In this study of seriously ill patients, elements of two domains of spirituality, spiritual history and current spiritual well-being, were associated with symptoms of anxiety and depression. Of the measures of spiritual history, only the Cost of Religiousness Subscale was related to the outcomes with greater past negative religious experiences associated with more symptoms of anxiety and depression. Past use of religious practices for support or participation in a religious community were not associated with anxiety and depression. On the other hand, greater current spiritual well-being, including measures of both the role of faith in illness and meaning, peace, and purpose in life were associated with fewer symptoms of anxiety and depression. The results of this study add to our understanding of the relationship between specific elements of the spiritual experience and health outcomes in patients with serious illness.
A number of studies have found a relationship between current spiritual well-being and anxiety and depression. Like this study, most have found lower levels of anxiety and depression in patients with higher levels of spiritual well-being7,8,24,34–41
. Much of this work has focused on cancer patients with fewer studies including those with other serious illnesses. This study extends these findings to a diagnostically diverse sample of patients, and suggests that the search for meaning, peace, and purpose in life and the role of faith in illness are important to the spiritual experience of many patients facing serious illness regardless of their specific diagnosis.
Although religious beliefs often serve as a source of support for those with serious illness, some have documented an association between religious beliefs and adverse health outcomes. For example, negative religious coping (i.e. feeling abandoned or punished by God, spiritual discontent) has been associated with an increased risk of anxiety, depression, and poor quality of life4,5,9,24,42
. Similarly, in this study, those with more past negative religious experiences, including the extent to which past religious life has caused stress, suffering, or conflict, reported more symptoms of anxiety and depression. Additionally, reports of negative religious experiences were not limited to those who described themselves as “very religious/spiritual”. Compared to those who rated themselves as fairly religious/spiritual, both those who rated themselves as very or not at all religious/spiritual scored higher on the measure of past negative religious experiences (Table ). Thus, even seriously ill patients who do not currently consider themselves as religious/spiritual, may still struggle with conflict related to past religious life. These struggles may surface as patients search for meaning and purpose in the context of advanced illness.
The results of this study suggest that for some seriously ill patients asking about current spiritual well-being and negative religious experiences may uncover spiritual concerns which may be related to emotional distress. The most commonly used tools for completing a spiritual assessment include questions for assessing current spiritual well-being, both the role of faith in illness and whether one is able to find meaning, peace, and purpose in life16,43,44
. Examples include: “What role does faith or belief have in your life?” “What are your sources of hope, strength, comfort, and peace?” Additionally, a single item, “Are you at peace?” has been shown to correlate with spiritual well-being45
. Based on the response to these broad questions, physicians can inquire more specifically about spiritual concerns and when appropriate, offer referral to a chaplain or other provider (i.e. social worker, psychologist) with expertise addressing spiritual issues.
Because most spiritual assessment tools focus on the use of spiritual beliefs and practices as a source of support and a resource for coping with illness16,43,44
, healthcare providers may feel less comfortable asking about negative religious experiences. Below is an example of how physicians can explore and respond to concerns related to negative religious experiences.
Physician: “What role, if any, does faith or spirituality play in your life?”
Patient: Not much.
Physician: Was there a time when religion or spirituality was more important in your life?
Patient: Yes, when I was growing up.
Physician: What changed?
Patient: We used to go to church every week. But after a while I looked around and decided they were all a bunch of hypocrites, so I never went back.
Physician: It sounds like that was a difficult time for you. People with serious illness often think a lot about religious and spiritual experiences. Have you been thinking about any of this lately?
Patient: Yes, I have.
Physician: Tell me more.
Patient: I’m not sure what I believe now, and when you think about being really sick, it sure would help if I had some clear answers.
Physician: That is tough. I’d love to hear more about that.
After further discussion
Physician: How can I help?
Patient: I don’t know.
Physician: Would you be interested in speaking with a chaplain about your experiences and feelings?
The dialogue above is one example of how physicians might ask patients about past negative religious experiences. Not all patients will volunteer these experiences in response to a general question, but some will. Also, not all patients with prior negative religious experiences will have emotional distress related to these experiences. In the absence of emotional distress or concerns, physicians may choose to listen empathetically, but may not find the need for further action. However, if patients express spiritual concerns or distress related to past religious experiences, physicians can offer referral to a chaplain. Although chaplains are trained to provide spiritual care regardless of patients’ beliefs and practices, some patients with prior negative religious experiences may not want to discuss their concerns with someone whom they identify as a “religious” care provider. In those cases, referral to a social worker or psychologist with experience addressing religious or spiritual concerns may be helpful.
This study has some limitations. The majority of participants were non-Hispanic Whites who identified themselves as Christian and resided in southeastern United States. Our results may not be applicable to patients of other religious groups, those in other geographic regions, or because of the inclusion criteria, those with less advanced illness or stable chronic disease. Another issue is that we were not able to determine causality. We do not know if concerns related to current spiritual well-being or past negative religious experiences cause anxiety and depression or if anxiety and depression lead to concerns in these domains of spirituality.
The findings of this study provide an empirical basis for the relationship between some domains of spirituality and symptoms of anxiety and depression in seriously-ill patients. Future research should examine how information obtained in a spiritual assessment focusing on those domains of spirituality associated with adverse health outcomes can be used to improve patient care.