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January 2006 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Burker, E. J., Evon, D. M., Sedway, J. A. and Egan, T. "Religious and non-religious coping in lung transplant candidates: Does adding God to the picture tell us more?" Journal of Behavioral Medicine 28, no. 6 (December 2005): 513-526.


SUMMARY and COMMENT: The authors describe at the outset the stress commonly experienced by patients awaiting a lung transplant--a process that may take as long as three years and is set within the context of end-stage pulmonary disease--and how this stress demands a variety of coping strategies. The study looks at a number of Non-Religious Coping [NRC] and Religious Coping [RC] strategies, as identified by the COPE measure and select items from the RCOPE measure, in a sample of 81 lung transplant candidates. The purpose: first, to see if NRC and RC appear to be functionally redundant for clinical assessment or whether assessment of these two types of coping strategies show that each offers particular information; and second, to see if specific subscales for these two types of coping strategies are associated with outcome factors of depression, trait anxiety, and overall disability.

The study has been selected for our Article-of-the-Month because of three interesting findings: namely, that RC and NRC are not functionally redundant for assessment, that assessment for RC may require an in-depth instrument to capture effect, and that patients who cope by engaging in so-called "punishing God reappraisals" may be especially at risk for poor health outcomes.

On the finding that RC and NRC are not functionally redundant for assessment, the authors sum up their detailed statistical analysis:

In five out of six regressions, NRC and RC provided additional information over and above the effects of each other. For anxiety, there was strong support for the unique contribution of both RC and NRC, with RC contributing an additional 6% and NRC contributing an additional 22% of unique variance, beyond that contributed by the other measure. For depression, RC contributed 12% of unique variance beyond the contribution of NRC, and the 8% contribution of NRC was marginally significant (p=0.052). For disability, we found that NRC contributed an additional 16% beyond the contribution of RC, but RC did not contribute uniquely, over and above that accounted for by NRC. [p. 523]
This analysis suggests that research should consider both types of coping in order to understand in a population more fully.

On the issue of the sensitivity of measures of spiritual dynamics, the "Turning to Religion" subscale of the COPE measure did not indicate the associations between RC and health outcomes that were captured by the RCOPE. The authors speculate that the COPE subscale (consisting of only four items) was insufficiently "fine-grained" [--see p. 521] compared to the more in-depth items on the RCOPE. [While the RCOPE is a 21-item measure, only nine items were used here, based upon other research that showed these nine items to have "the most promise for being useful predictors of outcomes" [p. 516]: Benevolent Religious Reappraisal, Punishing God Reappraisal, Collaborative Religious Coping, Passive Religious Deferral, Self-Directing Religious Coping, Seeking Spiritual Support, Spiritual Discontent, Seeking Support from Clergy or Members, and Interpersonal Religious Discontent. --see Table II on p. 517.] This reflects an overall trend in Spirituality & Health research to refine measures to become attuned to subtle effects, and to balance the desire for simple instruments with the complexity of spirituality. Indeed, the authors endorse using the more detailed RCOPE, but with the hope that future research will be able to "streamline our coping measures to include only those subscales that offer the most value" [p. 525]. Pastoral care researchers might consider using both shorter and longer instruments with similar foci, rather than selecting a single instrument, to see if the more detailed measure points up findings missed by the less detailed one. [Note that the April 2004 Article-of-the Month looked at religious and non-religious coping, using the COPE and RCOPE measures.]

The third reason for recommending this article is its finding that patients who cope by means of "punishing God reappraisals" may be at risk of poorer health outcomes--at least in the current population. A number of studies in the past decade have shown “negative religious coping” to be a health risk factor, and the authors cite Kenneth Pargament’s 1997 review in The Psychology of Religion and Coping: Theory, Research, and Practice [--see Related Items of Interest (below)] as support for the association of "punishing reappraisal" with poor outcomes. Note, however, that the Pargament book cited is now becoming dated, and while it does survey studies relating to "God's punishment" as a form of negative religious reframing (see Appendix D, on pp. 446-448 of the book), Pargament himself is cautious about drawing lines of connection between this form of coping and outcomes (see Negative Religious Reframing: God's Punishment, on p. 291 of the book). This would be an excellent topic for pastoral care research, since chaplains often encounter variations of punishing reappraisals in patients who ask about their illness, "Why?" Chaplains might want to consult the study by Pargament, et al., "Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study" [--see Related Items of Interest (below)], which found that "'Felt punished by God for my lack of devotion''…was marginally predictive of mortality after controlling for demographic variables…but not after controlling for physical health and mental health" [p. 1883 of that article]. The latter article by Pargament is not cited in our featured study.

Burker and her colleagues offer much to consider, and they provide a convenient list of RC and NRC coping methods [--see Table II on p. 517] and extensive tables summarizing their data analysis [--see especially Tables IV-VII on pp. 519-523]. Their Introduction is a quick overview of the circumstance of lung transplant candidates and coping, and it describes two earlier studies by the authors that informed the present research. The Discussion section is succinct, yet it expands appropriately the basic reporting of results and nicely lays out limitations and questions for future investigation. The article should be helpful to chaplains interested in coping strategies and risk factors, and those working with lung transplant patients. For researchers, it is a contribution to thought about measures and coping outcomes.


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

As with most articles that present a large amount of statistical data, CPE students will likely gravitate toward the more narrative sections of the Introduction and Discussion; but this article should work well that way. Yet those who want to delve into the statistical analysis will find a wealth of information clearly presented. Discussion could revolve around differences between religious and non-religious coping strategies [--see especially the list in Table II on p. 517], the phenomenon of "punishing reappraisal," or the case of lung transplant patients in general. Advanced students may want to discuss the difficulties of developing instruments in the field of Spirituality & Health. Discussion could also lead to the topic of religious struggle, and students may be interested in such research as has been highlighted in the November 2004 Article-of-the-Month page.


Related Items of Interest: 

Carver, C. S., Scheier, M. F., and Weintraub, J. K. "Assessing coping strategies: a theoretically based approach." Journal of Personality and Social Psychology 56, no. 2 (1989): 267–283. [This is the original presentation of the COPE measure, of which one of 14 subscales is Turning to Religion, consisting of four items: "I seek God's help," "I put my trust in God," "I try to find comfort in my religion" and "I pray more than usual." See especially the note about the concept of this subscale on p. 270.]

Pargament, K. I. The Psychology of Religion and Coping: Theory, Research, and Practice. New York: Guilford Press, 1997.

Pargament, K. I., Koenig, H. G. and Perez, L. M. "The many methods of religious coping: development and initial validation of the RCOPE." Journal of Clinical Psychology 56, no. 4 (August 13-27, 2001): 519-543. [This is a thorough exposition on the RCOPE measure.]

Pargament, K. I., Koenig, H. G., Tarakeshwar, N. and Hahn, J. "Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: a two-year longitudinal study." Archives of Internal Medicine 161, no. 15 (August 13-27, 2001): 1881-1885. [This study used the Brief RCOPE, and while it found that "'Felt punished by God for my lack of devotion''…was marginally predictive of mortality after controlling for demographic variables…but not after controlling for physical health and mental health" (p. 1883); it found significant associations for increased risk of mortality in its sample for the following items: "Wondered whether God had abandoned me," "Questioned God's love for me," and "Decided the Devil made this happen."]

Also, the 1998 General Social Survey--with data from a random sample of 1,445 adults in the US--included the item: "Think about how you understand and try to deal with major problems in your life. To what extent is each of the following involved in the way you cope? …I feel that God is punishing me for my sins or lack of spirituality." Results: 74.8% of respondents said, "Not at all," 17% said, "Somewhat," "3.7% said, "Quite a bit," and 1.9% said, "A great deal." The GSS data is available on line (along with data from earlier GSS surveys) through the National Opinion Research Center at the University of Chicago: go to, and under Browse Variables look for the Subject Index for Religion.

For more on religious coping in general, see the Related Items of Interest section of the April 2003 Article-of-the-Month page.


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