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January 2009 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Edmondson, D., Park, C. L., Chaudoir, S. R. and Wortmann, J. H. "Death without God: religious struggle, death concerns, and depression in the terminally ill." Psychological Science 19, no. 8 (August 2008): 754-758.


SUMMARY and COMMENT: This month's article looks at relationships between religious struggle, death concerns, depression, and beliefs in an afterlife; with the particular perspective of Terror Management Theory (TMT).

According to TMT, individuals neutralize the ubiquitous, paralyzing fear of death by adopting cultural worldviews that imbue the world with meaning and order, lend meaning to human activity, and provide self-esteem. Individuals invested in these cultural worldviews are rewarded with assurances that life is ultimately meaningful and that personal mortality will be transcended, either symbolically or literally…. …Religious worldviews are among the most common cultural worldviews…. When functioning effectively, religious worldviews provide individuals with religious comfort, a generally pleasant and orderly view of the world and their place in it, a promise of life's eternal significance, and an ultimate source of self-worth…. However, religious worldviews can become sources of self-esteem threat, uncertainty, or despair if they break down, such as is the case in religious struggle, when individuals perceive that they are being punished or abandoned by God in the course of stressful life circumstances…. [p. 754]

Data from 98 patients with end-stage congestive heart failure (CHF) at a cardiology practice in Cincinnati, Ohio, completed a battery of measures consisting of items from Fetzer's Daily Spiritual Experience Scale (re: religious comfort), Exline & Yali's Spiritual Strain Scale (re: religious struggle [--but see NOTE #1, below]), and the Death and Dying Subscale of the World Health Organization's Quality of Life Measure (re: death concerns [--but see NOTE #2, below]), the Center for Epidemiological Studies Depression Scale (re: depression), and single items asking about belief in an afterlife and the extent to which the patient considered himself/herself a religious person.

Among the findings: death concerns mediated the effect of both religious struggle and religious comfort on depression, yet there was no support for alternate models whereby religious struggle or religious comfort mediated the relationship between death concerns and depression. The authors write: "Our conclusions regarding the relationships among these variables are also supported by converging evidence from experimental studies suggesting that people may rely on religious worldviews in the face of mortality salience…, but are buffered from death concerns only if these worldviews are fully functioning (i.e., provide meaning and value…)" [p. 757]. Moreover, the results showed that "a primary mechanism by which religious struggle affects depression in terminally ill CHF patients is through increased concerns about personal mortality," and suggest that "the expectation of literal immortality is a significant aspect of the comfort that religious worldviews provide individuals near death" [p. 757]. In sum:

These findings lend further support to the idea that religious worldviews serve a terror management function and, more generally, provide external validation for the fundamental assertions of TMT. Our findings suggest that properly functioning religious worldviews offer comfort by buffering the individual against death concerns near life's end, but that the breakdown of these worldviews (i.e., the experience of religious struggle) leaves the individual vulnerable to the terror of death. [p. 757]

For clinical chaplains, this study raises at least a couple of questions. First, might it be important specifically to assess for beliefs in an afterlife for patients who indicate religious struggle in the face of the prospect of dying? Second, might there be particular value in assessing for death concerns, especially where there is some indication of depression? The researchers here assessed for death concerns by asking the degree to which patients "worried about (a) death, (b) 'the thought of not being able to die the way you would want to,' and (c) 'how and where you will die'…" [p. 755 --but also see NOTE #2, below]. For chaplain researchers, the study raises the broad question of whether Terror Management Theory holds promise as a construct to guide investigation. [For more on TMT, see Related Items of Interest, below.] The researchers here claim that it is a valid theory for work with patients "under conditions of chronic and extreme mortality salience" [p. 757].

NOTE #1: The authors state that Religious Struggle was measured by the Spiritual Strain Scale and give as a reference for that measure a 2000 article by Julie J. Exline and Ann Marie Yali. However, the scale does not precisely appear in the cited reference. Donald Edmondson has personally confirmed that the scale used consisted of six items: 1) Feel angry at God, 2) Feel abandoned by God, 3) See God’s actions as unfair, 4) Feel that God has let you down, 5) View God as unkind, and 6) Feel loved by God. In subsequent personal communication from Julie J. Exline, the scale version used by Edmondson, et al. is said to have continued to evolve and is now in the form of a nine-item Attitudes Toward God scale, measuring anger toward God and feeling comforted by God. This latest version has been made available to the Research Network by Dr. Exline [--click HERE (PDF)], but it should not be used without first contacting the developers, since its formal publication is still in process.

NOTE #2: The authors state that their three items to measure death concerns came from the "World Health Organization's Quality of Life measure" [p. 755], and they give as a reference a 1998 article in Psychological Medicine by Harper & Powell, "Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment." However, their three items do not appear to be addressed in the cited article nor the WHOQOL-BREF. Instead, the items appear to have come from the WHOQOL-HIV measure, which is available online at


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

The article is brief and to the point (though the title is a bit curious) and should be accessible to all students, with the usual caution not to become bogged down in statistics. Discussion could consider the role of "death concerns" or "mortality salience" in pastoral conversation. When patients bring up such concerns, what do students make of this, and how do they respond? What might the findings of this month's article suggest about patients diagnosed with depression who bring up these concerns? Also, how much attention do students give to patients' issues about an afterlife? Another course of discussion could focus on Terror Management Theory and whether or not that resonates with students. [See Related Items of Interest, below.] Do students tend to think of religion in the broad terms of a worldview? How central is the prospect of death to what humans think, feel, and do?

While it is not necessary for students to be accomplished at statistics in order to read the article, they might want to discuss the basic concept of a mediator variable in a model that seeks to explain the effect of one thing upon another. The most straightforward representation of this type of model is:

Here, an independent variable affects a mediator variable (relationship A) which then affects a dependent variable (relationship B). The mechanism of mediation differs from one by which an independent variable would directly affect a dependent variable (relationship C). Comparing a mediated effect with a direct effect allows statisticians to determine how big an influence the mediator variable has on the relationship between the other variables. The authors of this month's article use this same graphic form to show how their data regarding death concerns indicates a mediating effect on the relationship between religious struggle/comfort and depressive symptoms [--see p. 756].


Related Items of Interest:

I. For more on Terror Management Theory, see the University of Missouri's website: Among the faculty listed on the site are the three social psychologists who proposed TMT in 1986: Jeff Greenberg, Tom Pyszczynski, and Sheldon Solomon. While the theory does not focus largely on spirituality/religion, one recent article may be of special interest:

Jonas, E. and Fischer, P. "Terror management and religion: evidence that intrinsic religiousness mitigates worldview defense following mortality salience." Journal of Personality & Social Psychology 91, no. 3 (September 2006): 553-567. [(Abstract:) Terror management theory suggests that people cope with awareness of death by investing in some kind of literal or symbolic immortality. Given the centrality of death transcendence beliefs in most religions, the authors hypothesized that religious beliefs play a protective role in managing terror of death. The authors report three studies suggesting that affirming intrinsic religiousness reduces both death-thought accessibility following mortality salience and the use of terror management defenses with regard to a secular belief system. Study 1 showed that after a naturally occurring reminder of mortality, people who scored high on intrinsic religiousness did not react with worldview defense, whereas people low on intrinsic religiousness did. Study 2 specified that intrinsic religious belief mitigated worldview defense only if participants had the opportunity to affirm their religious beliefs. Study 3 illustrated that affirmation of religious belief decreased death-thought accessibility following mortality salience only for those participants who scored high on the intrinsic religiousness scale. Taken as a whole, these results suggest that only those people who are intrinsically vested in their religion derive terror management benefits from religious beliefs.]
Also, a recent article (not listed on the TMT website) has addressed apparent contradictions between the theory of terror management the phenomenon of posttraumatic growth (which has been a topic addressed previously, in our May 2005 Articles-of-the-Month):
Lykins, E. L., Segerstrom, S. C., Averill, A. J., Evans, D. R. and Kemeny, M. E. "Goal shifts following reminders of mortality: reconciling posttraumatic growth and terror management theory." Personality & Social Psychology Bulletin 33, no. 8 (August 2007): 1088-1099. [(Abstract:) Research findings within posttraumatic growth (PTG) and terror management theory (TMT) currently appear contradictory. Following confrontations with mortality, PTG research demonstrates intrinsic goal shifts, whereas TMT suggests extrinsic shifts. The current studies examine factors contributing to these inconsistent results. Study 1 demonstrates that perceived death threat is associated with PTG effects. Study 2 illuminates the importance of duration of death processing. Study 3 demonstrates that existing goal values and duration and type of processing all interact in determining ultimate goal structure, with a match between level of goals and processing producing the most psychologically advantageous outcomes. Although previous research suggests that short-term confrontations with death may lead to defensiveness, the current studies suggest that encountering death over a longer period or in a manner consistent with goal structure may lead individuals to transcend defensiveness and maintain intrinsic goals or become more intrinsically oriented.]
Other articles on Terror Management and spirituality/religion:

[ADDED 3/22/10]: Vail, K. E. 3rd., Rothschild, Z. K., Weise, D. R., Solomon, S., Pyszczynski, T. and Greenberg, J. "A terror management analysis of the psychological functions of religion." Personality & Social Psychology Review 14, no. 1 (February 2010): 84-94. [(Abstract:) From a terror management theory (TMT) perspective, religion serves to manage the potential terror engendered by the uniquely human awareness of death by affording a sense of psychological security and hope of immortality. Although secular beliefs can also serve a terror management function, religious beliefs are particularly well suited to mitigate death anxiety because they are all encompassing, rely on concepts that are not easily disconfirmed, and promise literal immortality. Research is reviewed demonstrating that mortality salience produces increased belief in afterlife, supernatural agency, human ascension from nature, and spiritual distinctions between mind and body. The social costs and benefits of religious beliefs are considered and compared to those of secular worldviews. The terror management functions of, and benefits and costs associated with, different types of religious orientation, such as intrinsic religiosity, quest, and religious fundamentalism, are then examined. Finally, the TMT analysis is compared to other accounts of religion.

II. The Daily Spiritual Experience Scale items used by Edmondson, et al., is part of the Fetzer Institute's 1999 Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research: A Report of the Fetzer Institute/National Institute on Aging Working Group. [Note that this document includes in the front matter the blanket permission (in bold type) that the document "may be used and reprinted without special permission."] For some background to the larger multidimensional measure, see the January 2004 Article-of-the-Month. Also, another study recently used the Daily Spiritual Experiences Scale to investigate the relationship between depression and depressive symptoms, and that investigation is quite different from the one in this month's featured article. See: Mofidi, M., et al., "The relationship between spirituality and depressive symptoms: testing psychosocial mechanisms, Journal of Nervous and Mental Disease 195, no. 8 (August 2007): 681-688 [--noted in the Related Items of Interest section of the August 2007 Article-of-the-Month. The Daily Spiritual Experiences Scale and the larger multidimensional measure by Fetzer have shown strong potential for spirituality research.

III. For more on connections between spirituality/religion and depression, see the August 2007 Article-of-the-Month page; and for more on religious struggle, see the November 2004 Article-of-the-Month page (which highlights the Brief RCOPE measure for religious struggle).


If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at .
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