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September 2017 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Currier, J. M., Foster, J. D., Abernethy, A. D., Witvliet, C. V. O., Root Luna, L. M., Putman, K. M., Schnitker, S. A., VanHarn, K. and Carter, J. "God imagery and affective outcomes in a spiritually integrative inpatient program." Psychiatry Research 254 (August 2017): 317-322.


SUMMARY and COMMENT: Our authors this month hold their study to be "the test the potential role of God imagery in influencing affective outcomes in psychiatric care" [p. 321]. Their focus is on how patients enter and leave psychiatric treatment imagining a God's-eye view of them, plus the potential importance of experiences of religious/spiritual (R/S) comforts and strains.

Patients seeking psychiatric care can espouse a range of views regarding the divine, including benevolent and loving, punitive and cruel, or disinterested and distant from human affairs.... Understanding the affective consequences of such God images may clarify intervention targets of spiritually integrative approaches with patients who are drawing on their faith systems in adaptive and maladaptive ways. [p. 317]
This research works both from general studies regarding attachment figures [--see Related Items of Interest, #I, below], supporting the idea that "God images broadly refer to internalized working models of a divine attachment figure (e.g., Allah, Buddha, Jesus Christ) and experience of self in the context of relationship with this deity" [p. 318] and from the authors' own previous research that linked patients' experiences of R/S comforts and strains to psychiatric symptomology and to outcomes [--see Related Items of Interest, #II, below].

Data were analyzed from 241 adult psychiatric inpatients at Pine Rest Christian Mental Health Services (Grand Rapids, MI) between 2013 and 2015. The sample was predominantly Christian (59.2% Protestant; 14.6% Roman Catholic) but also involved patients from other traditions (2.3%), those with no religious affiliation (10%), and those who identified as spiritual but not religious (15%) [--see Table 1, p. 319]. Participants were surveyed within 48 hours of admission and at discharge, with an average length of stay being 7.19 days (SD = 3.89). Measures included the question: "When God looks at you, how would God describe you?" plus the Religious Comforts and Strain Scale (Exline) and the Positive and Negative Affect Schedule (PANAS-X). The open-ended question was assessed by a Linguistic Inquiry and Word Count program "focused on two domains, Positive Emotion and Negative Emotion, which are subsequently referred to as Positive God Imagery and Negative God Imagery, respectively" [p. 319]. A "chaplain or chaplaincy intern completed the consenting procedure and oversaw completion of the study measures at the two assessments" [p. 319]. Among the findings:

  • From admission to discharge, patients indicated less negative God imagery, but positive God imagery did not change significantly. [--see p. 321]
  • "[P]atients demonstrated improvements in religious comforts/strains and positive/negative affect over the course of treatment." [p. 321]
  • "[P]atients whose written language [from the open-ended question] reflected positive relational God imagery in the initial qualitative assessment endorsed higher positive affect and lower negative affect at the end of their hospitalization periods." [p. 321]
  • " [H]igher levels of positive imagery of God's view of oneself at the start of treatment were linked with greater religious comforts at discharge, which was concurrently associated with higher levels of positive affect when exiting the program." [p. 321]
  • "[P]atients with more negative God imagery related to oneself in their baseline narratives were more likely to struggle with their faith and/or spirituality at the end of treatment, and these religious strains were also linked with more negative affect." [p. 321]
  • The effect of God imagery at admission upon patients' affect at discharge was found to be indirect, mediated by religious comforts and strains [--see pp. 319 and 322]. "This suggests that there is a significant interplay between positive and negative God imagery and religious comforts and strains that are important in caring for people in psychiatric contexts" [p. 321].
  • However, "religious comforts did not clearly buffer against negative affect, and spiritual struggles did not inversely bear on positive emotion." [p. 321]
The results suggest a somewhat complex set of relationships (as presented in a statistical diagram on p. 320), but the authors paint a picture of the "overall pattern of findings":
...God images represent a salient indicator of the manner in which distressed persons will draw on R/S in their manner of coping. Namely, patients who described positive imagery of God in relationship to oneself had a greater probability of utilizing R/S in ways that have been linked with adaptive adjustment to stress. Consistent with the notion of God as a symbolic attachment figure..., having recourse to a kind and loving deity potentially broadened these patients' coping repertoires and fostered the experience of positive emotions that are often emphasized in R/S traditions (e.g., joy, peace). In contrast, patients whose imagery of God characterized them in negative emotional terms were more likely to experience religious strains and negative affect. In such cases, a relationship with God predominantly defined by such negative elements potentially narrowed patients' resources for coping and increased the probability for negative affect to persist at the time of discharge. [p. 321]
So, what might be clinical implications of this research? The authors hope that their work will "begin to illuminate targets for spiritually integrative interventions" [p. 322].
Despite the tendency in mental health professions to avoid discussion of R/S concerns..., clinicians and researchers need to develop basic competencies in this multicultural domain.... For example, integrative clinicians can incorporate adaptive aspects of patients' faith systems in their interventions and/or implement strategies to alleviate distress associated with R/S when indicated, making referrals to R/S leaders in cases that exceed their expertise. [p. 322]
The authors acknowledge limitations in this study [--see p. 322] and encourage further inquiry with more diverse samples, but they offer special concern with regard to patients who identify as spiritual but not religious or as non-religious. In light of a quote from one participant -- "I'm not religious, but if God were to look at me, I'm sure he'd find me disappointing" -- they caution, "researchers and clinicians might sometimes miss crucial information by not assessing for potential struggles with the divine among people who are religiously unaffiliated" [p. 323]. For this reader, the article is especially important in merely putting forward the assessment question, "When God looks at you, how would God describe you?" Even non-religious patients were apparently able to relate to it. Perhaps additional research could expand upon its psychometrics and refine variations.

One final note: Two of the co-authors are chaplains. Karl Van Harn (whose last name properly includes a character space) is an ACPE Certified Educator, and Janet Carter is an APC board certified chaplain and staff chaplain at Pine Rest Christian Mental Health Services.

Special Comment to the Network by Kathy Bird DeYoung, ACPE Certified Educator, Pine Rest Christian Mental Health Services, Grand Rapids, MI:

As an ACPE Certified Educator, as well as having served as an APC board certified chaplain, I was excited and honored to be part of the data collection process for this study when I started working with Pine Rest Christian Mental Health Services. Our research project began with Pine Rest chaplains who wanted to study the relationship between forgiveness and mental health. In the process we learned much more. Several years ago, I heard Dr. Harold Koenig speak at an Association of Professional Chaplains conference. He emphasized the importance of chaplains doing research. At the time, that goal was worthy and admirable, but it also seemed overwhelming and completely out of reach for me as a solo Director of Pastoral Care. Here at Pine Rest, being part of the nuts and bolts of data gathering was time consuming and even occasionally anxiety producing for me, as we had to follow the protocols of the study exactly. However, it has also been an exciting and rewarding experience -- especially now that we have this article. I have learned much about data gathering and research, and I am looking forward to applying the outcomes of this study to our pastoral care and thinking about further studies which we can engage to extend knowledge in our field. We are currently conducting a follow-up study on the impact of pastoral care on patient outcomes.


Suggestions for Use of the Article for Student Discussion: 

This article would seem best suited for at least moderately research savvy students, who could appreciate the interplay of factors in terms of direct and indirect effects. For advanced students, the statistics given in a section on Structural Equation Modeling [pp. 319-321] are rich. Nevertheless, most CPE students should be able to follow the text and find it thought-provoking. The significance of this work extends well beyond the psychiatric setting, and chaplains might begin by discussing how God imagery comes up in various pastoral contexts. What do students think of the potential utility of a question like, "When God looks at you, how would God describe you?" What do they make of the authors' use of attachment theory to understand the nature of God images? Does the group see in this research encouragement for spiritual interventions, particularly with patients who have negative God images? Finally, the footnote on the opening page, about definitions of religion and spirituality, deserves attention. Do the students agree that "unless there is a reason for drawing a distinction," it is acceptable to "use these terms interchangeably" [p. 317]?


Related Items of Interest:

I.  Regarding attachment theory, the paragraph on p. 318 of our featured article touches concisely on key aspects, and our authors suggest reading:

Granqvist, P. and Kirkpatrick, L. A. "Religion, spirituality, and attachment." In Pargament, K. I., Exline, J. J. and Jones, J. (eds.), APA Handbook of Psychology, Religion, and Spirituality (Vol. 1: Context, Theory and Research), pp. 139-155. Washington DC: American Psychological Association Press, 2013. [(Abstract:) In this chapter, we summarize the contribution of attachment theory and research to the psychology of religion and spirituality. Much of the research on which the review is based was originally undertaken to test the basic applicability of attachment theory to aspects of religion and spirituality. As this research progressed, however, it became apparent that some key findings may have considerable practical and clinical implications, which also are highlighted. The bulk of the chapter is thematically organized according to six central theoretical propositions that have come to guide the research on religion and spirituality from an attachment perspective. Each proposition contains an introduction to the relevant constructs and ideas behind the proposition as well as a necessarily selective review of research findings that have tested the proposition. First, we argue that religion and spirituality capitalize on the operation of the attachment system and that believers' perceived relationships with God can be characterized as symbolic attachment relationships. Second, we describe how the generalization of attachment-related mental representations may be expressed in the context of religion and spirituality. Third, we suggest that care-giving quality and attachment security influence the individual's receptivity to parental religious standards. Fourth, we argue that religion provides surrogate attachment figures (most notably gods) that may be used to regulate distress and gain a sense of "felt security^quot; also in the wake of experiences with insensitive caregivers and insecure attachment. Fifth, we review research suggesting that individual differences in attachment to God may affect psychosocial adjustment as well as attachment in the secular domain. Finally, we argue that, via carefully selected mediating variables, attachment may be indirectly linked to aspects of nontheistic spirituality that in themselves are not captured by the central parameters of an attachment framework. We end by discussing limitations and future directions for the attachment–religion/spirituality connection.]

Pehr Granqvist, from Stockholm University (Sweden), has also published the following more detailed articles that may be of interest to chaplains wanting to read further about attachment theory:

Granqvist, P. "Mental health and religion from an attachment viewpoint: overview with implications for future research." Mental Health, Religion & Culture 17, no. 8 (2014): 777-793. [This is a kind of companion piece to the book section noted above. (Abstract:) I argue in this article that attachment theoretical considerations provide insights into why certain moderators underlie the links observed between religion and mental health. Three sets of moderators are discussed. First, contextual factors associated with heightened attachment activation (e.g., stress, unavailability of one's secular attachment figures, low social welfare) increase the strength of the links observed between religion and mental health. Second, aspects of mental health that are most notably affected by having a safe haven to turn to and a secure base to depart from are particularly reliably linked to religion. Other attachment-related aspects of mental health that religion may promote concerns attenuation of grief and reparation of internal working models following loss of and/or experiences of having been insensitively cared for by other attachment figures. Finally, aspects of religion that are most consistently linked to mental health are partially those that express attachment-components, including belief in a personal, loving God with whom one experiences a close and secure relationship.]

Granqvist, P. and Nkara, F. "Nature meets nurture in religious and spiritual development." British Journal of Developmental Psychology 35, no. 1 (March 2017): 142-155. [This article puts forward a new conceptualization of the nature-nurture model, working from an evolutionary perspective. Regarding attachment theory specifically, see the third section of the article, pp. 150-151, for A Specific Illustration: Attachment, Religious, and Spiritual Development. FYI: This article produced some critical reaction, to which the authors have responded in Granqvist, P. and Nkara, F., "Religious and spiritual development are determined 100% by nature, and 100% by nurture: a playful response to Boyatzis," British Journal of Developmental Psychology 35, no. 1 (March 2017): 162-165.]

In addition, the following article comes from within chaplaincy circles:

Flannelly, K. J. and Galek, K. "Religion, evolution, and mental health: attachment theory and ETAS theory." Journal of Religion and Health 49, no. 3 (September 2010): 337-350. [(From the abstract:) This article reviews the historical origins of Attachment Theory and Evolutionary Threat Assessment Systems Theory (ETAS Theory), their evolutionary basis and their application in research on religion and mental health. Attachment Theory has been most commonly applied to religion and mental health in research on God as an attachment figure, which has shown that secure attachment to God is positively associated with psychological well-being. ...ETAS Theory explains why certain religious beliefs--including beliefs about God and life-after-death--should have an adverse association, an advantageous association, or no association at all with mental health. Moreover, it makes specific predictions to this effect, which have been confirmed, in part. The authors advocate the application of ETAS Theory in research on religion and mental health because it explains how religious and other beliefs related to the dangerousness of the world can directly affect psychiatric symptoms through their affects on specific brain structures.]


II.  The authors' earlier work on this topic (described on p. 318 of the current article) is unpublished but was presented as a paper at the 37th Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, Washington DC, March 31, 2016, under the title: "Understanding the role of religious comfort and strain on affective outcomes in an inpatient psychiatric setting," by Abernethy, A. D., Schnitker, S., Currier, J. M., Putman, K. M., Witvliet, C. V. O., Ro, D., Jones, H., VanHarn, K. J. and Carter, J. It was also noted briefly in the Spring 2016 Newsletter of the Society of Behavioral Medicine's Special Interest Group (SIG) on Spirituality & Health. This SIG may be of general interest to chaplains, as may the Society itself. See, for instance, a recent article in the Society's Outlook publication by Kathleen Isaac, from the Spirituality & Health SIG: "Navigating a Career in Spirituality and Health Research: An Interview with Cheryl Holt."


III.  There is a broad and rich literature pertaining to God images. Below is a sample of articles not cited in our featured study, for chaplains wanting to explore this topic further.

Dezutter, J., Luyckx, K., Schaap-Jonker, H., Bussing, A., Corveleyn, J. and Hutsebaut, D. "God image and happiness in chronic pain patients: the mediating role of disease interpretation." Pain Medicine 11, no. 5 (May 2010): 765-773. [(Abstract:) OBJECTIVE: The present study explored the role of the emotional experience of God (i.e., positive and negative God images) in the happiness of chronic pain (CP) patients. Framed in the transactional model of stress, we tested a model in which God images would influence happiness partially through its influence on disease interpretation as a mediating mechanism. We expected God images to have both a direct and an indirect (through the interpretation of disease) effect on happiness. DESIGN: A cross-sectional questionnaire design was adopted in order to measure demographics, pain condition, God images, disease interpretation, and happiness. One hundred thirty-six CP patients, all members of a national patients' association, completed the questionnaires. RESULTS: Correlational analyses showed meaningful associations among God images, disease interpretation, and happiness. Path analyses from a structural equation modeling approach indicated that positive God images seemed to influence happiness, both directly and indirectly through the pathway of positive interpretation of the disease. Ancillary analyses showed that the negative influence of angry God images on happiness disappeared after controlling for pain severity. CONCLUSION: The results indicated that one's emotional experience of God has an influence on happiness in CP patients, both directly and indirectly through the pathway of positive disease interpretation. These findings can be framed within the transactional theory of stress and can stimulate further pain research investigating the possible effects of religion in the adaptation to CP.]

Grossoehme, D. H. and Springer, L. S. "Images of God used by self-injurious burn patients." Burns 25, no. 5 (August 1999): 443-448. [(Abstract:) Suicide by burning and other forms of self-injurious behaviors which involve burning are sometimes considered to have religious overtones. The ritual death of widows upon their husband's funeral pyre is closely associated with Hindu beliefs. Buddhists have used self-immolation as a form of protest. The Judaeo-Christian traditions have imagery of fire as cleansing and purifying; there is also secular imagery associating fire with images of condemnation and evil. Previous studies have described religiosity as a common theme among survivors. The present study describes the ways in which persons who inflicted self-injurious behaviors through burning, including attempted suicide, imagine the Divinity and use religious language to give meaning to their experience.]

Ironson, G., Stuetzle, R., Ironson, D., Balbin, E., Kremer, H., George, A., Schneiderman, N. and Fletcher, M. A. "View of God as benevolent and forgiving or punishing and judgmental predicts HIV disease progression." Journal of Behavioral Medicine 34, no. 6 (December 2011): 414-425. [(Abstract:) This study assessed the predictive relationship between View of God beliefs and change in CD4-cell and Viral Load (VL) in HIV positive people over an extended period. A diverse sample of HIVseropositive participants (N = 101) undergoing comprehensive psychological assessment and blood draws over the course of 4 years completed the View of God Inventory with subscales measuring Positive View (benevolent/forgiving) and Negative View of God (harsh/judgmental/punishing). Adjusting for initial disease status, age, gender, ethnicity, education, and antiretroviral medication (at every 6-month visit), a Positive View of God predicted significantly slower disease-progression (better preservation of CD4-cells, better control of VL), whereas a Negative View of God predicted faster disease-progression over 4 years. Effect sizes were greater than those previously demonstrated for psychosocial variables known to predict HIV-disease-progression, such as depression and coping. Results remained significant even after adjusting for church attendance and psychosocial variables (health behaviors, mood, and coping). These results provide good initial evidence that spiritual beliefs may predict health outcomes.] [NOTE: This was our December 2011 Article-of-the-Month.]

Krause, N., Emmons, R. A. and Ironson, G. "Benevolent images of God, gratitude, and physical health status." Journal of Religion and Health 54, no. 4 (August 2015): 1503-1519. [(Abstract:) This study has two goals. The first is to assess whether a benevolent image of God is associated with better physical health. The second goal is to examine the aspects of congregational life that is associated with a benevolent image of God. Data from a new nationwide survey (N = 1774) are used to test the following core hypotheses: (1) people who attend worship services more often and individuals who receive more spiritual support from fellow church members (i.e., informal assistance that is intended to increase the religious beliefs and behaviors of the recipient) will have more benevolent images of God, (2) individuals who believe that God is benevolent will feel more grateful to God, (3) study participants who are more grateful to God will be more hopeful about the future, and (4) greater hope will be associated with better health. The data provide support for each of these relationships.]

Moriarty, G. L., Hoffman, L. and Grimes, C. "Understanding the God image through attachment theory: theory, research, and practice." Journal of Spirituality in Mental Health 9, no. 2 (2006): 43-56. [This paper uses attachment theory as an explanatory framework to better understand the God image. The first part explores theoretical foundations and contemporary perspectives on attachment theory. Next, empirical research on the God image and attachment is reviewed. The final part discusses how clinicians can use this framework to conceptualize and collaborate with clients who wish to address their relationship with God in the psychotherapy process.] [NOTE: This is a precursor article to one cited in our featured study: namely, Davis, E. B., Moriarty, G. L. and Mauch, J. C., "God images and God concepts: definitions, development, and dynamics," Psychology of Religion & Spirituality 5, no. 1 (February 2013): 51-60.]


IV.  The present study uses Structural Equation Modeling (SEM) for statistical analysis [--see pp. 319-321]. For a brief sense of how SEM figures into the array of statistical strategies, see its characterization in Koenig, H. G., Spirituality and Health Research: Methods, Measurements, Statistics, and Resources [Philadelphia, PA: Templeton Press, 2011], pp. 277 and 282-283. However, for a relatively basic explanation of SEM -- though still requiring a familiarity with statistics -- see the 2015 blog post: "Structural Equation Modeling: What is it, what does it have in common with hippie music, and why does it eat cake to get rid of measurement error?" by Peter Edelsbrunner and Christian Thurn, on the website of JEPS Bulletin: The Official Blog of the Journal of European Psychology Students. It is one of the least overwhelming (and certainly the most amusing) explanations on the web. But, for a more standard introduction to SEM, see:

Hox, J. J. and Bechger, T. M. "An introduction to structural equation modeling." Family Science Review 11, no. 4 (November 1998): 354-373. [(Abstract:) This article presents a short and non-technical introduction to Structural Equation Modeling or SEM. SEM is a powerful technique that can combine complex path models with latent variables (factors). Using SEM, researchers can specify confirmatory factor analysis models, regression models, and complex path models. We present the basic elements of a structural equation model, introduce the estimation technique, which is most often maximum Likelihood (ML), and discuss some problems concerning the assessment and improvement of the model fit, and model extensions to multigroup problems including factor means. Finally, we discuss some of the software, and list useful handbooks and Internet sites.] [NOTE: This article is available online from the authors in a final manuscript form. Its web references are outdated but are not essential to the core focus.]


V.  Articles by lead author Joseph M. Currier, PhD, Psychology Department, University of South Alabama (Mobile, AL), have recently been cited by our Network on the Article-of-the-Month pages for February 2016 (Related Items of Interest, §III and §IV) and December 2016 (Related Items of Interest, §II), and in our Summer 2016 Newsletter (item #7). Two other articles of interest newly published are:

Currier, J. M., Drescher, K. D., Nieuwsma, J. A. and McCormick, W. H. "Theodicies and professional quality of life in a nationally representative sample of chaplains in the veterans' health administration." Journal of Prevention & Intervention in the Community 45, no. 4 (October-December 2017): 286-296. [(Abstract:) This study examined the role of theodicies or theological/philosophic attempts to resolve existential dilemmas related to evil and human suffering in chaplains' professional quality of life (ProQOL). A nationally representative sample of 298 VHA chaplains completed the recently developed Views of Suffering Scale (Hale-Smith, Park, & Edmondson, 2012) and ProQOL-5 (Stamm, 2010). Descriptive results revealed that 20-50% endorsed strong theistic beliefs in a compassionate deity who reciprocally suffers with hurting people, God ultimately being responsible for suffering, and that suffering can provide opportunities for intimate encounters with God and personal growth. Other results indicated that chaplains' beliefs about human suffering were differentially linked with their sense of enjoyment/purpose in working with veterans. These results suggest that theodicies might serve as a pathway to resilience for individuals in spiritual communities and traditions in USA, particularly for clinicians and ministry professionals who are committed to serving the needs of traumatized persons.]

Currier, J. M. and Eriksson, C. B. "Trauma and spirituality: empirical advances in an understudied area of community experience." Journal of Prevention & Intervention in the Community 45, no. 4 (October-December 2017): 231-237. [Trauma and spirituality represent an understudied area of community experience. As in introductory article for this themed issue for the Journal of Prevention & Intervention in the Community, this article describes the importance of considering these topics together for individuals and communities across the world.]

Dr. Currier is also a co-author of the 2016 book, Trauma, Meaning, and Spirituality: Translating Research into Clinical Practice (Washington, DC: American Psychological Association), along with Crystal L. Park, J. Irene Harris, and Jeanne M. Slattery.



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