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May 2008 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Cole, B. S., Hopkins, C. M., Tisak, J., Steel, J. L. and Carr, B. I. "Assessing spiritual growth and spiritual decline following a diagnosis of cancer: reliability and validity of the Spiritual Transformation Scale." Psycho-Oncology 17, no. 2 (February 2008): 112-121.


SUMMARY and COMMENT: This month's article reports the validity and reliability of a new 40-item measure, the Spiritual Transformation Scale (STS), useful in assessing both Spiritual Growth (SG) and Spiritual Decline (SD) across the domains of world view, goals/priorities, sense of self, and relationships. The authors build upon the literature and research about the potential for positive changes/growth in patients following trauma, recognizing that "for many people, post-trauma transformations have spiritual dimensions" [p. 112], and they aim to improve upon existing instruments for study in the field, such as the Spiritual Well-Being Scale (SWBS), the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp), the Systems of Belief Inventory, or the Spiritual Involvement and Beliefs Scale.

None of these tools directly measure the construct of SG or transformation following trauma in a way that differentiates spiritual change from other, perhaps related, spiritual variables such as a stable tendency to find spiritual meaning in traumatic events. None of the scales include items that correspond to all of the various domains of change (e.g., change in self or change in world view) that have been included in measures of post-traumatic growth scales that are not specifically spiritually based. And finally, while Pargament…[see: Kenneth I. Pargament's 1997 Psychology of Religion, Coping: Theory, Research, Practice]…has pointed to the importance of assessing both positive and negative aspects of spiritual coping in the face of trauma, no scales of post-trauma growth have assessed the counter to SG (i.e. spiritual decline (SD)).
The STS in intended to fill these gaps.

Most of the article is devoted to a detailed analysis of the STS, from testing based upon data from 244 participants from cancer patients at medical clinics in Pittsburgh, PA. In sum, "The results indicate that the STS is psychometrically sound, with SG predicting better, and SD predicting poorer, mental and spiritual well-being following a diagnosis of cancer" [p. 112, abstract]. Chaplain researchers will want to look at the the technical specifics of the testing, but for the wider audience reading these Article-of-the-Month summaries, two aspects of the article should be of particular interest. First, the instrument items are given on p. 116, with 29 items worded toward the dynamic of SG and 11 items worded toward the dynamic of SD. (The items are scored on a 7-point Likert scale.) Second, general readers will discover thought-provoking associations with the concepts of SG and SD in the testing sample.

For example, SG "was associated with being more spiritual or religious (based on self ratings or more frequent religious behaviors)," "declined with age and increased with time since diagnosis," was found in greater effect among women than men, and tended to be higher when the patient's cancer was a recurrence or was advanced [see p. 117]. SG was also associated with "spiritual well-being, positive spiritual coping, intrinsic religiousness, post-traumatic growth, and positive affect " [p. 118]. On the other hand, SD "was associated with being less spiritual or religious, having less than a high school education, and a Protestant religious affiliation" [p. 117]. Also, "SD was positively associated with negative spiritual coping, depressive symptoms, and negative affect, ...[and] negatively associated with intrinsic religiousness, spiritual well-being, and positive affect" [p. 118]. Both SG and SD appeared to decline with age: "This might indicate that as one ages, one’s level of spirituality matures and stabilizes, and is less impacted by traumatic events" [p. 117].

The authors note that their results indicate that "SG and SD assess an aspect of spirituality that is distinct from intrinsic religiousness or spiritual coping," and that "SD, but not SG, also seems to be unique from the construct of post-traumatic growth" [p. 118]. They further relate their work to a broader theory of "the spiritual or religious aspects of trauma experiences": namely...

...when a trauma occurs, the spiritual aspects of the individual’s world view and related resources (e.g., practices and relationships) may be threatened. This threat initiates a spiritual struggle (i.e., spiritual coping) in order to either 'conserve or transform' one’s sense of the spiritual or sacred aspects of life. Following this model, the success of coping efforts directed toward transformation would be reflected by measures such as the STS subscales and in adjustment measures. The results of this study support this theory and further suggest that the level of spiritual transformation uniquely predicts adjustment to the event beyond the coping efforts themselves. [pp. 118-119]

Limitations of the study are addressed [--see p. 119], but the authors assert that not only do the results hold potential for further research (and they point out that the STS can easily be adapted for longitudinal use) but also suggest important clinical applications, especially for cancer patients. "The SD items provide a means by which people experiencing such decline can be identified and referred for clinical services" [p. 119]. Chaplains may wish to pursue research based upon the work here, particularly on SD.

One final comment: This measure was developed with attention to religious diversity, so it primarily employs the language of spiritual or spirituality --in fact, it uses one of those terms in 28 of the 40 items. [See the item list on p. 116.] The word sacred is used twice: once as an adjective ["I more often see my own life as sacred."] and once as a capitalized noun ["I have a stronger sense of the Sacred (God, Higher Power, Allah, Adonai, etc.) directing my life now."]. The word faith is used once ["I more often think that I have failed in my faith."], as is religion ["I am less interested in organized religion."]. The term blessed is also used in a single case ["I more often think about how blessed I am."]. For this reader, such language seems to be quite carefully chosen for a religiously diverse population, and it represents another step in instrument development along these lines, but future studies need to pay increasing attention to how specific language refracts across the various lines of religious diversity. The authors state that their population was "comprised primarily of Caucasian, middle-aged, married women who were Judeo-Christian" [p. 119]. They also point out that language appeared to be a problem with one of the measures in the battery of questionnaires used with their subjects: the Mysticism Scale --"…several participants complained about the mysticism scale, possibly indicating that this 1970s scale developed with college students may not accurately capture the language used by older adults today to describe mystical experiences" [p. 118]. The dynamics of language in spirituality & health research remains a sharp, growing edge in the development of the field.


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

This month's article may be difficult for students who are not very familiar with the research literature, but it should be a rich source of material for those who are. For an advanced research seminar on instrument development, on concept analysis, or on the topic of spiritual trajectories, the article is clearly well-suited. However, even for general CPE students, it can be useful for discussion, if they are merely steered toward the more narrative sections of the piece: the first three paragraphs of the Introduction [p. 112] and the Discussion [pp. 117-120]. Students may want to talk about what it is like to read around the statistics in order to discover the important insights of research, and some students may even become motivated to learn more about statistics. Of course, the very ideas of Spiritual Growth and Spiritual Decline could be the center of a far-reaching discussion, and this could lead into such related topics as spiritual trajectories (--a topic explored in our November 2007 Article-of-the-Month) and the potential effects of trauma on spirituality (--the topic of our May 2005 Article-of-the-Month). Students should be encouraged to read carefully through the items of the STS [p. 116] to see which items strike them as especially "on target" or possibly "off target," and which ones may help them think more perceptively about their own practice of spiritual assessment. Finally, discussion could turn to potential interventions with patients for whom a referral would be made because of an indication of spiritual decline.


Related Items of Interest:

I. Kenneth I. Pargament, who has often been cited on our website, is mentioned several times in this month's article (--see pp, 113, 118 and 119), and the following four references are given with him as author or co-author:

  • Hill, P. C. and Pargament, K. I. "Advances in the conceptualization and measurement of religion and spirituality: implications for physical and mental health research." American Psychologist 58, no. 1 (January 2003): 64-74.
  • Pargament, K. I. The Psychology of Religion and Coping: Theory, Research, Practice (New York: Guilford Press, 1997).
  • Pargament, K. I., Murray-Swank, N. A., Magyar, G. M. and Ano, G. G. "Spiritual struggle: a phenomenon of interest to psychology and religion." Pp. 245-268 in Miller, W. and Delaney, H., eds., Judeo-Christian Perspectives on Psychology: Human Nature, Motivation, and Change (Washington: APA Press, 2005).
  • Pargament, K. I., Smith, B. W., Koenig, H. G. and Perez, L. "Patterns of positive and negative religious coping with major life stressors." Journal for the Scientific Study of Religion 37, no. 4 (December 1998): 710-724.

In addition, chaplains may be interested in a 2006 Masters thesis by Kavita M. Desai, for whom Pargament was the advisor at Bowling Green State University: "Predictors of Growth and Decline Following Spiritual Struggles," available on the Internet from

II. See the related Articles-of-the-Month on Illness Trajectories and Spirituality (November 2007) and How Spirituality May Be Affected by Trauma (May 2005). Also, note the Articles-of-the-Month regarding the FACIT-Sp (February 2004) and the Spiritual Well-Being Scale (March 2004) --both of which were pertinent to the development of the STS. This month's study used the RCOPE as part of the testing of the STS, and that measure was the subject of the April 2004 Article-of-the-Month, as well as Related Items of Interest in the April 2003 Article-of-the-Month. Another instrument included in the battery of questionnaires given to participants was the Daily Spiritual Experiences Scale, which is part of the Multidimensional Measurement of Religiousness/Spirituality for Use in Health Research and is available in a 1999 report from the Fetzer Institute at [NOTE (added 11/2/09): This online text from omits the printed booklet's covers, title page, preface, and table of contents --reproduced here and showing the booklet's statement that the publication "may be used and reprinted without special permission."] --and that larger measure was the subject of the January 2004 Article-of-the-Month.


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