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1.  Initial Evidence of Religious Practice and Belief in Depressed African American Cancer Patients 
Objective:
This study examined spiritual coping (beliefs and practices) of depressed African American cancer patients through a comparison with depressed White cancer patients and non-depressed African American cancer patients.
Methods:
Using mixed methods, 74 breast (n=41) and prostate (n=33) cancer survivors including 34 depressed and 23 nondepressed African Americans and 17 depressed Whites were interviewed. The interviews were audiotaped and transcribed. Qualitative data analysis identified themes that were coded. The codes were entered into SPSS software. The Fisher’s exact test was performed to examine group differences in self-reported spiritual coping.
Results:
Significantly more depressed African Americans questioned God when learning of a cancer diagnosis than the non-depressed African Americans (p=.03), but they did not differ from the depressed Whites in this regard (p=.70). Significantly more depressed African Americans reported having faith in God (p=.04), reading the bible (p=.02), and conversing with God (p=.01) than did the depressed Whites. They also reported praying alone (p=.01) more frequently than the depressed Whites who, on the other hand, reported praying with others (non-family members) together for one’s own health more frequently (p=.04).
Conclusions:
Depression is associated with a deepening need for spirituality and it affects religious beliefs and practices more in African American than White cancer patients. Given its important role in the lives of African American cancer patients, spirituality may be utilized as a reasonable, culturally-based approach to better assess and treat depression in these patients.
doi:10.2174/1874434601307010001
PMCID: PMC3551236  PMID: 23346265
African American; cancer; depression; race; pray; religion; spirituality.
2.  Spiritual Dryness as a Measure of a Specific Spiritual Crisis in Catholic Priests: Associations with Symptoms of Burnout and Distress 
Spirituality/religiosity is recognized as a resource to cope with burdening life events and chronic illness. However, less is known about the consequences of the lack of positive spiritual feelings. Spiritual dryness in clergy has been described as spiritual lethargy, a lack of vibrant spiritual encounter with God, and an absence of spiritual resources, such as spiritual renewal practices. To operationalize experiences of “spiritual dryness” in terms of a specific spiritual crisis, we have developed the “spiritual dryness scale” (SDS). Here, we describe the validation of the instrument which was applied among other standardized questionnaires in a sample of 425 Catholic priests who professionally care for the spiritual sake of others. Feelings of “spiritual dryness” were experienced occasionally by up to 40%, often or even regularly by up to 13%. These experiences can explain 44% of variance in daily spiritual experiences, 30% in depressive symptoms, 22% in perceived stress, 20% in emotional exhaustion, 19% in work engagement, and 21% of variance of ascribed importance of religious activity. The SDS-5 can be used as a specific measure of spiritual crisis with good reliability and validity in further studies.
doi:10.1155/2013/246797
PMCID: PMC3703410  PMID: 23843867
3.  Positive and Negative Religious Coping and Well-Being in Women with Breast Cancer 
Journal of palliative medicine  2009;12(6):537-545.
Background
Although religions is important to many people with cancer, few studies have explored the relationship between religious coping and well-being in a prospective manner, using validated measures, while controlling for important covariates.
Methods
One hundred ninety-eight women with stage I or II and 86 women with stage IV stage breast cancer were recruited. Standardized assessment instruments and structured questions were used to collect data at study entry and 8 to 12 months later. Religious coping was measured with validated measures of positive and negative religious coping. Linear regression models were used to explore the relationships between positive and negative religious coping and overall physical and mental well-being, depression, and life satisfaction.
Results
The percentage of women who used positive religious coping (i.e., partnering with God or looking to God for strength, support, or guidance) “a moderate amount” or “a lot” was 76%. Negative religious coping (i.e., feeling abandoned by or anger at God) was much less prevalent; 15% of women reported feeling abandoned by or angry at God at least “a little.” Positive religious coping was not associated with any measures of well-being. Negative religious coping predicted worse overall mental health, depressive symptoms, and lower life satisfaction after controlling for sociodemographics and other covariates. In addition, changes in negative religious coping from study entry to follow-up predicted changes in these well-being measures over the same time period. Cancer stage did not moderate the relationships between religious coping and well-being.
Conclusions
Negative religious coping methods predict worse mental heath and life satisfaction in women with breast cancer.
doi:10.1089/jpm.2008.0250
PMCID: PMC2789454  PMID: 19508140
4.  Positive and Negative Religious Coping and Well-Being in Women with Breast Cancer 
Journal of Palliative Medicine  2009;12(6):537-545.
Abstract
Background
Although religions is important to many people with cancer, few studies have explored the relationship between religious coping and well-being in a prospective manner, using validated measures, while controlling for important covariates.
Methods
One hundred ninety-eight women with stage I or II and 86 women with stage IV stage breast cancer were recruited. Standardized assessment instruments and structured questions were used to collect data at study entry and 8 to 12 months later. Religious coping was measured with validated measures of positive and negative religious coping. Linear regression models were used to explore the relationships between positive and negative religious coping and overall physical and mental well-being, depression, and life satisfaction.
Results
The percentage of women who used positive religious coping (i.e., partnering with God or looking to God for strength, support, or guidance) “a moderate amount” or “a lot” was 76%. Negative religious coping (i.e., feeling abandoned by or anger at God) was much less prevalent; 15% of women reported feeling abandoned by or angry at God at least “a little.” Positive religious coping was not associated with any measures of well-being. Negative religious coping predicted worse overall mental health, depressive symptoms, and lower life satisfaction after controlling for sociodemographics and other covariates. In addition, changes in negative religious coping from study entry to follow-up predicted changes in these well-being measures over the same time period. Cancer stage did not moderate the relationships between religious coping and well-being.
Conclusions
Negative religious coping methods predict worse mental heath and life satisfaction in women with breast cancer.
doi:10.1089/jpm.2008.0250
PMCID: PMC2789454  PMID: 19508140
5.  Spirituality and Religion in Patients with HIV/AIDS 
Journal of General Internal Medicine  2006;21(Suppl 5):S5-S13.
BACKGROUND
Spirituality and religion are often central issues for patients dealing with chronic illness. The purpose of this study is to characterize spirituality/religion in a large and diverse sample of patients with HIV/AIDS by using several measures of spirituality/religion, to examine associations between spirituality/religion and a number of demographic, clinical, and psychosocial variables, and to assess changes in levels of spirituality over 12 to 18 months.
METHODS
We interviewed 450 patients from 4 clinical sites. Spirituality/religion was assessed by using 8 measures: the Functional Assessment of Chronic Illness Therapy—Spirituality-Expanded scale (meaning/peace, faith, and overall spirituality); the Duke Religion Index (organized and nonorganized religious activities, and intrinsic religiosity); and the Brief RCOPE scale (positive and negative religious coping). Covariates included demographics and clinical characteristics, HIV symptoms, health status, social support, self-esteem, optimism, and depressive symptoms.
RESULTS
The patients’ mean (SD) age was 43.3 (8.4) years; 387 (86%) were male; 246 (55%) were minorities; and 358 (80%) indicated a specific religious preference. Ninety-five (23%) participants attended religious services weekly, and 143 (32%) engaged in prayer or meditation at least daily. Three hundred thirty-nine (75%) patients said that their illness had strengthened their faith at least a little, and patients used positive religious coping strategies (e.g., sought God’s love and care) more often than negative ones (e.g., wondered whether God has abandoned me; P<.0001). In 8 multivariable models, factors associated with most facets of spirituality/religion included ethnic and racial minority status, greater optimism, less alcohol use, having a religion, greater self-esteem, greater life satisfaction, and lower overall functioning (R2=.16 to .74). Mean levels of spirituality did not change significantly over 12 to 18 months.
CONCLUSIONS
Most patients with HIV/AIDS belonged to an organized religion and use their religion to cope with their illness. Patients with greater optimism, greater self-esteem, greater life satisfaction, minorities, and patients who drink less alcohol tend to be both more spiritual and religious. Spirituality levels remain stable over 12 to 18 months.
doi:10.1111/j.1525-1497.2006.00642.x
PMCID: PMC1924778  PMID: 17083501
religion; spirituality; HIV; AIDS
6.  The spiritual experiences of patients with diabetes- related limb amputation 
Background:
Confrontation with the consequences of diabetes causes a crisis in physical, mental, and spiritual dimensions. Sometimes the spiritual crisis can be tremendous. Since spiritual health coordinates different aspects of human life, this study aimed to identify the spiritual health of patients with defects caused by diabetes.
Materials and Methods:
This was a qualitative-phenomenological and descriptive study and the participants were selected from rehabilitation centers in Isfahan and Valiasr Hospital in Zanjan. A purposive sample of 15 participants underwent deep interviews. Colaizzi’s method of analysis was used to analyze the data.
Findings:
outcome of this phase of the study was 173 codes and 2 groups that included hindering factors in spiritual health and the promotion of the relation with God. The concepts that patients had experienced as hindering factors of the treatment process were disappointment and hopelessness, guilt, feeling distant from God, quitting obligatory acts and knowing God as cruel. The concepts that patients had experienced as contributing factors to the healing process were resorting to Imams, God’s ordering the disease as a reward, fear of God’s punishment, believing in miracles, being closer to God, believing in the mercy of God, returning to religious practice, feeling of enjoying life and knowing that the disease is the atonement of sins.
Conclusions:
With regard to the importance of spiritual and religious care as one of the tasks of nurses, as the key members of health team, they should respect the patients’ beliefs and values in addition to considering their physical and mental conditions.
PMCID: PMC3696216  PMID: 23833617
Spiritual experiences; organ amputations; diabetes
7.  Gandhi on Religion, Faith and Conversion: Secular Blueprint Relevant Today* 
Mens Sana Monographs  2004;2(1):79-88.
Gandhi believed in judging people of other faiths from their stand point rather than his own. He welcomed contact of Hinduism with other religions, especially the Christian doctrines, for he did not want to be debarred from assimilating good anywhere else. He believed a respectful study of other's religion was a sacred duty and it did not reduce reverence for one's own. He was looking out for those universal principles which transcended religion as a dogma. He expected religion to take account of practical life, he wanted it to appeal to reason and not be in conflict with morality. He believed it was his right and duty to point out the defects of his own religion, but to desist from doing so with other's faith. He refused to abuse a man for his fanatical deeds for he tried to see them from the other person's point of view. He believed Jesus expressed the will and spirit of God but could not accept Jesus as the only incarnate son of God. If Jesus was like God or God himself, then all men were like God or God Himself. But neither could he accept the Vedas as the inspired word of God, for if they were inspired why not also the Bible and the Koran? He believed all great religions were fundamentally equal and that there should be innate respect for them, not just mutual tolerance. He felt a person wanting to convert should try to be a good follower of his own faith rather than seek goodness in change of faith. His early impressions of Christianity were unfortunate which underwent a change when he discovered the New Testament and the Sermon on the Mount, whose ideal of renunciation appealed to him greatly. He thought Parliament of Religions or International Fellowship of Religions could be based only on equality of status, a common platform. An attitude of patronising tolerance was false to the spirit of international fellowship. He believed that all religions were more or less true, but had errors because they came to us though imperfect human instrumentality. Religious symbols could not be made into a fetish to prove the superiority of one religion over another.
In a multi-religious secular polity like that of India, Gandhi's ideas on religion and attitude toward other religions could serve as a secular blueprint to ponder over and implement.
PMCID: PMC3400300  PMID: 22815610
Religion; Reason; Proselytization; Hinduism; Christianity; Conversion; Secularism
8.  Social Involvement in Religious Institutions and God-Mediated Control Beliefs: A Longitudinal Investigation 
This study examines the relationships among race, education, formal as well as informal involvement in the church, and God-mediated control. Formal involvement in the church was assessed by the frequency of attendance at worship services, Bible study groups, and prayer groups. Informal involvement was measured with an index of spiritual support provided by fellow church members. Data from a nationwide longitudinal survey of older people suggest that both formal and informal church involvement tend to sustain feelings of God-mediated control over time. The findings further reveal that compared to older whites, older African Americans are more likely to have stronger feelings of God-mediated control at the baseline survey and older blacks are more likely to sustain their sense of God-mediated control over time. In contrast, the data suggest that education is not significantly related to feelings of God-mediated control.
doi:10.1111/j.1468-5906.2007.00375.x
PMCID: PMC3043601  PMID: 21359114
9.  The Meaning and Use of Spirituality Among African American Women Living With HIV/AIDS 
The purpose of this qualitative study was to explore the meaning and use of spirituality among African American (AA), predominantly Christian women with HIV. A nonrandom sample of 20 AA women from a large infectious disease clinic in Metro-Atlanta participated in the study. The study used focus groups and individual interviews to interview women about their lived spiritual experience. Content analysis and NUDIST software were used to analyze transcripts. The findings revealed the spiritual views and practices of AA women with HIV. The following themes (and subthemes) emerged: Spirituality is a process/journey or connection (connection to God, higher power, or spirit and HIV brought me closer to God), spiritual expression (religion/church attendance, prayer, helping others, having faith), and spiritual benefits (health/healing, spiritual support, inner peace/strength/ability to keep going, and here for a reason or purpose/a second chance). Findings highlight the importance of spirituality in health and well-being among AA women with HIV/AIDS.
doi:10.1177/0193945912443740
PMCID: PMC3978577  PMID: 22566288
focus groups; methods; qualitative methods; immune clinical focus; spirituality; health behavior/symptom focus; Black population focus; HIV/AIDS
10.  Development of the Ways of Helping Questionnaire: A Measure of Preferred Coping Strategies for Older African American Cancer Survivors 
Research in nursing & health  2009;32(3):243-259.
Although researchers have identified beneficial coping strategies for cancer patients, existing coping measures do not capture the preferred coping strategies of older African American cancer survivors. A new measure, the Ways of Helping Questionnaire (WHQ), was evaluated with 385 African American cancer survivors. Validity evidence from factor analysis resulted in 10 WHQ subscales (Others There for Me, Physical and Treatment Care Needs, Help from God, Church Family Support, Helping Others, Being Strong for Others, Encouraging My Healthy Behaviors, Others Distract Me, Learning about Cancer, and Distracting Myself). Reliability evidence was generally strong. Evidence regarding hypothesized relationships with measures of well-being and another coping measure was mixed. The WHQ’s content coverage makes it especially relevant for older African American cancer survivors.
doi:10.1002/nur.20321
PMCID: PMC2752043  PMID: 19259991
coping; social support; African Americans; cancer; instrument development
11.  "Driving the devil away": qualitative insights into miraculous cures for AIDS in a rural Tanzanian ward 
BMC Public Health  2010;10:427.
Background
The role of religious beliefs in the prevention of HIV and attitudes towards the infected has received considerable attention. However, little research has been conducted on Faith Leaders' (FLs) perceptions of antiretroviral therapy (ART) in the developing world. This study investigated FLs' attitudes towards different HIV treatment options (traditional, medical and spiritual) available in a rural Tanzanian ward.
Methods
Qualitative interviews were conducted with 25 FLs purposively selected to account for all the denominations present in the area. Data was organised into themes using the software package NVIVO-7. The field work guidelines were tailored as new topics emerged and additional codes progressively added to the coding frame.
Results
Traditional healers (THs) and FLs were often reported as antagonists but duality prevailed and many FLs simultaneously believed in traditional healing. Inter-denomination mobility was high and guided by pragmatism.
Praying for the sick was a common practice and over one third of respondents said that prayer could cure HIV. Being HIV-positive was often seen as "a punishment from God" and a consequence of sin. As sinning could result from "the work of Satan", forgiveness was possible, and a "reconciliation with God" deemed as essential for a favourable remission of the disease. Several FLs believed that "evil spirits" inflicted through witchcraft could cause the disease and claimed that they could cast "demons" away.
While prayers could potentially cure HIV "completely", ART use was generally not discouraged because God had "only a part to play". The perceived potential superiority of spiritual options could however lead some users to interrupt treatment.
Conclusions
The roll-out of ART is taking place in a context in which the new drugs are competing with a diversity of existing options. As long as the complementarities of prayers and ART are not clearly and explicitly stated by FLs, spiritual options may be interpreted as a superior alternative and contribute to hampering adherence to ART. In contexts where ambivalent attitudes towards the new drugs prevail, enhancing FLs understanding of ART's strengths and pitfalls is an essential step to engage them as active partners in ART scale-up programs.
doi:10.1186/1471-2458-10-427
PMCID: PMC2916904  PMID: 20646300
12.  Assessing the Role of Spirituality in Coping Among African Americans Diagnosed with Cancer 
Journal of religion and health  2012;51(2):507-521.
Spirituality plays an important role in cancer coping among African Americans. The purpose of this study was to report on the initial psychometric properties of instruments specific to the cancer context, assessing the role of spirituality in coping. Items were developed based on a theoretical model of spirituality and qualitative patient interviews. The instruments reflected connections to self, others, God, and the world. One hundred African American cancer survivors completed the instruments by telephone. The instruments showed adequate internal reliability, mixed convergent validity, discriminant validity, and interpretable factor structures.
doi:10.1007/s10943-011-9453-0
PMCID: PMC3653318  PMID: 21246282
Spirituality; Cancer coping; Quality of life; African American; Instrument development
13.  Feelings of Gratitude Toward God Among Older Whites, Older African Americans, and Older Mexican Americans 
Research on aging  2011;34(2):156-173.
The first goal of this study is to see if social relationships in the church influence feelings of gratitude toward God. The second goal is to assess the impact of race and ethnicity on this relationship. The data support the following hypotheses: (1) older people who go to church more often tend to receive more spiritual support from fellow church members; (2) older adults who receive more spiritual support at church will derive a deeper understanding of themselves and others; (3) older people who develop greater insight into themselves and others will derive a greater sense of religious meaning in life; and (4) older adults who develop a deeper sense of religious meaning in life will feel more grateful to God. The results also indicate that the study model explains how feelings of gratitude toward God arise among older blacks and whites, but not older Mexican Americans.
doi:10.1177/0164027511417884
PMCID: PMC3611881  PMID: 23543840
Gratitude to God; race and ethnic; spiritual support
14.  Which Domains of Spirituality are Associated with Anxiety and Depression in Patients with Advanced Illness? 
Background
Anxiety and depression are common in seriously ill patients and may be associated with spiritual concerns. Little research has examined how concerns in different domains of spirituality are related to anxiety and depression.
Objective
To examine the association of spiritual history and current spiritual well-being with symptoms of anxiety and depression in patients with advanced illness.
Design
Cross-sectional cohort study
Participants
Two hundred and ten patients with advanced illness, of whom 1/3 were diagnosed with cancer, 1/3 COPD, and 1/3 CHF. The mean age of the sample was 66 years, and 91% were Christian.
Measurements
Outcome measures were the Profile of Mood States’ Anxiety Subscale (POMS) and 10-item Center for Epidemiologic Studies Depression Scale (CESD). Predictors were three subscales of the Spiritual History Scale measuring past religious help-seeking and support, past religious participation, and past negative religious experiences and two subscales of the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale measuring the role of faith in illness and meaning, peace, and purpose in life. We conducted multiple regression analyses, controlling for demographics, disease type and severity, self-rated religiousness/spirituality, and frequency of religious attendance and devotion.
Results
In adjusted analyses, greater spiritual well-being, including both beliefs about the role of faith in illness and meaning, peace, and purpose in life were associated with fewer symptoms of anxiety (P ≤ 0.001) and depression (P < 0.001). Greater past negative religious experiences were associated with more symptoms of anxiety (P = 0.04) and depression (P = 0.004). No other measures of spiritual history were associated with the outcomes.
Conclusions
In this diverse sample of seriously ill patients, current spiritual well-being and past negative religious experiences were associated with symptoms of anxiety and depression. Healthcare providers should consider asking about current spiritual well-being and past negative religious experiences in their assessment of seriously ill patients with symptoms of anxiety and depression.
doi:10.1007/s11606-011-1656-2
PMCID: PMC3138578  PMID: 21336669
spirituality; anxiety; depression; end-of-life care; terminal illness
15.  Faith Pinnacle Moments: Stress, Miraculous Experiences, and Life Satisfaction in Young Adulthood 
Sociology of religion  2012;74(2):176-198.
Religious beliefs often persist among unaffiliated young adults, and certain beliefs about God have been shown to support subjective well-being. Yet we know much less about the persistence or psychological impact of religious experiences, specifically miracles from God. I conceive of such experiences as faith pinnacle moments which express and reinvigorate the individual's reciprocal bond with God, frequently occur in response to certain types of stress, and support well-being by solidifying one's sense of that bond. My results show that net of institutional religiosity, young adults who experience stress from traumas are more likely to report miracles. This suggests that these reports often refer to healings or similar interventions. Stress from family breakups, however, is negatively correlated with miracles, presumably since these disruptions damage the bond with God due to the established connection between parental relationships and perceived relationship with God. Finally, miracles are positively correlated with life satisfaction and partially protect against the negative effects of stress on life satisfaction.
doi:10.1093/socrel/srs071
PMCID: PMC3753892  PMID: 23990701
personal religiosity; adolescences; religious experiences; coping; stress; beliefs; life satisfaction; subjective well-being
16.  Compassion in Jewish, Christian and Secular Nursing. A Systematic Comparison of a Key Concept of Nursing (Part I) 
Background
The topos of the Compassionate God is a dominant motive of the Jewish and Christian traditions. It is relevant for nursing because it asks the nurse to imitate God so as to become God-like. Also, to think that God suffers with the suffering believers is thought to give comfort to them. Because in the western world the topos of the Compassionate God represents the basis of the ethics of compassion/caring, this piece of basic research is important for clinical practice. This study explores to what extent Jewish and Christian nursing adhered to the biblical topos of the Compassionate God at different periods and in different cultural contexts.
Method
A mixed methods approach was used. It included variations of hermeneutical text analysis as used in historical, philosophical, theological, science of religion, and nursing research.
Results
The analysis of the literary sources shows that the topos of the Compassionate God was interpreted differently in different cultural contexts. However, at all times it directed religious and secular nursing. Since the beginning of the 21st century it builds the core of “compassionate caring” as propagated by North American nursing science.
Conclusions
The topos of the Compassionate God laid the foundation of the tradition of the ethics of compassion in nursing. More research is required to learn whether it also plays a role in Islamic nursing.
PMCID: PMC3713770  PMID: 23908713
Compassion; Caring; Religious and secular nursing; Nursing ethics
17.  Spirituality in survivors of myocardial infarction 
Background:
Life-threatening and stressful events, such as myocardial infarction (MI) can lead to an actual crisis, which affects the patients spiritually as well as physically, psychologically, and socially. However, the focus of health care providers is on physical needs. Furthermore, the spirituality of the patients experiencing heart attack in the light of our cultural context is not well addressed in the literature. This study is aimed at exploring the spiritual experiences of the survivors of the MI.
Materials and Methods:
In this qualitative research a grounded theory approach was used. Key informants were 9 MI patients hospitalized in the coronary care units of 3 hospitals in Shiraz. In addition, 7 nurses participated in the study. In-depth interviews and a focus group were used to generate data. Data analysis was done based on Strauss and Corbin method. Constant comparison analysis was performed until data saturation.
Results:
Five main categories emerged from the data, including perceived threat, seeking spiritual support, referring to religious values, increasing faith, and realization. The latter with its 3 subcategories was recognized as core category and represents a deep understanding beyond knowing. At the time of encountering MI, spirituality provided hope, strength, and peace for the participants.
Conclusion:
Based on the results we can conclude that connecting to God, religious values, and interconnectedness to others are the essential components of the participants’ spiritual experience during the occurrence of MI. Spirituality helps patients to overcome this stressful life-threatening situation.
PMCID: PMC3703074  PMID: 23853646
Grounded theory; heart attack; myocardial infarction; qualitative research; religion; spirituality
18.  The encounter with God in myth and madness 
Background
It is well known how often psychiatric patients report religious experiences. These are especially frequent in schizophrenic and epileptic patients as the subject of their delusions. The question we pose is: are there differences between this kind of religious experiences and those we find in religious texts or in the mythological tradition?
Results
An overview on famous mythological narratives, such as The Aeneid, allows us to establish that the divinities become recognizable to the human being at the moment of their departure. Thus, Aeneas does not recognise his mother, Venus, when she appears to him in the middle of the forest at the coast of Africa. A dialogue between the two takes place, and only at the end of the encounter, when she is going away and already with her back to Aeneas, she shows her son the signs of her divinity: the rose-flush emanating from her neck, her hair perfume and the majesty of her gait. Something analogous can be observed in the encounter of Moses with Yahweh on Mount Sinai. Moses asks God: "Show me your glory, I beg you". And God replies, among other things: "you shall see the back of me, but my face is not to be seen". In the same sense, the Emmaus disciples do not recognise Jesus till the moment of his disappearance ("but he had vanished from their sight"), and Saul of Tars falls off his horse just in the moment when he feels the divine presence. In short, the direct encounter with the divinity seems not to occur in the realm of myth or in religious tradition. The realm of madness is exactly the opposite. Our research on religious experiences in schizophrenic and epileptic patients leads us to conclude that God appears to them face to face, and the patient describes God the father, Jesus or the Virgin Mary in intimate detail, always in an everyday setting. So, the divinity is seen in the garden, or in the bedroom, or maybe above the wardrobe, without any of its majesty. The nearness to God also tends to be so extreme that even an identification of patient and God can occur. That light emanating from the world of the divine ceases to be perceived by them.
Conclusion
While in mythological narratives God appears to the human being at the moment of His departure or showing His back, psychiatric patients with religious delusions experience the divinity in a direct way, face to face. Given the deformation of the divine occurring on the edge of madness we can better understand the mysterious words from Yahweh to Moses in Exodus: "for man cannot see me and live".
doi:10.1186/1747-5341-2-12
PMCID: PMC1934374  PMID: 17608933
19.  Moving beyond attitudinal barriers: understanding African Americans' support for organ and tissue donation. 
PURPOSE: African Americans are disproportionately represented among individuals in need of an organ transplant, due in part to low donation rates in this population. The research literature has focused on attitudinal barriers to donation; however, the current study explores individual experiences and values that contribute to supportive attitudes toward organ and tissue donation. PROCEDURES: Focus group participants were 26 African-American clergymen and 42 African-American parishioners recruited from seven Christian churches in the metro Atlanta area. FINDINGS: Although a large number of participants had previous exposure to organ and tissue donation and transplantation, the majority of these experiences were negative, and participants felt a general fear and lack of knowledge about the process of donation and transplantation. Despite these negative experiences, respondents reported personal values (e.g., the desire to help others and acceptance of group responsibility) and religious values (e.g., the desire to carry out God's will and to have faith in God) that contribute to supportive attitudes toward organ and tissue donation. CONCLUSION: An understanding of supportive attitudes toward donation may help improve the development of effective culturally sensitive intervention messages targeting the African-American religious community with the ultimate goal of increasing the pool of organs available for transplantation.
PMCID: PMC2568639  PMID: 15779498
20.  Iranian cancer patients’ perception of spirituality: a qualitative content analysis study 
BMC Nursing  2012;11:19.
Background
Spirituality is a subjective and multi-dimensional concept. The ambiguity in its meaning can create barriers in its application in both education and medicine. The present study aimed to explore the Iranian cancer patients’ perception of spirituality.
Methods
A qualitative study, using the content analysis approach, was conducted. Semi-structured interviews were held with 11 cancer patients and six members of their families in one of Tehran’s hospitals and a charity institute. The data generated were transcribed verbatim and content analysis approach was used for data reduction, naming data, obtaining analytical code and determining categories and themes.
Results
Three themes (and seven sub-themes) emerged from the data analysis: 1) God as the spiritual truth (relationship with God and trust in God), 2) Moralities as a spiritual sign (considering personal and social moral codes) and 3) Spiritual resources as the source of hope (religious, personal and social resources).
Conclusions
Overall, in the view of cancer patients, spirituality can be defined in a religious context. However, some of them believe in morality beside religiosity, so health care staff must pay due attention to these aspects, to provide them with the opportunity to use spiritual resources.
doi:10.1186/1472-6955-11-19
PMCID: PMC3500707  PMID: 23043231
Spirituality; Perception; Experience; Cancer patients; Content analysis
21.  Mentalizing Deficits Constrain Belief in a Personal God 
PLoS ONE  2012;7(5):e36880.
Religious believers intuitively conceptualize deities as intentional agents with mental states who anticipate and respond to human beliefs, desires and concerns. It follows that mentalizing deficits, associated with the autistic spectrum and also commonly found in men more than in women, may undermine this intuitive support and reduce belief in a personal God. Autistic adolescents expressed less belief in God than did matched neuro-typical controls (Study 1). In a Canadian student sample (Study 2), and two American national samples that controlled for demographic characteristics and other correlates of autism and religiosity (Study 3 and 4), the autism spectrum predicted reduced belief in God, and mentalizing mediated this relationship. Systemizing (Studies 2 and 3) and two personality dimensions related to religious belief, Conscientiousness and Agreeableness (Study 3), failed as mediators. Mentalizing also explained the robust and well-known, but theoretically debated, gender gap in religious belief wherein men show reduced religious belief (Studies 2–4).
doi:10.1371/journal.pone.0036880
PMCID: PMC3364254  PMID: 22666332
22.  Exploring spirituality in Iranian healthy elderly people: A qualitative content analysis 
Background:
Spirituality is recognized as a personally important matter to the elderly, and there are evidences of its impact on their health. The aim of this study was to explore the concept of spirituality from the perspectives of Iranian healthy elderly individuals.
Materials and Methods:
A conventional qualitative content analysis of carried out with 21 healthy elderly people from both male and female genders were chosen using a purposive sampling method in Tehran in 2010-2011. Data collection was done through semi structured interviews. A qualitative content analysis was used to analyze the participants’ experiences and perceptions on spirituality, using a central question ‘what characterizes the spirituality in the Iranian healthy elderly people?’
Results:
The following categories emerged from the data analysis: (1) Spiritual health, with four sub categories including saying prayer as a calming factor; beneficence as a way to God; loss of psychological and spiritual support; faith as a way to happiness; (2) spiritual beliefs, with three sub categories including seeking help from God in difficulties; God's power over life and death; doing good deeds is the God's will; and (3) religious practice with three sub categories including saying prayer; reading Quran; and going to mosque, religious ceremonies and pilgrimage.
Conclusions:
In this study was found that spirituality was a fundamental element in elderly individuals’ lives that help them to adapt with daily living conditions.
PMCID: PMC3748574  PMID: 23983748
Content analysis; elderly; Iran; qualitative research; spirituality
23.  Validation and test-retest reliability of the Royal Free Interview for Spiritual and Religious Beliefs when adapted to a Greek population 
Background
The self-report version of the Royal Free Interview for Religious and Spiritual Beliefs has been confirmed as a valid and reliable scale, assessing the manner and nature in which spiritual beliefs are expressed. The aim of the present study was to evaluate the test-retest reliability and psychometric properties of the Greek version of the Royal Free Interview for Religious and Spiritual Beliefs.
Methods
A total of 209 persons (77 men and 132 women) with a mean age of 28.33 ± 9.44 years participated in the study (test group). We subsequently approached 139 participants of the test group with a mean age of 28.93 ± 9.60 years, who were asked to complete the Royal Free Questionnaire a second time two weeks later (retest group).
Results
The vast majority of participants (58.9%) reported both a religious and a spiritual belief, compared to 52 (25.1%) who told of a religious belief only. The internal consistency of the spiritual scale for the test group proved to be good, as standardized inter-item reliability / Cronbach's alpha was 0.83. Item-total correlations ranged from 0.51 to 0.73. They indicated very good levels of differentiation, thus showing that the questions were appropriate. Internal consistency of the spiritual scale for the retest group proved as good as for the test group. Standardized inter-item reliability / Cronbach's alpha was 0.84. Item-total correlations ranged from 0.52 to 0.75. The Pearson correlation coefficient for the total test-retest score of the spiritual scale was 0.754 (p < 0.001).
Conclusion
The Greek version of the Royal Free Interview for Religious and Spiritual Beliefs is reliable and thus suitable for use in Greece.
doi:10.1186/1744-859X-4-6
PMCID: PMC1088012  PMID: 15845142
24.  Theodicy and End-of-Life Care 
This article examines theodicy—the vindication of God's goodness and justice in the face of the existence of evil from the perspectives of Judaism, Christianity, and Islam. We focus on the thought processes that chaplains, social workers, and other professionals may use in their care interventions to address issues of theodicy for patients. Theodical issues may cause anxiety and distress for believers, but they can also potentially be a source of relief and release. Palliative care patients with a religious worldview often struggle with whether God cares about, or has sent, their pain. How social workers and other clinicians respond to such questions will have a great impact on how patients express themselves and use their religious beliefs to cope with their situations. For patients holding religious/spiritual perspectives, discussion of theodicy may facilitate closer relationships between patients and their caregivers and result in more compassionate and empathic care.
doi:10.1080/15524256.2013.794056
PMCID: PMC4118910  PMID: 23777234
Christianity; end of life; God; Islam; Judaism; religion; suffering; theodicy
25.  Engagement of patients in religious and spiritual practices: Confirmatory results with the SpREUK-P 1.1 questionnaire as a tool of quality of life research 
Background
Quality of life is a multidimensional construct composed of functional, physical, emotional, social and spiritual well-being. In order to examine how patients with severe diseases view the impact of spirituality and religiosity on their health and how they cope with illness, we have developed the SpREUK questionnaire. We deliberately avoided the intermingling of attitudes, convictions and practices, and thus addressed the distinct forms and frequencies of spiritual/religious practices in an additional manual, the SpREUK-P questionnaire.
Methods
The SpREUK-P was designed to differentiate spiritual, religious, existentialistic and philosophical practices. It was tested in a sample of 354 German subjects (71% women; 49.0 ± 12.5 years). Half of them were healthy controls, while among the patients cancer was diagnosed in 54%, multiple sclerosis in 22%, and other chronic diseases in 23%. Reliability and factor analysis of the inventory were performed according to the standard procedures.
Results
We confirmed the structure and consistency of the previously described 18-item SpREUK-P manual and improved the quality of the current construct by adding several new items. The new 25-item SpREUK-P 1.1 (Cronbach's alpha = 0.8517) has the following scales: (1) conventional religious practice (CRP), (2) existentialistic practice (ExP), (3) unconventional spiritual practice (USP), (4) nature/environment-oriented practice (NoP), and (5) humanistic practice (HuP). Among the tested individuals, the highest engagement scores were found for HuP and NoP, while the lowest were found for the USP. Women had significantly higher scores for ExP than male patients. With respect to age, the engagement in CRP increases with increasing age, while the engagement in a HuP decreased. Individuals with a Christian orientation and with a religious and spiritual attitude had the highest engagement scores for CRP, while the engagement in an USP was high with respect to a spiritual attitude. Variance analyses confirmed that the SpR attitude and religious affiliation are the main relevant covariates for CRP and ExP, while for the USP the SpR attitude and the educational level are of significance, but not religious affiliation. Patients with multiple sclerosis overall had the lowest engagement scores for all five forms of SpR practice, while it is remarkable that cancer patients had lower scores for HuP and USP than healthy subjects.
Conclusion
The current re-evaluation of the SpREUK-P questionnaire (Version 1.1) indicates that it is a reliable, valid measure of five distinct forms of spiritual, religious and philosophical practice that may be especially useful for assessing the role of spirituality and religiosity in health related research. An advantage of our instruments is the clear-cut differentiation between convictions and attitudes on the one hand, and the expression of these attitudes in a concrete engagement on the other hand.
doi:10.1186/1477-7525-3-53
PMCID: PMC1253527  PMID: 16144546
Questionnaires; Religion and Medicine; Spirituality and Religion; religious practices; coping; chronic disease, cancer; multiple sclerosis

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