koenig, H. G. "Why research is important for chaplains." Journal of Health Care Chaplaincy 14, no. 2 (2008): 83-90. [(Abstract:) Research forms the basis for all health care disciplines, including nursing, medicine, and psychology. This research is necessary to document both the benefits and the costs of health care services, and applies equally to the services and interventions that chaplains provide. It is important that chaplains do this research, rather than others without sensitivity to the main issues at stake. Unfortunately, training in how to conduct research is not usually part of the education that chaplains receive. There are specific skills that need to be acquired in order to identify a research question, design a study to answer that question, obtain funding, manage the project, and publish the results. Learning these research skills will at some point become non-optional if chaplaincy is to continue to grow and flourish as a profession and receive the recognition and respect that it deserves.]

Murphy, P. E. and Fitchett, G. "Introducing chaplains to research: "This could help me"." Journal of Health Care Chaplaincy 16, nos. 3-4 (2010): 79-94. [This was our November 2010 Article-of-the-Month.] [(Abstract:) Health care chaplains are beginning to recognize the need to become an evidence-based profession. This will require that all chaplains become informed consumers of research. There has been little investigation into the barriers that chaplains face as they attempt to become research literate. This study employed comments of 94 chaplains who attended pastoral research workshops to examine attitudes chaplains report about research that might represent these barriers. The study also assessed the effects of the workshops on changing chaplains' feelings about research. Initially, many chaplains reported feeling anxious and inadequate when they thought about research. After the workshops, they reported a significant change to more positive feelings such as encouragement. As one chaplain wrote, "I feel hopeful. This could help me in my work." This study suggests that, if provided with appropriate education, many chaplains are ready to become more active research consumers and a few would consider becoming investigators.]

Weaver, A. J., Flannelly, K. J. and Liu, C. "Chaplaincy research: its value, its quality, and its future." Journal of Health Care Chaplaincy 14, no. 1 (2008): 3-19. [(Abstract:) The article is divided into four major sections, the first of which presents and discusses various reasons given by major researchers in the field why chaplains should do research. The second section summarizes findings on the sophistication of research on religion and health published in (a) medical and other healthcare journals, and (b) specialty journals on religion and health, chaplaincy, and pastoral care and counseling. The third section revisits suggestions that have been made by prominent chaplain researchers to increase and improve research by chaplains. The last section offers some suggestions for expanding several lines of current research in the future, including research: (1) to elucidate the nature of spiritual care chaplains provide to different populations, including patients, families and staff; (2) to assess the prevalence and intensity of patients' spiritual needs and the degree to which they are being met; (3) to identify that subset of patients who are spiritually at risk in terms of having high needs and slow religious resources; (4) to identify the biological causal mechanisms by which religion influences health; and (5) to measure the effectiveness of chaplain interventions.]


II. The following are the two original articles that Koenig uses to illustrate the misinterpretation of results. (Note, however, that the title of the Owen, et al. article is incorrectly given in Koenig's references.)

McCullough, M. E. and Willoughby, B. L. "Religion, self-regulation, and self-control: Associations, explanations, and implications." Psychological Bulletin 135, no. 1 (January 2009): 69-93. [(Abstract:) Many of the links of religiousness with health, well-being, and social behavior may be due to religion's influences on self-control or self-regulation. Using Carver and Scheier's (1998) theory of self-regulation as a framework for organizing the empirical research, the authors review evidence relevant to 6 propositions: (a) that religion can promote self-control; (b) that religion influences how goals are selected, pursued, and organized; (c) that religion facilitates self-monitoring; (d) that religion fosters the development of self-regulatory strength; (e) that religion prescribes and fosters proficiency in a suite of self-regulatory behaviors; and (f) that some of religion's influences on health, well-being, and social behavior may result from religion's influences on self-control and self-regulation. The authors conclude with suggestions for future research.]

Owen, A. D., Hayward, R. D., Koenig, H. G., Steffens, D. C. and Payne, M. E. "Religious factors and hippocampal atrophy in late life." PLoS ONE 6, no. 3 (2011): e17006 [electronic journal article designation]. [(Abstract:) Despite a growing interest in the ways spiritual beliefs and practices are reflected in brain activity, there have been relatively few studies using neuroimaging data to assess potential relationships between religious factors and structural neuroanatomy. This study examined prospective relationships between religious factors and hippocampal volume change using high-resolution MRI data of a sample of 268 older adults. Religious factors assessed included life-changing religious experiences, spiritual practices, and religious group membership. Hippocampal volumes were analyzed using the GRID program, which is based on a manual point-counting method and allows for semi-automated determination of region of interest volumes. Significantly greater hippocampal atrophy was observed for participants reporting a life-changing religious experience. Significantly greater hippocampal atrophy was also observed from baseline to final assessment among born-again Protestants, Catholics, and those with no religious affiliation, compared with Protestants not identifying as born-again. These associations were not explained by psychosocial or demographic factors, or baseline cerebral volume. Hippocampal volume has been linked to clinical outcomes, such as depression, dementia, and Alzheimer's Disease. The findings of this study indicate that hippocampal atrophy in late life may be uniquely influenced by certain types of religious factors.]


III. For more on Harold Koenig's perspective about the value of research into religion/spirituality and health, see his presentation on "Religion, Spirituality and Public Health: Research, Applications, and Recommendations," which was testimony before the U.S. House of Representatives' Committee on Science and Technology--Subcommittee on Research and Science Education, September 18, 2008. Dr. Koenig's testimony is available online [PDF] from the Committee on Science and Technology. This overview puts more emphasis on issues of public health than is normally found in the literature. He subsequently reworked this testimony for a December 3, 2008 conference in Washington on Religious Practice and Health: What the Research Says, and that paper, titled "Religious Practices and Health: Overview," is also available online (from the Heritage Foundation).


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