May 2003 Articles of the Month
Miller, W. R. and Thoresen, C. E. [Department of Psychology, University of New Mexico; and School of Education and Department of Psychology, Stanford University, CA]. "Spirituality, religion, and health: an emerging research field." American Psychologist 58, no. 1 (January 2003): 24-35.
Powell, L. H., Shahabi, L. and Thoresen, C. E. [Rush-Presbyterian Medical Center, Chicago; Department of Psychology, University of Miami; and School of Education and Department of Psychology, Stanford University, CA]. "Religion and spirituality: linkages to physical health." American Psychologist 58, no. 1 (January 2003): 36-52.
Seeman, T. E., Dubin, L. F., and Seeman, M. [University of California, Los Angeles]. "Religiosity/spirituality and health: a critical review of the evidence for biological pathways." American Psychologist 58, no. 1 (January 2003): 53-63.
Hill, P. C. and Pargament, K. I. [Rosemead School of Psychology, Biola University; Department of Psychology, Bowling Green State University]. "Advances in the conceptualization and measurement of religion and spirituality: implications for physical and mental health research." American Psychologist 58, no. 1 (January 2003): 64-74.
SUMMARIES AND COMMENTS: These four articles, taken together, offer a thorough assessment of the state-of-the-science of spirituality and health, and they point up both substantial developments in the field and promising directions for further work. These are sophisticated overviews that are content-rich and methodologically-minded, and as such they constitute fifty pages of essential reading for all researchers in the field. [Also, non-researchers should not be put off by the detail and volume of the information here, and the section below on the Use of the Articles for Discussion in CPE suggests ways that non-researchers especially may engage this material.]
Miller and Thoresen's introductory article, "Spirituality, religion, and health: an emerging research field," was prepared in association with the NIH Working Group on Research on Spirituality, Religion, and Health. The authors champion the idea that spirituality can be studied scientifically, just as other "elusive phenomena, such as complex cognitive processes, emotional states, and the inner workings of psychotherapy are now regular topics of scientific study" [p. 25]; and they respond to the various arguments of opponents who hold that this research either cannot or should not be conducted [see pp. 26-7]. They do take seriously, however, some of the concerns shared by critics of research in this area, including consideration of possible adverse effects of religion on health, the use of flawed methodologies in many instances, and the misuse of religion in the clinical setting; but they do not find these concerns to be more than reminders of the caution necessary in the field [see pp. 32-3].
A particularly important section of the article examines the question of how to define spirituality and religion--in terms of popular usage and operational definition. The authors observe that the concepts are changing, evolving, with that of religion seeming to become more narrow and that of spirituality becoming more broad. The concepts are said to be multidimensional and overlapping (e.g., religion can be conceptualized in private as well as public forms), and there is likely to be a tension between the operational definitions of scientists and the perspective of believers. "Scientists study beliefs or feelings or perspectives about spirituality, or they study behavioral effects and practices related to religion, all of which, from the believer's perspective, are essentially physical manifestations that fall short of representing or comprehending the real thing, the essence of what is experienced as spirituality" [p. 27]. The authors go on to characterize religion and spirituality in the methodological language of latent constructs--"conceptual underlying entities that are not observed directly but can be inferred from observations of some of their component dimensions" [p. 28].
A further feature of the article is a somewhat technical exposition of analysis of the accumulated body of research by a levels-of-evidence approach (which is subsequently used in two of the other articles in the series, preferred over a meta-analysis strategy). This approach looks at particular hypotheses and the strength of the evidence for them. The authors further address two approaches to statistical control in interpreting the scientific literature: the unique variance approach, which focuses on risk factors influencing health outcomes that are above and beyond already-recognized risk or protective factors, and a causal modeling approach, which takes into account causal relationships. These sections [pp. 29-32] are of particular interest to experienced researchers, and they illustrate the advanced character of Miller and Thoresen's treatment of the material. (Non-researchers may want to save this section of the article for last.) The authors close with a general exhortation about research into spirituality that indicates how their technical expertise is paired with passion: "Scientific investigation of this neglected aspect of human nature may lead to important new clues to helping people live together with better health, richer positive experiences, and greater meaning and satisfaction in life" [p. 33].
The second article in the series, Powell, Shahabi and Thoresen's "Religion and spirituality: linkages to physical health," is an application of the levels-of-evidence methodology outlined in the first article. The authors assess the evidence of studies to date for "nine hypotheses that underlie most of the investigations that test for a link between religion or spirituality and health" [p. 39]. To sum up the basic results of the analysis: there appears to be persuasive evidence for the hypothesis that church/service attendance protects against death; there appears to be some evidence for the hypotheses that religion or spirituality protects against cardiovascular disease and that being prayed for improves physical recovery from acute illness; and there appears to be either inadequate evidence or consistent failures to show evidence for the hypotheses that religion or spirituality protects against cancer mortality, that deeply religious people are protected against death, that religion or spirituality protects against disability, that religion or spirituality slows the progression of cancer, that people who use religion to cope with difficulties live longer, and that religion or spirituality improves recovery from illness--actually, in the last case, there is said to be some evidence to the contrary: that religion or spirituality impedes recovery from acute illness. Each of the hypotheses are addressed narratively in detail along with tables giving information about the pertinent studies being examined [see pp. 40-8].
In their general discussion [pp. 48-50], the authors look more thoroughly at the hypothesis for which there seems to be persuasive evidence: that church/service attendance protects against death; and they muse about possible mechanisms by which such an effect may occur. They also address their finding that there appears to be inadequate evidence to date to substantiate the effect of religion or spirituality as "a coping resource to buffer the impact of disease in patients" [p. 49], noting the potential importance here for the issue of increasing support for spiritual counselors as part of medical teams. (They do add a comment at this point: "This does not, however, bear on the issue of the value of spiritual counseling at times of sickness and loss in providing emotional and instrumental support and comfort" [p. 50].) They also comment briefly about "the file drawer effect," whereby unpublished studies cannot be included in such an analysis as presented here. In conclusion, the authors state that "a relationship between religion or spirituality and physical health does exist but that it may be more limited and more complex than has been suggested by others" [p. 50].
In the third article, "Religiosity/spirituality and health: a critical review of the evidence for biological pathways," Seeman, Dubin and Seeman use (again) the levels-of-evidence methodology "to review and evaluate the available evidence linking religiosity/spirituality to biologic processes that may serve as mechanisms for any health effects of religiosity/spirituality" [p. 54]. They concentrate on eleven propositions in the literature: three regarding Judeo-Christian religious practices and seven regarding Zen, yoga, meditation/relaxation practices. They note that "a surprisingly small number of studies analyze the biologic correlates of Judeo-Christian religious practices" [p. 54], and they call for greater attention to be given to this area, "including individual and group prayer, reading of religious texts, and various aspects of religious services" [p. 61].
According to the findings of the review: regarding Judeo-Christian religious practices, there appears to be reasonable evidence for the propositions that religiosity/spirituality is associated with lower blood pressure and less hypertension and with better immune function, and there appears to be some evidence that religiosity/spirituality is associated with better lipid profiles. Regarding Zen, yoga, meditation/relaxation practices, there appears to be evidence that is persuasive for the proposition that meditation/relaxation is associated with better health outcomes in clinical patient populations, and there is evidence that is more than reasonable but not yet persuasive (to use the language of levels-of-evidence analysis) for the proposition that meditation/relaxation is associated with lower blood pressure. There appears to be reasonable evidence for the propositions that meditation/relaxation is associated with lower cholesterol, with lower stress hormone levels, and with differential patterns of brain activity; and there appears to be some evidence that meditation/relaxation is associated with less oxidative stress, with less blood pressure reactivity under challenge, and with less stress hormone reactivity under challenge. The findings are discussed narratively [pp. 54-60] and presented in sum as a table [p. 55].
The authors believe that "evidence reported to date is generally consistent with the hypothesis that aspects of religiosity/spirituality may indeed be linked to physiological processes--including cardiovascular, neuroendocrine, and immune function--that are importantly related to health" [p. 61]. They suggest a number of issues for future research [p. 61] and hold out especially the promising opportunities for study through "recent innovations in measurement of physiological parameters, including the development of less invasive protocols (e.g., salivary cortisol protocols) as well as protocols to permit assessment of brain function (e.g., functional brain imaging)" [p. 62]. For pastoral care researchers reading this article, the emphasis on physiology and the use of obviously advanced medical protocols might make this material seem less than immediately pertinent, but this review may be especially valuable in two ways: first, it presents a perspective on the evidence which is most attractive to medical researchers with whom pastoral care researchers may partner; and second, it raises with specificity the question of mechanisms, which is a significant and sometimes tense subject for discussion between pastoral care givers and researchers.
In the final article, "Advances in the conceptualization and measurement of religion and spirituality: implications for physical and mental health research," Hill and Pargament observe that most studies have employed measures of religiosity or spirituality that are global (e.g., frequency of church attendance or self-related religiousness) and have limited reliability, yet in spite of this these measures have shown religion and spirituality to be "surprisingly robust variables in predicting health-related outcomes" [p. 66]. Ironically, the success of global measures may have hindered the development of "more conceptually grounded and psychometrically sophisticated measures that specifically apply to health-related issues" [p. 66]. The authors hope to bring to bear upon the broad field of research recent advances in the conceptual and empirical work of the psychology of religion that focus on inherent qualities of the religious or spiritual experience and see religion and spirituality as "complex variables involving cognitive, emotional, behavioral, interpersonal, and physiological dimensions" [p. 66].
Four religion and spirituality constructs are highlighted that appear to be functionally related to health: 1) perceived closeness to God, 2) orienting, motivating forces, 3) religious support, and 4) religious and spiritual struggle; and in each case Hill and Pargament suggest published measures [see pp. 67-70]. These four are characterized as "in some sense psychospiritual constructs...[that] have roots in religious and spiritual worldviews as well as in psychological theory" [p. 72]. The authors also suggest needs for further work in the conceptualization and measurement of religion and spirituality, including the need for more contextually sensitive measures, alternatives to self-report measures, development of measures of religious and spiritual outcomes, and development of measures of religious and spiritual change and transformation [see pp. 70-1].
Though not the focus of their article, one of the most interesting sections is the authors' treatment of the meaning of religion and spirituality, which echoes in part some of the concerns of Miller and Thoresen's article. Hill and Pargament write of the "bifurcation" of religion and spirituality: "one is witnessing, particularly in the United States, the polarization of religiousness and spirituality, with the former representing an institutional, formal, outward, doctrinal, authoritarian, inhibiting expression and the latter representing an individual, subjective, emotional, inward, unsystematic, freeing expression" [p. 64, citing Harold Koenig on the subject]; and they note dangers in such a conceptual trend. They offer their own definition of spirituality: "a search for the sacred, a process through which people seek to discover, hold on to, and, when necessary, transform whatever they hold sacred in their lives"--a search that "takes place in a larger religious context, one that may be traditional or nontraditional" [p. 65]. They continue: "The sacred is what distinguishes religion and spirituality from other phenomena," and it is "the common denominator of religious and spiritual life" [p. 65]. The authors' emphasis on the sacred is striking, since that concept is surprisingly rare in definitions used in the health care literature. For this reason, and because the article proffers so much practical information about useful measures, it is engaging reading for pastoral care researchers as well as pastoral care providers. Though it appears last in the series, it perhaps should be read first.
Suggestions for the Use of the Articles for Discussion in CPE:
As mentioned immediately above, the article by Hill and Pargament may hold the most promise for discussion with CPE students, in part because of the treatment of the concept of spirituality [pp. 64-5], but also because students may be challenged to think carefully about the place of measures of spirituality and religion in the pursuit of research. The listing of the four religion and spirituality constructs functionally related to health--1) perceived closeness to God, 2) orienting, motivating forces, 3) religious support, and 4) religious and spiritual struggle [pp. 67-70]--can also serve as a structure for a general discussion of the possible impact of religion on health. It may be usefully paired with Miller and Thoresen's introductory article, which also takes up the topic of the conceptualization and the usage of spirituality and religion [pp. 27-9] and goes on to addresses broadly the debate over whether this is an area to which scientific research really can or should be applied. [However, students who are not familiar with research may be cautioned not to become bogged down in the details of the sections on pp. 29-32, dealing the levels-of-evidence approach and two approaches to statistical controls.] The articles by Powell, Shahabi and Thoresen, and by Seeman, Dubin and Seeman are of such a technical character that they may best be used with students who are especially interested in research, but all students should find thought provoking the basic findings of the reviews as summarized in the tables on pp. 39 and 55. Many students new to research in spirituality and health begin with little interest in (the extremely important subject of) methodology but rather want to know simply what the studies show. These articles give a credible overview of the current state-of-the-science, both in terms of the evidence so far accumulated and the complexity of investigating religion/spirituality and its connections to health.
Related Items of Interest:
For other recent--and very readable--overviews of research into spirituality and health, see:
George, L. K., Larson, D. B., Keonig, H. G. and McCullough, M. E. "Spirituality and health: what we know, and what we need to know." Journal of Social and Clinical Psychology 19, no. 1 (Spring 2000): 102-16.
Thoresen, C. E. and Harris, H. A. "Spirituality and health: what's the evidence and what's needed?" Annals of Behavioral Medicine 24, no. 1 (Winter 2002): 3-13.
[Added 5/5/06:] Weaver, A. J. and Koenig, H. G. "Religion, spirituality, and their relevance to medicine: an update." American Family Physician 73, no. 8 (April 15, 2006): 1336-1337.
For more on the conceptualization and operational definition of spirituality, see the September 2002 Articles-of-the-Month page of this web site.
If you have suggestions about the form and/or content of the site, e-mail Chaplain John Ehman (Network Convener) at firstname.lastname@example.org