IN FOCUS: Religion, spirituality, and health

Over recent years, researchers have gotten serious about studying the effects of religion on health. Before the turn of the millennium, there were abundant studies that seemed to link church attendance with better health and lower mortality, but investigators weren’t sure what those connections might mean. Was religious activity actually causing better health among adherents, or were there other factors in play? As part of current efforts to address questions like these, the Journal of Behavioral Medicine recently devoted an entire issue to exploring the concrete relationship between religion and measures of physical and mental well-being. Here, the editors of review these articles for you.

One weakness of many earlier studies on religiosity and health was that they were often cross-sectional. That is, researchers measured respondents’ health and religiousness at a single time, which meant that they could only prove a correlation between the two, not a causal relationship. Another problem was the lack of a good theoretical groundwork: aside from a few simple suggestions – such as that churchgoers were less likely to do drugs or engage in other risky behaviors – no one had a rigorous proposal for why religious belief might affect people’s health.

In its December 2011 issue, the Journal of Behavioral Medicine published work from a wide variety of specializations that tried to solve these methodological riddles. The thread running through all the articles in the issue is what the editors call “explanatory research.” In contrast to descriptive research, explanatory research methodologies actually try to identify the underlying mechanisms of the effects they’re investigating.

An article on types of prayer and depression among cancer patients serves as a perfect example of this type of research. The researchers, led by John E. Pérez of the University of San Francisco, identified a number of different prayer styles and then hypothesized how those different types of prayer might affect rates of depression in cancer patients. They found that prayers of thanksgiving and prayers for others both seemed to reduce depression in cancer patients, while supplication prayers (asking God for favors) and confession prayers (confessing one’s sins and asking for forgiveness) didn’t affect depression one way or another.

Analyzing the data further, Pérez and his colleagues found that the link between thanksgiving prayer and lowered depression was fully mediated by less rumination. This means that cancer patients who often gave prayers of thanks to God were brooding less on their own conditions and difficulties. This seemed to explain why thanksgiving prayer led to less depression: the patients just weren’t dwelling on their problems as much, and thus naturally felt better. Meanwhile, prayer for others seemed to increase patients’ sense of social support, and this in turn made them less depressed. The interesting thing was that social support didn’t fully mediate the link between prayer for others and depression. That is, while praying for others’ well-being did help the patients to feel more connected, such prayer also seemed to reduce depression directly, or perhaps through other means such as encouraging patients to feel more grateful or increasing their ability to forgive.

Another study, this one led by Jessie Dezutter of the Catholic University of Leuven, also focused on prayer. This study looked at the relationship between chronic pain and prayer in a large group of Flemish chronic pain patients. The authors hypothesized that prayer would help patients to cognitively reappraise their situations, reorienting their thought processes to think of their conditions as part of a greater spiritual framework or divine plan. This model implied that prayer would not actually reduce the severity of the pain, but would instead make it more bearable by changing the way patients thought about it.

As sometimes happens, the researchers’ hypothesis was only partly confirmed: when the patient group was examined as a whole, it seemed that prayer did, in fact, make pain more bearable, but didn’t lessen its actual severity. When the additional factor of religious commitment was brought in, though, this relationship changed. Prayer seemed to only be effective for those who considered themselves religious or who identified with a religious group. Furthermore, for religious patients prayer actually reduced the subjective severity of the pain itself as well as making it more bearable via cognitive reframing. The positive effects of prayer weren’t nearly as strong for non-religious patients. Drawing conclusions from their data, Dezutter and colleagues suggested that prayer may need “to be incorporated in the religious meaning system” of each person before it can have a beneficial impact on pain.

Other teams of researchers examined the effects of religiosity on cardiac health. For example, Kevin Masters of the University of Colorado, Denver, and Andrea Knestel of Brigham Young University measured a group of healthy volunteers for their style of religious motivation and then tested to see whether style of motivation affected their cardiac reactivity, or the amount that their cardiovascular systems responded negatively to stress.

Religious motivation is usually described as either extrinsic and intrinsic: extrinsically religious people participate in religion for ancillary benefits such as social connections, while the intrinsically religious consider religiousness to be something personal, pursued for its own sake. People who score high on both extrinsic and intrinsic religion are considered “indiscriminately pro-religious.” While intrinsic religiosity is often correlated with positive mental health and well-being, people who score as pro-religious are often less well-adjusted.

Masters’ and Knestels’ study showed that pro-religious people were more neurotic, more hostile, and more unhealthy than their intrinsically religious peers. What’s more, they also expressed a weaker sense of personal coherence – they found less meaning in life. Strangely, however, the pro-religious respondents showed the least cardiovascular reactivity to a negative social stressor. This meant that they found social stresses, well, not very stressful – a characteristic that should predict good health and high levels of well-being. But since this group of volunteers reported low levels of physical health and demonstrated a fairly poor psychological profile, the authors suggested that indiscriminately pro-religious people may have more emotionally stressful lives, with the result that they may wear out “physiological pathways” that react to stress. In other words, people who score high in both intrinsic and extrinsic religiosity suffer from low levels of psychological health, and they might just be burned out because of it.

Brigham Young University also played a role in a similar study that investigated the connections between spiritual well-being and a variety of highly specific cardiovascular health indicators. Led by Julianne Holt-Lunstad of BYU, the team measured 100 healthy, religious subjects for their spiritual well-being using a survey that included items such as “I feel connected to a higher power (God)” and “I find comfort in my faith or spiritual beliefs.” Then the respondents’ scores on the spiritual wellness survey were compared with systolic and diastolic blood pressure, C-reactive protein levels, and fasting glucose levels (an indicator of diabetes). Also measured were cholesterol levels and nocturnal blood pressure dipping, both important signals of overall cardiac health.

As in many similar studies, subjects were also rated for stress and depression; in keeping with trends in the research literature, spiritual well-being was associated with less depression and less stress. It was also strongly correlated with better cardiac health, including lower systolic and diastolic blood pressure, stronger blood pressure dipping at night, and lower levels of the inflammatory agent C-reactive protein. Spirituality additionally predicted better fasting blood glucose levels and lower levels of dangerous cholesterols such as triglycerides and VLDL. Perhaps surprisingly, the relationship between spirituality and cardiac health was not fully mediated by spirituality’s effect on depression. Even fully controlling for depression and stress, spiritual well-being had a significant positive effect on cardiac health.

One important characteristic of this study was that all the participants were married, healthy, regular churchgoers with no negative health habits such as smoking or drug use. This means that one of the most common suggestions for how religion affects health – that it puts people in social environments where, say, excessive drinking is frowned upon – now must contend with some countervailing evidence. Even within a population where nobody drank too much, ate poorly, or smoked, having a highly positive spiritual life predicted significantly better cardiac health.

In another study related to the heart, Crystal L. Park of the University of Connecticut and colleagues examined the effects of religious struggle on people suffering from advanced heart disease. Religious struggle refers to negative feelings about God, one’s own spiritual life, or the religious tradition one belongs to. People who express religious struggle may be highly religious, but they have difficulties reconciling themselves to their beliefs or to God.

Park and her fellow researchers measured religious struggle, depression, and hospitalization rates among heart failure patients over three months. They found that people who expressed high levels of religious struggle at the beginning of the study were very likely to have been hospitalized for more days at the end of the three months. This effect was independent of sickness measures, which means that the findings weren’t just because growing sicker makes people more likely to struggle with God. Instead, Park and her colleagues argued that people who are going through spiritual struggle may wind up at the hospital for minor ailments because they are unconsciously searching for help with their religious uncertainties and spiritual struggle.

Like Pérez’s work, two additional studies focused on the relationship between religion, spirituality, and cancer. The first, directed by Cheryl L. Holt of the University of Maryland, examined how religiousness and spirituality played into the lives of African-American women with cancer. In contrast to many other studies on religion and health, Holt and colleagues found that being religious or spiritual didn’t seem to help their respondents in terms of physical functioning. The patients had about the same level of physical health whether they were religious or spiritual or not. However, religious behaviors, such as attending church and praying, did seem to positively impact the respondents’ emotional well-being. The researchers found that this was mostly due to increased positive affect – that is, people who did more religious things experienced more positive emotions, and this in turn helped them to lead better emotional lives.

Of course, it’s not exactly saying much to claim that religion boosts emotional functioning because it encourages positive emotions. However, Holt’s study may have suffered from the fact that its respondents were all African-American women, a highly religious demographic group. Since practically all the respondents considered themselves very religious, there may not have been enough of a contrast between the respondents to accurately measure the effects of religiousness or spirituality. Still, Holt’s paper is a good example of how complex spirituality-and-health research can be, and how the relationship is not always a clear one.

A study led by Jean L. Kristeller of Indiana State University looked at the relationship between religiousness, spirituality, and well-being in cancer patients, finding that people who scored highly in both religiosity and spirituality expressed the highest levels of well-being and suffered the least depression. Those with high spirituality and low religiosity – people who considered themselves “spiritual but not religious” – were also relatively happy and well-adjusted. People with low scores in both religiosity and spirituality exhibited markedly less well-being and were more depressed. Most interestingly, however, people who had high religiosity scores and low spirituality scores showed remarkably high levels of negative religious coping – blaming God for their sickness, feeling spiritually abandoned, and questioning God’s power to do good in the world.

Of all four groups, this high-religiosity, low-spirituality group was the most depressed. However, they also showed fairly robust abilities to find benefits amidst adversity. Importantly, none of the groups differed from each other in terms of cancer status, length of time since diagnosis, or other objective physical measures of health – the differences in their levels of depression and happiness seemed to genuinely be products of their religious and spiritual status.

This is Part I of a two-part review. Check back soon at for Part II.

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