Course # 91982 • The Role of Spirituality in Health and Mental Health


Study Points

  1. Define the concepts of spirituality and religiosity.
  2. Describe the historical evolution of spirituality and religiosity in the fields of nursing, medicine, social work, and mental health counseling.
  3. Summarize the advantages and disadvantages of incorporating issues of spirituality into clinical practice and the challenges associated with defining and measuring spirituality.
  4. Discuss the role of spirituality in the course and prognosis of health conditions.
  5. Outline the role of spirituality in mental health.
  6. Analyze the effects that spirituality and religion might have on coping.
  7. Describe how different ethnicities or cultures define spirituality.
  8. Identify spiritually sensitive assessment and intervention guidelines and possible ethical issues that might arise.

    1 . Which of the following is NOT considered a dimension of spirituality?
    A) Coming to an understanding of self
    B) Making personal meaning out of situations
    C) Participation in activities with spiritual goals
    D) Appreciating the importance of connections with others

    SPIRITUALITY AND RELIGIOSITY

    Spirituality refers to the belief that there is a power or powers outside one's own that transcend understanding [7]. It has been stated that there are three dimensions of spirituality [8]:

    • Making personal meaning out of situations

    • Coming to an understanding of self

    • Appreciating the importance of connections with others

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    2 . Historically, rationalism emphasized that
    A) the primary authority for truth is logic.
    B) spirituality and religion are logical sources of truth.
    C) knowledge stems from direct, first-hand observations.
    D) care for the needy is primarily the responsibility of religious organizations.

    HISTORICAL ROOTS

    During the Age of Enlightenment in the 1700s, the intellectual climate was marked by two movements: rationalism and empiricism [17]. Rationalism emphasized that the primary authority for truth is rationality or logic; spirituality, faith, and religion were considered outside these rational boundaries [17]. Empiricism focused on the idea that knowledge stems from direct, first-hand observations or sensory experiences [17]. Ultimately, these two intellectual movements challenged the authority of the church and affected the provision of general health and mental health care.

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    3 . Which movement in the field of psychology brought the issue of spirituality and religion back into the forefront of clinical practice?
    A) Humanism
    B) Empiricism
    C) Behaviorism
    D) Cognitive theory

    HISTORICAL ROOTS

    In the 1950s, humanism emerged in the psychology landscape, primarily guided by the work of Abraham Maslow [18]. His theoretical constructs of self-actualization and the hierarchy of needs included a spiritual component. Later, humanist psychologists such as Viktor Frankl and Rollo May shifted the discussion of spirituality to focus more on individual values rather than a supreme being, leading to the label "secular humanists" [139]. During this same period, spirituality and religiosity became more prominent in the counseling professions [18,19]. The division of Catholic Counselors in the American Personnel and Guidance Association (APGA) emerged in the 1950s. In 1974, this group became known as the Association for Religious Values in Counseling (ARVIC), and in 1993, ARVIC changed its name to the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC) [18,19].

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    4 . All of the following are considered possible disadvantages of incorporating spirituality into practice, EXCEPT:
    A) It would impede the provision of culturally competent care.
    B) Spirituality is not easily measured, placing it outside the realm of empirical science.
    C) Practitioners are not adequately trained in assessing and addressing spiritual concerns.
    D) Utilization of public funds in addressing spiritual concerns may conflict with the notion of a division between church and state.

    INCORPORATING SPIRITUALITY/RELIGIOSITY INTO PRACTICE

    One of the key attributes of any profession is that it possesses a unique set of competencies meant to facilitate problem solving based on scientific theory and technique [29]. In Western society, scientific theory is based on empiricism and rationalism, with a focus on measuring and observing phenomena. Because spirituality is an intangible concept, it is not easily subjected to measurement. Therefore, proponents of the empirical science of health and mental health care maintain that it is vital for professionals to remain objective and distant in order to maintain appropriate boundaries [30,170].

    There are also concerns that incorporating spirituality into practice may exacerbate symptoms, particularly in the case of psychiatric symptoms, which then would adversely affect recovery [172]. This is a particular issue when symptoms may be linked to religion or spirituality in some way.

    Another area of concern is with practitioners' levels of competence and confidence. Connelly and Light assert that most practitioners are generally not well trained to address faith-based aspects of care despite the fact that more electives on spirituality and religiosity are being offered in nursing, medical, counseling, and social work curricula [31]. A study of a random sample of baccalaureate nursing programs indicated that there was sparse teaching on spirituality and religiosity in most nursing curricula [32]. Spiritual and faith-based interventions and reflective practice were not covered in depth. Consequently, many nurses were not comfortable with their role in raising spiritual questions to patients and expressed fear or reluctance to invade a patient's private space [33]. On the other hand, a cohort of nursing students who received teaching on the spiritual dimension in care overwhelmingly found the instruction to be both personally and professionally beneficial [34]. In general, healthcare providers report feeling inadequately equipped in addressing spiritual issues with their patients while also maintaining professional boundaries [173].

    Providers who use tools addressing religion/spirituality should refer to the available evidence-based practice literature to assess the efficacy and define progress [142]. Religion should not obscure what has been defined as markers of progress [142]. There is also controversy regarding the use of public funds to study spirituality and religiosity [35]. Some contend that it is not appropriate to use public funding to study religious phenomena because of the notion of separation of church and state [35]. This discussion is ongoing, and it is unclear to what extent it will help or hinder the provision of care.

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    5 . A patient is asked to describe the role of spirituality or religion in his or her approach to life. This question addresses which dimension of spirituality?
    A) Sustaining force
    B) Religious support
    C) Struggle with religion and spirituality
    D) Perceived closeness or connection to God or higher power(s)

    CHALLENGES IN DEFINING SPIRITUALITY

    Another challenge when measuring spirituality and religiosity stems from the varied definitions. Hill and Pargament reviewed available quantitative instruments and found that existing instruments assessed different dimensions of spirituality and religiosity [36]. Aspects of spirituality that may be addressed include [36,37,38,39,40,41,168]:

    • Perceived closeness or connection to God or higher power(s): Questions related to this dimension assume that individuals who are spiritual or religious value a connection to God or a transcendent being. For example, some instruments ask individuals to rate how closely they feel or experience God. There are other instruments that instruct individuals to describe to what extent they turn to God or a higher power in times of need or challenges. There is some disagreement, however, of whether this transcendent dimension is a necessary component in the definition of spirituality.

    • Sustaining force: Some individuals view spirituality and religiosity as a force or motivation that provides direction and guidance for living. An instrument attempting to measure this aspect would inquire about the role of spirituality or religion in the patient's framework or approach to life.

    • Religious support: Some researchers measure spirituality or religiosity by examining the notion of religious support, whereby individuals derive their social support from church, their faith community, and a group of other individuals who share the same values and worldview. Perceived religious support may also derive from knowing that others are praying on their behalf.

    • Struggle with religion and spirituality: As with any worldview, there will be times when individuals challenge their faith or spirituality. Presence of this struggle may be an indication that the patient requires additional support.

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    6 . What is the most commonly used form of complementary/alternative medicine in the United States?
    A) Yoga
    B) Prayer
    C) Tai chi
    D) Echinacea

    OVERVIEW OF THE ROLE OF SPIRITUALITY/RELIGIOSITY IN HEALTH

    A survey conducted by the National Center for Complementary and Alternative Medicine (NCCAM) found that 52% of respondents had prayed for their own health [42]. Prayer was defined by NCCAM as "an active process of appealing to a higher spiritual power" [42]. Overall, prayer has been identified as the most commonly used form of complementary and alternative medicine in the United States. Other techniques with spiritual or religious basis include meditation, yoga, tai chi, qigong, and Reiki [42].

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    7 . After birth, male Muslim children are usually circumcised within
    A) 24 hours.
    B) 3 days.
    C) 7 days.
    D) 40 days.

    OVERVIEW OF THE ROLE OF SPIRITUALITY/RELIGIOSITY IN HEALTH

    AN OVERVIEW OF MAJOR RELIGIOUS IDEOLOGY AS IT RELATES TO HEALTH CAREa

    TopicsBuddhismCatholicismHinduismIslamJudaismProtestantism
    BirthAs part of the reincarnation cycle, birth may be viewed as an opportunity for the spirit to attain enlightenment in this life. Although there are no Buddhist rituals specific to the birth of a child, some practitioners may engage in a naming ceremony.Infants are usually baptized 40 days after birth.At birth, the sacrament of jatakarma is performed, in which the father smells and touches the child and whispers religious passages. Om symbols may be placed on or around the child to ward off evil. A naming ceremony takes place 10 to 12 days after birth. The time of birth is of special astrologic importance.Infants are usually bathed immediately after birth, prior to being given to the mother. The call to prayer is whispered in the child's ear, so it is the first sound heard. Male children are usually circumcised within seven days of birth.A rite of passage in the Jewish community, birth is celebratory and is marked by a bris (circumcision ceremony) and a naming ceremony. Circumcision usually takes place eight days after birth.Infants may be baptized in a symbolic ceremony, although this often takes place later in life.
    Birth controlPreconception birth control is acceptable.The official Church stance is against artificial birth control.Birth control is generally accepted.Preconception birth control that has no negative health consequences and does not lead to permanent sterilization is generally acceptable.Birth control is considered a private issue, between a woman, man, and their particular faith.There are diverse opinions regarding this subject among Protestant denominations.
    DeathIt is very important that everything be done to provide a quiet and calm environment for patients for whom death is imminent, as it is believed that calmness of mind at death translates to a better rebirth.A priest should be called to give the sacrament of the sick if death is imminent. Last confession may be made to any person, although the patient may prefer a priest. Cremation is allowed; scattering of ashes is not.A Hindu priest or Guru may be summoned for last rites. As the soul (jiva) is reincarnated until karmic absolution, death is seen as an opportunity to continue the spiritual journey.Dying patients may request to face Mecca. Burial usually takes place as soon as possible, and there are special washing and shrouding procedures.It is believed that one should not go into death alone; therefore, the dying individual will receive as much attention as possible. A confessional and shema (statement of faith) is read when death is imminent.Traditions regarding death are also diverse. Some traditions require prayer and liturgies.
    BereavementPrayers for an auspicious rebirth are said for the 49 days following an individual's death. Meditation on impermanence is also important.The presence of a priest may be necessary for support during this time. Prayers for the deceased soul may be said, informally and/or formally (Mass and/or the Rosary).Remorse for the deceased is believed to inhibit the spirit from leaving the body. Therefore, excessive mourning is discouraged, though not always avoided.The head should be covered when speaking of the deceased. Continuous prayers are recited in the home for three days following an individual's death. Guilt is a common component of grieving.Bereavement does not formally begin until the burial, after which there is generally a seven-day period of mourning.Among Protestants, bereavement is less structured than in other religions. Each person should be individually assessed.
    Common religious objectsPrayer beads, images of Buddha and other deitiesBible, crucifix, rosary, images of the Holy family or saints, saint medallionsPrayer beads, incense, images/statutes of deitiesPrayer rug, Koran, amuletYarmulke or kippah (head covering), tallit (prayer shawl), siddur (prayer book), tefillin or phylacteries, candlesBible, images of Jesus Christ or Biblical figures, religious jewelry
    Major holidaysWesak/Buddha Day, Losar, Parinirvana/Nirvana Day, Asalha/Dharma Day, Bodhi DayChristmas, Ash Wednesday, Lent, Palm Sunday, Maundy Thursday, Good Friday, Easter Makar Sankranti, Holi, Diwali, Mahashivratri, Vasant Panchami, Rama Navami, Janmashtami/ Krishna Jayanti Al-Hijra, Milad un Nabi, Ramadan, Eid al-Fitr, Eid al-Adha, Day of Ashura, Laylatul Qadr, HajjShabbat, Rosh Hashanah, Yom Kippur, Purim, Passover, Shavuot, Sukkot, HanukkahChristmas, Ash Wednesday, Palm Sunday, Good Friday, Easter
    aThis overview is meant only to give a simple, brief summary of general ideology of each religion. By no means are all of the rites, beliefs, or holidays described practiced by all members of each religion; likewise, not all religious rites, beliefs, or holidays are listed for each religion. As always, individualized assessment is encouraged.
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    8 . Meditation on impermanence is an important part of bereavement in which of the following religions?
    A) Islam
    B) Judaism
    C) Buddhism
    D) Protestantism

    OVERVIEW OF THE ROLE OF SPIRITUALITY/RELIGIOSITY IN HEALTH

    AN OVERVIEW OF MAJOR RELIGIOUS IDEOLOGY AS IT RELATES TO HEALTH CAREa

    TopicsBuddhismCatholicismHinduismIslamJudaismProtestantism
    BirthAs part of the reincarnation cycle, birth may be viewed as an opportunity for the spirit to attain enlightenment in this life. Although there are no Buddhist rituals specific to the birth of a child, some practitioners may engage in a naming ceremony.Infants are usually baptized 40 days after birth.At birth, the sacrament of jatakarma is performed, in which the father smells and touches the child and whispers religious passages. Om symbols may be placed on or around the child to ward off evil. A naming ceremony takes place 10 to 12 days after birth. The time of birth is of special astrologic importance.Infants are usually bathed immediately after birth, prior to being given to the mother. The call to prayer is whispered in the child's ear, so it is the first sound heard. Male children are usually circumcised within seven days of birth.A rite of passage in the Jewish community, birth is celebratory and is marked by a bris (circumcision ceremony) and a naming ceremony. Circumcision usually takes place eight days after birth.Infants may be baptized in a symbolic ceremony, although this often takes place later in life.
    Birth controlPreconception birth control is acceptable.The official Church stance is against artificial birth control.Birth control is generally accepted.Preconception birth control that has no negative health consequences and does not lead to permanent sterilization is generally acceptable.Birth control is considered a private issue, between a woman, man, and their particular faith.There are diverse opinions regarding this subject among Protestant denominations.
    DeathIt is very important that everything be done to provide a quiet and calm environment for patients for whom death is imminent, as it is believed that calmness of mind at death translates to a better rebirth.A priest should be called to give the sacrament of the sick if death is imminent. Last confession may be made to any person, although the patient may prefer a priest. Cremation is allowed; scattering of ashes is not.A Hindu priest or Guru may be summoned for last rites. As the soul (jiva) is reincarnated until karmic absolution, death is seen as an opportunity to continue the spiritual journey.Dying patients may request to face Mecca. Burial usually takes place as soon as possible, and there are special washing and shrouding procedures.It is believed that one should not go into death alone; therefore, the dying individual will receive as much attention as possible. A confessional and shema (statement of faith) is read when death is imminent.Traditions regarding death are also diverse. Some traditions require prayer and liturgies.
    BereavementPrayers for an auspicious rebirth are said for the 49 days following an individual's death. Meditation on impermanence is also important.The presence of a priest may be necessary for support during this time. Prayers for the deceased soul may be said, informally and/or formally (Mass and/or the Rosary).Remorse for the deceased is believed to inhibit the spirit from leaving the body. Therefore, excessive mourning is discouraged, though not always avoided.The head should be covered when speaking of the deceased. Continuous prayers are recited in the home for three days following an individual's death. Guilt is a common component of grieving.Bereavement does not formally begin until the burial, after which there is generally a seven-day period of mourning.Among Protestants, bereavement is less structured than in other religions. Each person should be individually assessed.
    Common religious objectsPrayer beads, images of Buddha and other deitiesBible, crucifix, rosary, images of the Holy family or saints, saint medallionsPrayer beads, incense, images/statutes of deitiesPrayer rug, Koran, amuletYarmulke or kippah (head covering), tallit (prayer shawl), siddur (prayer book), tefillin or phylacteries, candlesBible, images of Jesus Christ or Biblical figures, religious jewelry
    Major holidaysWesak/Buddha Day, Losar, Parinirvana/Nirvana Day, Asalha/Dharma Day, Bodhi DayChristmas, Ash Wednesday, Lent, Palm Sunday, Maundy Thursday, Good Friday, Easter Makar Sankranti, Holi, Diwali, Mahashivratri, Vasant Panchami, Rama Navami, Janmashtami/ Krishna Jayanti Al-Hijra, Milad un Nabi, Ramadan, Eid al-Fitr, Eid al-Adha, Day of Ashura, Laylatul Qadr, HajjShabbat, Rosh Hashanah, Yom Kippur, Purim, Passover, Shavuot, Sukkot, HanukkahChristmas, Ash Wednesday, Palm Sunday, Good Friday, Easter
    aThis overview is meant only to give a simple, brief summary of general ideology of each religion. By no means are all of the rites, beliefs, or holidays described practiced by all members of each religion; likewise, not all religious rites, beliefs, or holidays are listed for each religion. As always, individualized assessment is encouraged.
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    9 . Small studies of the effects of intercessory prayer on cardiovascular health have shown that, when compared to a control group, patients in the coronary care unit who are the subject of such prayer may require less
    A) diuretics.
    B) antibiotics.
    C) ventilatory assistance.
    D) All of the above

    OVERVIEW OF THE ROLE OF SPIRITUALITY/RELIGIOSITY IN HEALTH

    There is conflicting evidence, albeit in small studies, of the positive effects of intercessory prayer, or prayer on behalf of another person, on cardiovascular health. Two studies of patients admitted to coronary care units (CCUs) examined the effects of remote, directed prayer by an outside group of Christians [49,50]. The authors of the first study found that those who were the subjects of an intercessory prayer group required less ventilatory assistance, antibiotics, and diuretics than the control group; researchers in the second study determined that those who had been recipients of prayer had significantly lower CCU course scores [49,50]. However, a study completed in 2006 found no difference in cardiac bypass patients who were recipients of intercessory prayer [135]. In fact, patients who were certain that intercessors would pray for them had a higher rate of complications compared to patients who were unsure. The authors hypothesize that there are several potential reasons for this finding differing from earlier studies: the effect was smaller than the 10% difference the study was designed to detect, the measurement (complications within 30 days of coronary artery bypass graft surgery) was not appropriate, or intercessory prayer has no effect on outcomes in patients undergoing bypass graft surgery [135].

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    10 . The National Cancer Institute recommends that, for cancer patients, inquiries into spiritual or religious concerns be
    A) undertaken at every appointment.
    B) avoided in order to prevent undue stress.
    C) addressed, even if only briefly, at diagnosis.
    D) postponed until after diagnosis and treatment options are discussed and considered.

    OVERVIEW OF THE ROLE OF SPIRITUALITY/RELIGIOSITY IN HEALTH

    Although spirituality and religiosity should be considered as part of the assessment of cancer patients, there is not sufficient evidence to recommend participation in spiritual/religious activities as part of the treatment [65]. Addressing spiritual concerns has traditionally been regarded as an end-of-life issue, even though such concerns may arise at any time after diagnosis. The National Cancer Institute recommends that inquiries into spiritual and religious concerns be postponed for patients with cancer until after diagnosis and treatment options have been discussed and considered by the patient [43].

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    11 . Which of the following components of spirituality/religiosity is NOT considered a possible inhibitor of substance misuse?
    A) Social support
    B) Prosocial values
    C) Religious involvement
    D) Patriarchal gender roles

    OVERVIEW OF THE ROLE OF SPIRITUALITY/RELIGIOSITY IN MENTAL HEALTH

    It has also been surmised that spirituality and religion may reduce the risk of substance misuse [78,79,80,81]. In a large-scale national study involving 17,736 adolescents, greater religiosity was protective against recreational cannabis initiation and use [184]. In another study, researchers found that positive religious coping and aspects of spirituality are protective against drinking alcohol and cannabis use [149]. Using a longitudinal design, adolescents who endorsed higher levels of religiosity were found to have lower levels of use of cigarettes, alcohol, and cannabis compared to their less religious counterparts [150]. Finally, in a systematic review of the literature from 2007 to 2013, the researchers found an inverse relationship between substance use behaviors and spirituality and religion [151]. However, it is not clear which components of spirituality and religion (i.e., commitment to substance avoidance, social support, religious involvement, or prosocial values promoted by religious affiliation) actually act as the protective factors [79]. There is also some contrary evidence that shows a positive relationship between religion and increased risk of substance misuse [79].

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    12 . Religious scrupulosity is defined as
    A) rigid religious beliefs.
    B) preoccupation with recognizing lies.
    C) an obsessive concern with one's sins and moral behavior.
    D) an overwhelming need to convert others to one's own religion.

    OVERVIEW OF THE ROLE OF SPIRITUALITY/RELIGIOSITY IN MENTAL HEALTH

    Although there is an increasing emphasis on interventions that take a holistic approach to mental illness and working with patients and families toward recovery, some practitioners have expressed concern about focusing on spirituality and religiosity, particularly with patients who are diagnosed with severe mental and psychotic disorders [82]. Because patients with psychotic disorders may experience delusions and hallucinations with religious content, focusing on religion might exacerbate symptoms of disorganized thought and potentially promote injury to self or others [82,83,185]. Furthermore, rigid religious beliefs associated with guilt or sin may have the potential to aggravate major depression [82,146]. An extreme version of this is moral or religious scrupulosity, an obsessive concern with one's sins and moral behavior. This condition is generally considered to be a type of obsessive-compulsive disorder [84]. Scrupulosity is characterized by excessive guilt or obsession related to religious issues, often along with extreme moral or religious observance [85]. Treatment of this disorder is difficult, as practitioners often feel torn between addressing the pathology of the disorder and respecting the patient's religious beliefs. However, there is no doubt that some individuals turn to spirituality and religion in times of stress. An overwhelming number of psychiatric patients stated that religion was their source of comfort [86,87]. Religion/spirituality may be considered a mechanism of social support, positive coping and decision making, and avoidance of substance misuse. At times, it can positively impact psychologic well-being [83,87]. In a small study of adults with psychosis, participants reported finding religious rituals beneficial [185]. The adults chose which religious practices in which to engage, and some identified certain scriptures that communicated autonomy and control. Interestingly, many of the participants expressed a needed to take an active role in the recovery process versus a passive approach of merely relying on God. Religion was also described as a vehicle to experience hope and purpose, which was vital in the recovery process.

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    13 . In a large Canadian study, higher worship attendance frequency was associated with a lower risk for the development of
    A) cancer.
    B) obesity.
    C) anxiety disorders.
    D) obsessive-compulsive disorders.

    OVERVIEW OF THE ROLE OF SPIRITUALITY/RELIGIOSITY IN MENTAL HEALTH

    A separate study of Catholic and Protestant students in Northern Ireland found that increased prayer frequency was associated with a better level of psychologic health in terms of Eysenck's concept of psychoticism, which is characterized by recklessness, disregard for common sense, inappropriate emotional expression, and hostility toward authority figures [88]. Corrigan et al. found that spirituality and religiousness decreased psychiatric symptoms, increased overall management of daily tasks of life, and increased psychologic well-being among those with mental illness [89]. A study conducted in Pakistan involving adults hospitalized for depression found that participants' level of religiosity predicted mental well-being [186]. A Canadian study of approximately 37,000 individuals found that higher worship attendance frequency was associated with a lower risk for the development of mood, anxiety, and substance use disorders [90]. In a 2012 meta-analysis of 444 studies dating back to the 1960s, 61% reported an inverse relationship between spirituality/religion and depression [146]. In another systematic review focusing on research published between 1990 and 2010 and including all types of mental disorders, 72% of the studies demonstrated an inverse relationship between religion/spirituality and mental disorders [152]. However, the findings were mixed when focusing solely on schizophrenia, and no relationship was found in studies examining only bipolar disorder.

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    14 . Self-directed religious coping is characterized by
    A) participation in overt religious activities, such as Bible study.
    B) a lack of reliance on God or higher power(s) to solve problems.
    C) utilization of strategies within oneself and God or higher power(s) to solve problems.
    D) a passive attitude toward problems while waiting for God or higher power(s) to intervene.

    COPING AND SPIRITUALITY/RELIGIOSITY

    When individuals experience health or mental health problems, spirituality or religiosity may be utilized as a form of coping. Pargament identified three ways that religion might aid individuals in coping [91]. First, religion can influence the perspective an individual assumes toward the stressor; the source of stress may be viewed as part of a divine plan or acceptance of a larger life plan [153]. Second, religion can shape the coping process; that is, religion or spirituality can be employed as an inner resource to overcome the challenges associated with the health or mental health problem. Finally, the coping process may strengthen an individual's spiritual or religious orientation. Three different types of religious coping have been identified [91,92]:

    • Self-directed coping: No reliance on God or higher power(s) to solve problems. ("It's my problem to solve, not God's.")

    • Collaborative religious coping: Utilization of strategies within oneself and God or higher power(s). ("God helps those who help themselves.")

    • Deferred religious coping: Passive attitude toward problems; waiting for God or higher power(s) to intervene. ("It's in God's hands.")

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    15 . Which of the following statements is TRUE regarding African American spirituality/religiosity?
    A) In many cases, women play a lesser role in African American churches.
    B) There is a general belief that God is a cause of pain during times of suffering.
    C) Religious and spiritual orientations are often used among African Americans to deal with oppression.
    D) African American churches are often characterized by emotional restraint, as expression of emotion is believed to prolong suffering.

    CULTURE AND SPIRITUALITY/RELIGIOSITY

    God, Allah, and figures of a higher being are viewed as conquerors for the oppressed. Consequently, religious and spiritual orientations are often used among African Americans both to deal with and construct meaning from oppression and promote social justice and activism [96].

    The belief that God is a deliverance from pain during times of suffering is centered on the historical legacy of slavery and its attempt to destroy African culture and families [98]. Many African Americans indicate that they derive their strength from the belief that God is in a personal relationship with them and that life's adversities will eventually liberate them [99]. Prayer is one religious practice through which they experience God's support, presence, grace, and affirmation, particularly during crises [189].

    In a national survey, 83% of African Americans stated that they believed in God with certainty, and 75% indicated that religion was very important [190]. Almost half (47%) stated they attended religious services at least once a week [190]. Religious involvement has become a source of empowerment and strength for many African Americans. According to the National Survey of American Life, which included 6,082 adults in the United States, African Americans and Afro-Caribbean participants were more likely to report attendance at religious services and affiliation to a specific religious denomination than non-Hispanic white participants [5]. In many cases, African American women play critical roles in the church [98]. Emotional expressiveness often characterizes African American churches, as emotions provide a venue for suffering and sorrow [98]. The level of religiosity may correlate with older age. For example, one study found that 89% of African Americans reported being religious, but only 52% to 55% of African American adolescents indicated that religion played a very important role in their lives [155].

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    16 . Individuals who do not practice a particular religious tradition but who identify racially or ethnically as Jews are considered to be a part of
    A) Progressive Judaism.
    B) Humanistic Judaism.
    C) Conservative Judaism.
    D) Reconstructionist Judaism.

    CULTURE AND SPIRITUALITY/RELIGIOSITY

    As noted, Judaism is the second most commonly practiced religion in the United States, following Christian denominations [1]. There are four major branches of Judaism, although smaller movements do exist worldwide. For the most part, Jewish individuals may be classified as Reform (the most liberal expression of modern Judaism); Conservative (known as Masorti Judaism outside the United States); Orthodox (the most traditional expression of modern Judaism); or Hasidic [100,101]. Some individuals may not practice a particular religious tradition, but because of the long cultural and ethnic history, these individuals may identify either racially or ethnically as Jews [100]. Experts often refer to this as Humanistic Judaism [103].

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    17 . Approximately 90% of Hispanic/Latino Americans practice
    A) Santería.
    B) Espiritismo.
    C) Protestantism.
    D) Roman Catholicism.

    CULTURE AND SPIRITUALITY/RELIGIOSITY

    According to the Hispanic Churches in American Life Survey, the vast majority of Hispanics/Latinos self-identified as Christians [157]. The Hispanic/Latino culture is heavily influenced by Roman Catholicism. It is estimated that Roman Catholicism plays a predominant role in the lives of approximately 90% of Hispanic/Latino Americans [107,193]. Roman Catholics strongly adhere to religious values that are centered on marriage and family, and condemnation of premarital sex, abortion, and the use of contraception is stressed [107]. In addition, the concepts of penance and redemption are key for practicing Catholics. While the main figures of Christianity are foremost (i.e., God, Jesus, and the Apostles), the Virgin Mary and canonized saints play a large role in the creation of spiritual relationships.

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    18 . Spiritual genograms, one method available for assessing spirituality in an individual's life, are
    A) closed-ended questions in the form of a questionnaire.
    B) open-ended interviews exploring religious and spiritual beliefs and practices.
    C) pictorial illustrations of patients' spiritual journeys, in the form of a "road map."
    D) family trees focusing on religious and spiritual traditions, events, and experiences.

    CLINICAL ASSESSMENT AND INTERVENTIONS

    Spiritual histories, genograms, and life maps may also be useful assessment tools. A spiritual history consists of an open-ended interview that explores the patient's and his/her family's religious and spiritual beliefs, practices, and traditions. The public and private experiences of religion and spirituality are explored along a developmental life cycle [23]. Spiritual genograms are family trees that focus on religious and spiritual traditions, events, experiences, family orientation, and rituals that shape the patient's worldview and spirituality [23]. Spiritual life maps are pictorial illustrations of the patient's spiritual journey. Like a road map, the life map indicates where the patient has come from, where the patient is now, and what the patient is moving toward [117]. When creating this map, Hodge encourages practitioners to ask patients to "highlight the trials they have encountered and the spiritual resources they have used to cope in the course of their journey" [117].

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    19 . According to Richards and Potts, which of the following is a guideline for those considering the use of spiritual interventions?
    A) Spiritual interventions should be used universally.
    B) A trusting relationship between the patient and practitioner should exist before using spiritual interventions.
    C) Spiritual interventions should always be used in cases when spiritual issues are at the heart of a patient's problem.
    D) All of the above

    CLINICAL ASSESSMENT AND INTERVENTIONS

    Studies show that practitioners who use spiritual interventions, such as prayer, discussing religious concepts, and forgiveness, tend to combine them with traditional therapeutic frameworks [118]. Richards and Potts highlight several practice guidelines for those considering the use of spiritual interventions [119]:

    • A trusting relationship between the patient and practitioner should exist before using spiritual interventions.

    • Obtaining the patient's permission to discuss spiritual or religious issues is crucial. This is the heart of informed consent and self-determination.

    • The practitioner should assess the patient's understanding of his/her religious doctrines or spiritual beliefs before utilizing spiritual interventions.

    • Spiritual interventions should be used within the patient's value system, not universally.

    • Spiritual interventions should be used carefully, with much thought and planning.

    • It is important to assess the patient's mental status, as there is some concern that spiritual interventions may not be amenable with psychotic patients.

    • Spiritual interventions should be employed cautiously, particularly if spiritual issues are at the heart of the patient's problems.

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    20 . Patient M is a man, 24 years of age, who is referred for follow-up after being diagnosed with HIV. The patient is having trouble coping with his diagnosis and has been praying for answers. Research has indicated that spiritual interventions, such as prayer, may have positive effects for those suffering from chronic illness, such as HIV infection. Therefore, two of the four principles in the EBQT paradigm are supported. Based on this information,
    A) spiritual intervention is necessary and ethical.
    B) a spiritual adjunct might be useful and would likely be ethical.
    C) a spiritual adjunct would be inappropriate and may not be ethical.
    D) spiritual intervention is limited to special circumstances and may or may not be useful for this patient.

    CLINICAL ASSESSMENT AND INTERVENTIONS

    A scale to determine the suitability and the usefulness of including a spiritual adjunct to therapy has been developed. The scale ranges from appropriate to inappropriate based upon the number of principles upheld in the EBQT paradigm. An intervention is considered appropriate if the practitioner endorses all four principles. Endorsement of all four principles indicates that a spiritual adjunct might be useful and would likely be ethical given the patient's circumstances. Potential recommendations are those interventions supported by only two to three principles; the appropriateness of the action is limited to special circumstances and may not be useful for all practitioners [121]. Finally, a recommendation is inappropriate if the practitioner endorses only one or none of the principles; in these cases, a spiritual adjunct to therapy is unlikely to be useful and may not be ethical [121].

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