May 2007 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Russinova, Z. and Cash, D. [Boston University]. "Personal perspectives about the meaning of religion and spirituality among persons with serious mental illness." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 271-284.
COMMENT and SUMMARY: One of the most persistent problems in the study of spirituality/religion and health is the meaning of the terms spirituality and religion. It has been a running theme through many of these Article-of-the-Month pages, beginning with the very first, which in September 2002 looked at conceptualizations of spirituality. With no consensus about meanings, the terms must be clarified in every article, and their ambiguity is a weakness to survey instruments. The authors of this month's featured article write: " resolving the conceptual ambiguity that surrounds the constructs of religion and spirituality becomes an essential prerequisite for increasing the rigor of the research examining their impact on physical and mental health outcomes" [p.272]. While Russinova and Cash do not resolve the problem, their study does provide interesting and potentially valuable sets of descriptors for the terms and suggests some patterns to the way that patients may use them.
The study analyzed semi-structured telephone interviews with 40 individuals who identified themselves as having serious mental illness and who were part of a larger study on alternative medicine and recovery. Included in the 45-60-minute interviews was an inquiry about "respondents' understanding of the concepts of religion and spirituality" [p.273], and whether they distinguished between the terms. Results showed that "participants' used two completely different sets of descriptors for religion and spirituality" [p. 279] and that they identified two constituent dimensions of the concepts: core characteristics that described "the nature of each phenomenon as personally experienced" and functional characteristics that "described the impact" [p. 275] on a person.
The authors present the particulars of each of these descriptors in brief summaries with illustrative quotes [--see pp. 275-278] and in a table [--see pp. 280-281]. The following is an adaptation of material from the table:
DEFINITIONAL CHARACTERISTICS OF SPIRITUALITY AND RELIGION
(in order of incidence within each dimension)
[See pp. 280-281.]
- Personal --
- Spirituality represents the individual's experience of the transcendent, independent of a community.
- Informal --
- Spirituality is unstructured, guided by feelings and intuitions rather than established rules and rituals.
- Exploratory --
- Spirituality represents openness to various beliefs about and paths to the transcendent.
- Intrinsic --
- Spirituality is an internally generated experience, independent of setting or location.
- Personal Relationship with the transcendent --
- Spirituality represents one's own relationship with the transcendent.
- Awareness of one's own soul --
- Spirituality consists of one's awareness and connectedness with the sacred within oneself.
- Awareness of universal life force --
- Spirituality represents a belief in an omnipresent universal energy or life force.
- Sense of universal connectedness --
- Spirituality represents a belief in the interconnectedness of all things.
- Continuous --
- Spirituality represents a constantly accessible connection with the transcendent, not limited to a particular time or place.
- Dogmatic/prescriptive --
- Religion represents a rigidly defined set of unquestionable beliefs and rules of behavior.
- Organized --
- Religion is associated with a structured organization or institution for worshipping the sacred.
- Ritualistic --
- Religion requires involvement with and adherence to regularly repeated rituals and/or practices.
- Doctrinal --
- Religion represents an established system of beliefs.
- Communal --
- Religion is a community of people united by worship.
- Extrinsic --
- Religion represents an outward or public manifestation of the individual's experience of the transcendent.
- Man-made --
- Religion is a social/historical construction.
- Compassion and acceptance of others --
- Spirituality engenders understanding, tolerance, respect, and compassion for others.
- Meaning-finding --
- Spirituality is a source of meaning and purpose in one's life.
- Promoting healing --
- Spirituality promotes healing, wellness, and personal growth.
- Empowering --
- Spirituality is empowering, through a greater sense of hope and self-worth.
- Promoting harmony and balance --
- Spirituality promotes personal and/or social harmony.
- Letting go of control --
- Spirituality encourages surrender of one's need for control.
- Supportive/comforting --
- Religion provides comfort and support to worshipers.
- Judgmental --
- Religion engenders close-mindedness and judgmentalism.
- Disempowering --
- Religion is harmful or oppressive.
- Fear-inducing --
- Religion is fear- and guilt-inducing.
- Socially divisive --
- Religion causes social division or violence.
- Socially acceptable --
- Religion is historically integrated into the traditionally accepted fabric of society.
The authors also found that "[a]lthough study participants used two completely different sets of descriptors to explain their understanding of the concepts of religion and spirituality, the analysis of their responses revealed that often they juxtaposed the two concepts referring to the opposite ends of the same conceptual continuum" [p. 278]. They present the following continua: Organized - Informal, Communal - Personal, Extrinsic - Intrinsic, Prescriptive - Exploratory, and Ritualistic - Continuous [--see p. 278 and Figure 1 on p. 279].
One further major finding was that the degree of self-perceived religiosity affected respondents' definitions. "When compared to non-religious persons, religious individuals were more likely to describe religion as an extrinsic experience…[and]…[a]t the same time non-religious individuals were more likely to perceive religion as dogmatic and prescriptive…and spirituality as having an exploratory nature" [p. 279]. A table on pp. 282-283 lines out "Characteristics of Religion and Spirituality by Respondents' Degree of Religiosity" (--this is Table 3, though it is misidentified in the text on p. 279 as "Table 2"). Because of this pattern, Russinova and Cash caution that future "studies examining the role of spirituality in recovery account for the levels of self-perceived religiosity and spirituality of study participants" [p. 282].
The study's limits (discussed on p. 283) include its small sample size and a population that was predominantly Christian. Participants also were also distinctive in that they well along in a recovery process from mental illness, and they did not represent persons who say that they are religious but not spiritual. This reader further was struck by the way that the conceptualization of spirituality was broadly positive, whereas that of religion turned out to carry a negative tone --this may indicate some bias that needs to be tested in future research. Therefore, the authors' suggestion that "[c]linicians can use the various descriptors of religion and spirituality as a checklist that can direct the exploration of their clients' spiritual background and beliefs" [p. 282] might best be taken with caution. Nevertheless, this study is a significant contribution to the problem of the ambiguity of fundamental concepts in the field of religion/spirituality and health and deserves to be discussed, debated, and replicated.
Suggestions for the Use of the Article for Discussion in CPE:
This article is very readable, and should be accessible to any CPE student. It provides at the outset an introduction to the topic under study, and it considers implications for clinical practice. It describes well how data was collected and analyzed, and it presents quantitative findings in percentages, that are easy to understand and do not require a sophisticated knowledge of statistics, while illustrating the qualitative findings with quotes from the interviews. The fact that the population here is one that is recovering from severe mental illness should not limit discussion of the concepts of religion and spirituality in general.
Students might start by thinking of their own sense of the two key terms and then locating their conceptualizations on the graphic of "Continuums of Conceptual Distinction between Religion and Spirituality" --Figure 1 on p. 279 (discussed on p. 278). Another way to begin discussion might be for a group leader to create cards giving the 28 definitional characteristics from Table 2 on pp. 280-281 (and listed in the table above on this web page) and then have the group sort them, one by one, into descriptors of spirituality or religion.
The article offers a number of small points that could be topics for discussion, but one that would allow for a focus on mental health patients in particular is the comment that "religious persons with serious mental illness tend to attribute more power to their providers and expect options to be prescribed to them, while non-religious individuals tend to seek partnerships with mental health providers who are open to their input as well as to the exploration of new treatment possibilities" [p. 283], in light of the study's finding about "the way religious and non-religious respondents contrasted the prescriptive character of religion with the exploratory nature of spirituality" [p. .283].
Related Items of Interest:
I. This month's article is part of a special theme issue of the Psychiatric Rehabilitation Journal on Spirituality & Recovery in mental health. Other articles from the issue (in the order that they appear) are:
Russinova, Z. and Blanch, A. "Supported spirituality: a new frontier in the recovery-oriented mental health system." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 247-249.
Blanch, A. "Integrating religion and spirituality in mental health: the promise and the challenge." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 251-260.
Fallot, R. D. "Spirituality and religion in recovery: some current issues." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 261-270.
Bellamy, C. D., Jarrett, N. C., Mowbray, O., MacFarlane, P., Mowbray, C. T. and Holter, M. C. "Relevance of spirituality for people with mental illness attending consumer-centered services." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 287-294.
Wong-McDonald, A. "Spirituality and psychosocial rehabilitation: empowering persons with serious psychiatric disabilities at an inner-city community program." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 295-300.
Bussema, E. F. and Bussema, K. E. "Gilead revisited: faith and recovery." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 301-305.
Revheim, N. and Greenberg, W. M. "Spirituality matters: creating a time and place for hope." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 307-310.
Mulcahy, L. "My journey of spirituality and resilience." Psychiatric Rehabilitation Journal 30, no. 4 (Spring 2007): 311-312.
II. For a recent (pilot) study exploring the meaning of spirituality among adolescent mental health patients, see:
MacGillivray, P. S., Sumsion, T. and Wicks-Nicholls, J. "Critical elements of spirituality as identified by adolescent mental health clients." Canadian Journal of Occupational Therapy 73, no. 5 (December 2006): 295-302. [(From the abstract): PURPOSE: This exploratory study attempted to gain insight into the relevant elements of spirituality and its importance to inpatient adolescent mental health clients. METHOD: An adolescent spirituality questionnaire was developed from definitions of spirituality in the literature, modified by a focus group consisting of members of the target population, and administered to 11 respondents. RESULTS: Elements related to the individual and lifelong pursuits of the individual were most closely associated with spirituality while those items traditionally connected with spirituality and with external pursuits, activities, and relationships are considered less relevant by this population. Results suggest that spirituality is important to a majority of inpatient adolescent mental health clients.]
III. For recent analyses of the concepts of spirituality and religion in nursing, see:
Clarke, J. "Religion and spirituality: a discussion paper about negativity, reductionism and differentiation in nursing texts." International Journal of Nursing Studies 43, no. 6 (August 2006): 775-785. [(Abstract): BACKGROUND: The last 30 years have seen a proliferation of literature about spirituality in the nursing press. A dominant theme has been the need to differentiate spirituality from religion and this has provoked a number of authors to attempt to define and describe religion. As nursing advocates respect for the person's religious beliefs the way in which it is portrayed is very relevant. AIMS: This work explores how religion is defined and discussed in the nursing literature about spirituality to consider whether the way religion is portrayed could be said to demonstrate 'respect' for religious beliefs. METHODS: Texts about religion were examined in relation to theories of religion from anthropology, sociology and religious studies. These disciplines have produced substantive or irreducible accounts in contrast to functional and reductive theories about religion. RESULTS: The result of this analysis is that there appears to be a tendency to talk about religion without using sources which itself suggests a lack of respect as well as an inclination to view it only in reductive and functional terms. This is proved by the similarity of ideas in the nursing literature to the functionalist and reductionist theories of Frazer, Tylor, Marx, Durkheim and Freud. This approach is criticised with reference to the work of Otto, Bellah, Berger and Pals who suggest that religion should be seen as irreducibly to do with the sacred. It is proposed that this is a more appropriate outlook to take for an occupation which professes to respect the religious beliefs of all individuals. However, viewing religion in this more meaningful way, acknowledging their spirituality has implications for attempts to differentiate religion and spirituality. CONCLUSION: Reductive accounts of religion imply, probably inadvertently but nevertheless negative, attitudes towards religious belief. A more serious and deeper exploration of the meaning of religion from the standpoint of irreducibility might be more respectful and tolerant of religious belief. This is particularly salient in a society where religious practice is increasing both in the indigenous population and as a result of immigration.]
McSherry, W., Cash, K. and Ross, L. "Meaning of spirituality: implications for nursing practice." Journal of Clinical Nursing 13, no. 8 (November 2004): 934-941. [(Abstract:) BACKGROUND: This research outlines some preliminary findings emerging from a grounded theory investigation into the 'meaning of spirituality'. These initial results raise some important questions about the terminology and language that nurses use regarding the term spirituality. It seems that many of the policy directives and statutory guidelines make two major assumptions regarding 'spirituality'. Firstly, patients and nurses are aware and understand the concept, and secondly, patients may require their spiritual needs to be met. These preliminary findings suggest that a dichotomy is emerging between professional assumption and patient expectation regarding the meaning of spirituality. AIM: The study had one broad research aim, to gain a deeper insight into how patients, nurses, and people from the major world religions understand the concept of 'spirituality'. DESIGN: A qualitative research design was used involving a grounded theory method of inquiry. It was felt that this qualitative method would aid the investigation of this subjective dimension of peoples' existence, enabling existing theoretical constructs and arguments to be tested. METHODS: The constant comparative method was used throughout the data collection and analysis. Analysis was undertaken at two levels, 'overview analysis' and 'line-by-line analysis'. This enabled the creation of categories and central themes. RESULTS: Constant comparative analysis resulted in the formation of several categories and central themes. Two categories presented and discussed in detail are 'definitions of spirituality', and 'diverse perceptions of spirituality'. CONCLUSION: It would seem that there is now an urgent need for nursing to evaluate and perhaps adjust its vision regarding what constitutes spirituality. Such an approach may serve to reduce the gap between policy and public expectation. RELEVANCE TO CLINICAL PRACTICE: It seems that there may be no 'precise' terminology associated with the language used to define spirituality, raising possible implications for nursing practice and nurse education.]
IV. For a more extensive bibliography on the definition and use of the concept of spirituality--usually conceived vis-à-vis the concept of religion--in the health care literature, click HERE (PDF, 1 page).