SUMMARY and COMMENT: This is an extraordinarily well-written article, from eminent researchers in the field of spirituality & health, on a topic of great practical value to most chaplains. "...[T]his study was designed to rigorously test for the first time a variety of methods of R/S [Religious/Spiritual] distress screening to identify the best very brief screening items" [p. 472]. In the process, it establishes an important baseline of results in relation to which further research can build a continually refined understanding of spirituality screening.

A final thought: Since screening questions ultimately turn on the effectiveness of specific word choices, it is notable that the two top contenders out of this study -- Do you struggle with the loss of meaning and joy to your life?" and "Do you currently have what you would describe as religious or spiritual struggles?" -- both employ the word struggle. This reader wonders how that word in particular may be a key to opening up revealing responses about distress from HCT patients or patients in general. It is not a word that figures into any of the other assessments studied here, even the Brief RCOPE, but it may ring with a special clarity for many in the throes of healthcare crises. If so, then this raises a question of whether the term is as effective with patients in less severe circumstances and what analog terms in other languages are similarly effective.

Suggestions for Use of the Article for Student Discussion: 

This article should be engaging to chaplaincy students not only for the topic but as a result of the strength and clarity of the writing. While it focuses on specific screening questions, it broaches the wider issue of screening per se. What do students think of the idea of patients being screened for religious/spiritual distress by means of explicit questions? Do they imagine that this could be part of their pastoral practice, or would they prefer that the screening be done by someone else? If so, how would this bring the dynamics of referral into play? What might be the difference between asking explicit screening questions and a chaplain simply listening for the themes of certain screening questions during a pastoral conversation? What of the authors' point that, while the Negative Religious Coping subscale of the Brief RCOPE may be worthy of being a reference standard for the study, its "seven items...may be burdensome" [p. 472]? Our authors note the issue of screening for R/S distress in patients "with no explicit religious identity" [p. 472]. Is this a salient issue for students? And, how important is the timing of an assessment? It's not just about what to ask but when to do it [--see pp. 474 and 478]. Looking at the tested screening items themselves, do students have personal preferences that might not align with the findings of the article? If that's the case, then are they receptive to being swayed by the research? In light of the authors' comment about "balanc[ing] the value of sensitivity relative to that of specificity" [p. 474], students might consider closely the trade-offs implicit in Table 4 [p. 478] to see the practical compromises implicit in the various screening question combinations. What is the relationship between the empirical data here and the need for the authors to work with it in light of such factors as their "clinical experience" [--see p. 474]? For students more versed in research, the data presented in the tables could be rich source for discussion [--especially Table 3 on p. 477].

Related Items of Interest:

I.  For related research from our authors on hematopoietic cell transplant (HCT) survivors, see:

King, S. D. W., Fitchett, G., Murphy, P. E., Pargament, K. I., Martin, P. J., Johnson, R. H., Harrison, D. A. and Loggers, E. T. "Spiritual or religious struggle in hematopoietic cell transplant survivors." Psycho-Oncology (2015): published online ahead of print. [(Abstract:) BACKGROUND: This study describes the prevalence of religious or spiritual (R/S) struggle in long-term survivors after hematopoietic cell transplantation (HCT), demographic and medical correlates of R/S struggle, and its associations with depression and quality of life. METHODS: Data were collected in conjunction with an annual survey of adult (age ≥18 years) survivors of HCT. Study measures included R/S struggle (negative religious coping, NRC, from Brief RCOPE), measures of quality of life (subscales from 36-item Short Form Health Survey and McGill), and the Patient Health Questionnaire 8. R/S struggle was defined as any non-zero response on the NRC. Factors associated with R/S struggle were identified using multi-variable logistic regression models. RESULTS: The study analyzed data from 1449 respondents who ranged from 6 months to 40 years after HCT. Twenty-seven percent had some R/S struggle. In a multi-variable logistic regression model, R/S struggle was associated with greater depression and poorer quality of life. R/S struggle was also associated with younger age, non-White race, and self-identification as either religious but not spiritual or spiritual but not religious. R/S struggle was not associated with any medical variables, including time since transplant. CONCLUSIONS: Religious or spiritual struggle is common among HCT survivors, even many years after HCT. Survivors should be screened and, as indicated, referred to a professional with expertise in R/S struggle. Further study is needed to determine causal relationships, longitudinal trajectory, impact of struggle intensity, and effects of R/S struggle on health, mood, and social roles for HCT survivors.]

II.  The individual assessments tested here are each worthy of a closer look. For more on the Rush Protocol, see our January 2013 Article-of-the-Month page. The question "Are you at peace?" was the focus of our February 2006 Article-of-the-Month. And, the NCCN Distress Thermometer and Problem List, may be found on the National Comprehensive Cancer Network website.

III.  Our article references a joint position statement on screening for distress from the American Psychosocial Oncology Society, Association of Oncology Social Work, and Oncology Nursing Society [p. 472], including a recognition of R/S distress. The definition for distress given there comes from the National Comprehensive Cancer Network (NCCN): "unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social, and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment." The link to that joint statement, given in the bibliographical notes does not seem to work, though the document appears to be available from the Association of Oncology Social Work. For more on this, however, see:

Pirl, W. F., Fann, J. R., Greer, J. A., Braun, I., Deshields, T., Fulcher, C., Harvey, E., Holland, J., Kennedy, V., Lazenby, M., Wagner, L., Underhill, M., Walker, D. K., Zabora, J., Zebrack, B. and Bardwell, W. A. "Recommendations for the implementation of distress screening programs in cancer centers: report from the American Psychosocial Oncology Society (APOS), Association of Oncology Social Work (AOSW), and Oncology Nursing Society (ONS) joint task force." Cancer 120, no. 19 (October 1, 2014): 2946-2954. [(Abstract:) In 2015, the American College of Surgeons (ACoS) Commission on Cancer will require cancer centers to implement screening programs for psychosocial distress as a new criterion for accreditation. A joint task force from the American Psychosocial Oncology Society, the Association of Oncology Social Work, and the Oncology Nursing Society developed consensus-based recommendations to guide the implementation of this requirement. In this review, the authors provide recommendations regarding each of the 6 components necessary to meet the ACoS standard: 1) inclusion of psychosocial representation on the cancer committee, 2) timing of screening, 3) method/mode of screening, 4) tools for screening, 5) assessment and referral, and 6) documentation.]

IV.  The popular Brief RCOPE, used as the reference standard in this month's study, was developed from a longer RCOPE instrument, which is described in detail by Kenneth I. Pargament, Harold G. Koenig, and Lisa M. Perez in "The many methods of religious coping: development and initial validation of the RCOPE" [Journal of Clinical Psychology 56, no. 4 (April 2000): 519-543]. For a tabular summary of the Brief RCOPE, pairing its 14 items with religious coping methods and key religious functions, click HERE. For a formal and detailed introduction to, and explanation of, the measure, see:

Pargament, K., Feuille, M. and Burdzy, D. "The Brief RCOPE: current psychometric status of a short measure of religious coping." Religions 2, no. 1 (2011): 51-76. [The Brief RCOPE is a 14-item measure of religious coping with major life stressors. As the most commonly used measure of religious coping in the literature, it has helped contribute to the growth of knowledge about the roles religion serves in the process of dealing with crisis, trauma, and transition. This paper reports on the development of the Brief RCOPE and its psychometric status. The scale developed out of Pargament's (1997) program of theory and research on religious coping. The items themselves were generated through interviews with people experiencing major life stressors. Two overarching forms of religious coping, positive and negative, were articulated through factor analysis of the full RCOPE. Positive religious coping methods reflect a secure relationship with a transcendent force, a sense of spiritual connectedness with others, and a benevolent world view. Negative religious coping methods reflect underlying spiritual tensions and struggles within oneself, with others, and with the divine. Empirical studies document the internal consistency of the positive and negative subscales of the Brief RCOPE. Moreover, empirical studies provide support for the construct validity, predictive validity, and incremental validity of the subscales. The Negative Religious Coping subscale, in particular, has emerged as a robust predictor of health-related outcomes. Initial evidence suggests that the Brief RCOPE may be useful as an evaluative tool that is sensitive to the effects of psychological interventions. In short, the Brief RCOPE has demonstrated its utility as an instrument for research and practice in the psychology of religion and spirituality.] [This is an Open Access article.]

V.  For more on the American College of Surgeons' Commission on Cancer standards see the organization's website, which gives both the 2012 standards and the new ones for 2016. The 2012 standards address [pp. 76-77] the phase-in of the Psychosocial Distress Screening cited in our article and further mention spirituality on pp. 38 and 70. The 2016 standards covers the distress screening on pp. 56-57 and in the glossary on p. 80, and also mentions spirituality on pp. 25 and 53. [Note, however, that the explicit mention of chaplains occurs only in the 2012 standards (p. 70).]

VI.  Participants in our featured research were survivors of hematopoietic cell transplantation. For more on such patients, see our September 2015 Article-of-the-Month page.