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May 2005 Articles of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Presbyterian, Philadelphia PA.


Ai, A. L. and Park, C. L. "Possibilities of the positive following violence and trauma: informing the coming decade of research." Journal of Interpersonal Violence 20, no. 2 (February 2005): 242-250.

McColl, M. A., Bickenbach, J., Johnston, J., Nishihama, S., Schumaker, M., Smith, K., Smith, M. and Yealland, B. "Changes in spiritual beliefs after traumatic disability." Archives of Physical Medicine and Rehabilitation 81, no. 6 (June 2000): 817-823.

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.


COMMENT AND SUMMARY: Many CPE Centers are also trauma centers, and those that are not are still typically places where chaplains encounter patients dealing with various kinds of traumas--present and past. There may be great potential for chaplains to focus on trauma as a subject of research, especially because, as Amy L. Ai and Crystal L. Park observe in "Possibilities of the positive following violence and trauma," "relatively few studies have integrated the role of spirituality into violent trauma research and practice" [p. 245]. Ai's and Park's overview article addresses the role of spirituality and religion in trauma research (along with trends in the positive psychology movement and the development of studies in stress-related growth), and they state:

At least three interrelated questions regarding spirituality and trauma can be asked: (a) How do people cope spiritually with violence and trauma, (b) does spirituality protect mental health following traumatic events, and (c) how do such events affect spirituality? [p. 245]
It is only the last of these three questions which is the focus of the present Articles-of-the-Month selections: two quite different studies of changes in spirituality/religious beliefs in persons who have experienced traumatic events; but Ai's and Park's article is featured also because it places this research into a larger context and is a recent introduction to this general area of study.

In noting a few studies of the effects of traumatic experiences on spirituality/religion, Ai and Park illustrate how existing research seems to be pointing in two different directions. On the one hand, there is some evidence that spirituality can be strengthened in the wake of trauma; and on the other hand, trauma may cause some people to become less religious--and this latter finding may be particularly the case in studies involving PTSD.

The two other featured articles this month are further illustrations of the two trends in findings in the research literature to date.

First, McColl, et al., in "Changes in spiritual beliefs after traumatic disability," analyzed intensive semistructured interviews of 16 people who had suffered traumatic spinal cord or brain injury. The interviews were conducted within a two-year period after the patients had been discharged from rehabilitation. Spirituality-related changes were explored according to a conceptual matrix based in previous work by the authors [--see McColl, M. A., Bickenbach, J., Johnston, J., Nishihama, S., Schumaker, M., Smith, K., Smith, M. and Yealland, B., "Spiritual issues associated with traumatic-onset disability," Disability and Rehabilitation 22, no. 12 (August 15, 2000): 555-564], composed of three types of relationships (i.e., intrapersonal, interpersonal, and transpersonal) and five themes (i.e., awareness, closeness, trust, purpose, and vulnerability). The interview questions [--see the table on p. 818] were:

  1. Have you ever experienced a loss or gain in faith? If so, when? What were the circumstances?
  2. Would you describe yourself as a spiritual person?
  3. Have you experienced any changes in who you are, who your real self is, since you acquired your disability?
  4. Have you experienced any changes in your relationships with others since your disability?
  5. Has your way of viewing the world changed since your disability?
  6. Has your relationship with God or a higher power changed since the onset of your disability?
  7. Have your beliefs changed since the onset of your disability?
  8. Have your religious practices changed since the onset of your disability?
  9. Has your soul or spirit been affected by your disability?
The questions play out of the authors' working definition of spirituality as "relationships with the world, with a supreme power, with others, and with one's self" [p. 817].

Analysis of the interviews indicated that participants experienced "greater awareness of the self, a change in view of their own independence, a sense of purpose in life that was not present before the onset of the disability, greater awareness of their own mortality and vulnerability, a new understanding of trust, especially when depending on others; loss of some significant relationships, greater appreciation and closeness with others in the world, and greater understanding of other disadvantaged groups" [p. 817, abstract]. The results point up the potential for positive changes following traumatic events that in this case led to disabilities, though the authors concede that there could be a number of explanations for their subjects' largely positive tone. The success of the interview methodology itself, however, shows that patients who have suffered trauma may be well able to articulate changes in their spirituality.

The study by Sherry A. Falsetti, et al., "Changes in religious beliefs following trauma," suggests both the complexity of the associations between religious beliefs and traumatic experience and the risk that persons who have experienced trauma may become "less religious." The 120 participants in this study were part of a DSM-IV Field Trial Study on Post Traumatic Stress Disorder [PTSD], taken from community and clinical samples. Among the measures employed were the Intrinsic Religious Motivation Scale [--see Hodge, D. R., "A validated intrinsic religious motivation scale," Journal for the Scientific Study of Religion 11 (1972): 369-376] and the Changes in Religious Beliefs Scale [--an unpublished measure by Sherry A. Falsetti].

Among the findings: "an initial or only trauma may have a significant influence on one's religious beliefs, particularly if the individual meets criteria for PTSD" [p. 396]. "...[A]lmost 30% of those with PTSD reported becoming less religious after their first/only trauma compared to 6% of the PTSD negative group. In addition, about 20% of the PTSD positive group reported becoming more religious compared to 9% of the PTSD negative group" [p. 395]. However, the authors caution, "What is not yet clear and requires further investigation is whether PTSD in part results from the disruption or changes in beliefs or if the belief changes are in part a result of PTSD" [p. 396].

For victims of multiple traumas, no pattern in changes in religious beliefs was detected, though it is interesting that these individuals indicated higher intrinsic religiosity scores than those individuals who had suffered single traumas. The authors speculate in terms of information processing theory that the experience of multiple traumas could lead people to "look to religion/god/higher power as the one 'constant' in their lives and the only aspect of their world that they can trust, that provides the inner strength to go on in the midst of chaos" [p. 397].

Nevertheless, it is noteworthy that "...when asked about current religious beliefs, the majority of the [total] sample reported that their beliefs had never changed (39%) or were not that important to them (38%). Twenty-two percent reported that their beliefs had changed following a traumatic event and had remained changed, and 2% reported their beliefs changed following a traumatic event, but returned to what they were before the trauma(s)" [p. 396]. These figures attest to the resiliency of religious beliefs in the face of trauma, but they also show that a significant minority of trauma survivors may experience a spiritual change that could be either positive or negative. The authors point out that spiritual/religious issues may be important for the treatment of trauma victims, but since mental health providers may be uncomfortable or untrained in addressing spirituality, "they might consider enlisting assistance of the clergy or others more knowledgeable in spiritual matters" [p. 397].

Chaplains who work with trauma victims should consider the possibilities for research into patients'/clients' spiritual issues not only in the immediate aftermath of a traumatic event but in the months and years following. Such research might even be a collaboration between health care chaplains and community clergy. The articles highlighted above show that the effects of traumatic events need not be only negative but could be the source of "adversarial growth" in a variety of ways, and that while individuals' spirituality may tend to be resilient, the spiritual impact of a single traumatizing event may be entwined with lasting psychological issues such as with the case of PTSD. Understanding the impact of trauma on spirituality would seem to be significant pastorally and may in turn contribute to better interventions to help trauma survivors cope.

[While this month's topic has been the effect of trauma on spirituality, the role of spirituality/religion in coping with trauma will be the topic of a future Article-of-the-Month page, but for a sample of articles about spiritual/religious coping, see especially the April 2003, April 2004, and November 2004 Article-of-the-Month pages.]


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

The three featured articles this month are suited to three different types of discussion with CPE students. Ai's and Crystal's overview article may be used to introduce students to idea of "positive" consequences from trauma. Students may be challenged to think about how they have encountered "adversarial growth" in patients or how they may have come to know it in themselves in ways more complex and subtle than allowed by such platitudes as, "what doesn't kill you makes you stronger." [--see NOTE #1, below]. Students may want to discuss the process, described briefly on p. 246 [--but see NOTE #2, below] of the interplay between religious beliefs and traumatic experiences. The article may be paired with the study by McColl, et al., which breaks down some specific ways that spirituality may be affected, here generally positively. The article treats its five themes (i.e., awareness, closeness, trust, purpose, and vulnerability) individually, thus setting out manageable sections for discussion. There is good use of quotations to illustrate the themes, and a helpful table [p. 819] breaking down themes according to the three types of relationships (i.e., intrapersonal, interpersonal, and transpersonal). The study by Falsetti, et al. may be somewhat more difficult for students who don't have some grounding in research methodology and statistics, or who are not familiar with PTSD (as there is no explanation of PTSD itself), but it is surely not beyond any student's careful reading. The findings raise intriguing questions about the experience of single versus multiple traumas and about the significance of PTSD. The Discussion section [pp. 396-397] offers scenarios of religious perspectives and experiences to illustrate the authors' points, and these may well stir students to conversation and debate.

NOTE #1: In my experience as a chaplain, a surprising number of patients seem to believe that the saying, "what doesn't kill you makes you stronger," is a Bible verse, presumably somewhere in the writings of Paul (and often associated with the idea that God will not put upon people more than they can handle--generally an interpretation of 1 Corinthians 10:13b). For the record, the saying appears to be an adaptation of a line by Friedrich Nietzsche: "was ihn nicht umbringt, macht ihn starker," (--see Section 2 of "Why I am So Wise," in Nietzsche's 1908 Ecce Homo).

NOTE #2: The sentence beginning, "A strong faith may be related..." (near the end of the first full paragraph on p. 246), seems to have a word missing. The sentence should perhaps be read, "A strong faith may be related to more initial distress as the devout individual's positive worldviews are shattered by their sudden and inexplicable trauma yet [lead] to better adjustment as the stressful event is eventually integrated into their meaning system."


Related Items of Interest: 

Bidwell, D. R. "Developing an adequate 'pneumatraumatology': understanding the spiritual impacts of traumatic injury." The Journal of Pastoral Care and Counseling 56, no. 2 (Summer 2002): 135-143. [Though not a report of research, this article offers insights and speculation about the impact of trauma on spirituality, drawing especially upon Christian and Buddhist traditions.]

Drescher, K. D. and Foy. D. W. "Spirituality and trauma treatment: suggestions for including spirituality as a coping resource." PTSD Clinical Quarterly (of the National Center for Post-Traumatic Stress Disorder 5, no. 1 (Winter 1995): 4-5. [The purpose of this article is to "provide suggestions for incorporating spirituality as a core component in coping resources assessment or relapse prevention work for traumatized populations" (p. 4), but the authors report partial findings from their study of veterans in inpatient treatment programs for PTSD. They have found that "Vietnam combat veterans with PTSD score lower than average on measures of religious orientation," that "they are less likely to use religion as a way of getting social support when they need it," and most indicate "difficulty reconciling their religious beliefs with their combat experience," though "about 26% of patients said that combat experience made their faith stronger" (p. 4).]

Fontana, A. and Rosenheck, R. "Trauma, change in strength of religious faith, and mental health service use among veterans treated for PTSD." Journal of Nervous and Mental Disease 192. no. 9 (September 2004): 579-584. [This article reports a study of 554 inpatients and 831 outpatients receiving treatment for PTSD in Veterans Affairs programs. Among the findings, these participants indicated a weakened religious faith and issues of guilt. The authors note the potential role of chaplains in these patients' treatment (see pp. 582-583).]

Linley, P. A. and Joseph, S. "Positive change following trauma and adversity: a review." Journal of Traumatic Stress 17, no. 1 (February 2004): 11-21. [This recent review article mentions spirituality throughout, including a brief section on Coping, Social Support, and Religion (p. 16); and it notes quite a number of studies on adversarial growth (see the tables on pp. 13-14 and 15) and several specific measures of adversarial growth that consider spirituality (p. 12).]

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 1996): 455-464. [This study of 25 undergraduates who had experienced a variety of traumatic stressors (with a control group of 25 who had not had such experiences) found religious beliefs to be relatively unaffected by trauma. The authors note that this finding about the resilience of religious beliefs stands in contrast to the findings of an earlier study: Schwartzberg, S. S. and Janoff-Bulman, R., "Grief and the search for meaning: exploring the assumptive worlds of bereaved college students," Journal of Social and Clinical Psychology 10, no. 3 (Fall 1991): 270-288.]

[Added 3/19/07, revised 6/10/07:] Powell, T., Ekin-Wood, A. and Collin, C. "Post-traumatic growth after head injury: a long-term follow-up." Brain Injury 21, no. 1 (January 2007): 31-38. [This British study of survivors of traumatic head injury compared responses to a series of questionnaires from samples of two groups: people early in their recovery (with average 1.7 years from injury) and people late in their recovery (with an average of 11.6 years). One of the questionnaires was the Post-traumatic Growth Inventory (see: Tedeschi, R. and Calhoun, L., "The post-traumatic growth inventory," Journal of Traumatic Stress 9, no. 3 (1996): 455471), very slightly modified from the original (see p. 33). The PGI showed significant difference between the two groups, suggesting that post-traumatic growth tends to increase over time. Of the five subscales of the PGI (i.e., Relating to Others, New Possibilities, Personal Strength, Spirituality, and Appreciation of Life), differentiation between the groups was found at the p=0.001 level for Relating to Others, New Possibilities, Personal Strength, and Spirituality. A table showing specific results is given on p. 34. The authors do not focus on the spirituality finding, but chaplain researchers may wish to look into the PGI as a useful instrument --it consists of 21 items, two of which apply to the domain of spiritual change: "I have a better understanding of spiritual matters" and "I have a stronger religious faith."]

[ADDED 12/27/05]: Shaw, A., Joseph, S. and Linley, P. A. "Religion, spirituality, and posttraumatic growth: a systematic review." Mental Health, Religion & Culture 8, no. 1 (March 2005): 1-11. [This review of eleven studies linking spirituality with posttraumatic growth finds not only that patient spirituality appears to aid posttraumatic growth but that "traumatic experiences can lead to a deepening of religion or spirituality" (--from the abstract).]

Tedeschi, R. G. and Calhoun, L.G. "Posttraumatic growth: conceptual foundations and empirical evidence." Psychological Inquiry 15, no. 1 (2004): 1-18. [This recent review by two leaders in the field of research into posttraumatic growth notes briefly "growth in the domain of spiritual and existential matters" (p. 6). This is the main article in this issue of the journal, and it receives extensive comment as part of the issue. See especially the comments on Tedeschi's and Calhoun's ideas about spiritual development in Pals, J. L. and McAdams, D. P., "The transformed self: a narrative understanding of posttraumatic growth," on p. 68. ]

Tedeschi, R. G. and Calhoun, L. G. "The Posttraumatic Growth Inventory: measuring the positive legacy of trauma." Journal of Traumatic Stress 9, no. 3 (July 1996): 455-471. [This measure considers five major domains of posttraumatic growth: 1) greater appreciation of life and changed sense of priorities, 2) warmer, more intimate relationships with others, 3) a greater sense of personal strength, 4) recognition of new possibilities or paths for one's life, 5) and spiritual development.]


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