The study has been selected for our Article-of-the-Month because of three interesting findings: namely, that RC and NRC are not functionally redundant for assessment, that assessment for RC may require an in-depth instrument to capture effect, and that patients who cope by engaging in so-called "punishing God reappraisals" may be especially at risk for poor health outcomes.

On the finding that RC and NRC are not functionally redundant for assessment, the authors sum up their detailed statistical analysis:

In five out of six regressions, NRC and RC provided additional information over and above the effects of each other. For anxiety, there was strong support for the unique contribution of both RC and NRC, with RC contributing an additional 6% and NRC contributing an additional 22% of unique variance, beyond that contributed by the other measure. For depression, RC contributed 12% of unique variance beyond the contribution of NRC, and the 8% contribution of NRC was marginally significant (p=0.052). For disability, we found that NRC contributed an additional 16% beyond the contribution of RC, but RC did not contribute uniquely, over and above that accounted for by NRC. [p. 523]

On the issue of the sensitivity of measures of spiritual dynamics, the "Turning to Religion" subscale of the COPE measure did not indicate the associations between RC and health outcomes that were captured by the RCOPE. The authors speculate that the COPE subscale (consisting of only four items) was insufficiently "fine-grained" [--see p. 521] compared to the more in-depth items on the RCOPE. [While the RCOPE is a 21-item measure, only nine items were used here, based upon other research that showed these nine items to have "the most promise for being useful predictors of outcomes" [p. 516]: Benevolent Religious Reappraisal, Punishing God Reappraisal, Collaborative Religious Coping, Passive Religious Deferral, Self-Directing Religious Coping, Seeking Spiritual Support, Spiritual Discontent, Seeking Support from Clergy or Members, and Interpersonal Religious Discontent. --see Table II on p. 517.] This reflects an overall trend in Spirituality & Health research to refine measures to become attuned to subtle effects, and to balance the desire for simple instruments with the complexity of spirituality. Indeed, the authors endorse using the more detailed RCOPE, but with the hope that future research will be able to "streamline our coping measures to include only those subscales that offer the most value" [p. 525]. Pastoral care researchers might consider using both shorter and longer instruments with similar foci, rather than selecting a single instrument, to see if the more detailed measure points up findings missed by the less detailed one. [Note that the April 2004 Article-of-the Month looked at religious and non-religious coping, using the COPE and RCOPE measures.]

The third reason for recommending this article is its finding that patients who cope by means of "punishing God reappraisals" may be at risk of poorer health outcomes--at least in the current population. A number of studies in the past decade have shown “negative religious coping” to be a health risk factor, and the authors cite Kenneth Pargament’s 1997 review in The Psychology of Religion and Coping: Theory, Research, and Practice [--see Related Items of Interest (below)] as support for the association of "punishing reappraisal" with poor outcomes. Note, however, that the Pargament book cited is now becoming dated, and while it does survey studies relating to "God's punishment" as a form of negative religious reframing (see Appendix D, on pp. 446-448 of the book), Pargament himself is cautious about drawing lines of connection between this form of coping and outcomes (see Negative Religious Reframing: God's Punishment, on p. 291 of the book). This would be an excellent topic for pastoral care research, since chaplains often encounter variations of punishing reappraisals in patients who ask about their illness, "Why?" Chaplains might want to consult the study by Pargament, et al., "Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study" [--see Related Items of Interest (below)], which found that "'Felt punished by God for my lack of devotion''…was marginally predictive of mortality after controlling for demographic variables…but not after controlling for physical health and mental health" [p. 1883 of that article]. The latter article by Pargament is not cited in our featured study.

Burker and her colleagues offer much to consider, and they provide a convenient list of RC and NRC coping methods [--see Table II on p. 517] and extensive tables summarizing their data analysis [--see especially Tables IV-VII on pp. 519-523]. Their Introduction is a quick overview of the circumstance of lung transplant candidates and coping, and it describes two earlier studies by the authors that informed the present research. The Discussion section is succinct, yet it expands appropriately the basic reporting of results and nicely lays out limitations and questions for future investigation. The article should be helpful to chaplains interested in coping strategies and risk factors, and those working with lung transplant patients. For researchers, it is a contribution to thought about measures and coping outcomes.