UNDERSTANDING THE RELATIONSHIP BETWEEN SPIRITUAL STRUGGLES AND PHYSICAL HEALTH: A PHYSIOLOGICAL STUDY
Kavita M. Desai
A Dissertation
Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of
DOCTOR OF PHILOSOPHY
August 2009
Committee:
Kenneth I. Pargament, Advisor
C. Carney Strange Graduate Faculty Representative
Anne Gordon
Annette Mahoney
William O'Brien
ii
ABSTRACT
Kenneth Pargament, Advisor
Psychological research has demonstrated links between religion and physical health and well-being. Although religion is generally beneficial for individuals, spiritual struggles can be detrimental for physical health. Studies have linked spiritual struggles with poor physical health, such as declines in somatic recovery (Fitchett, Rybarczyk, DeMarco, and Nicholas, 1999) and increased risk of mortality (Pargament, Koenig, Tarakeshwar, & Hahn, 2001). Given that spiritual struggles have been tied to harmful health consequences, it is important to understand the biological mechanisms underlying this relationship. Research has demonstrated that life stress causes cardiovascular reactivity, which in turn, is related to cardiovascular problems. The present study explored whether the same mechanism holds true for spiritual struggles and health problems; specifically, whether spiritual struggles were associated with increased cardiovascular reactivity. In addition, the study investigated whether the experiences of spiritual and life struggles were associated with different levels of cardiovascular distress.
Undergraduate students experiencing both spiritual and life struggles were identified.
Using a counter-balanced experimental design, participants (n = 80) were prompted to talk about neutral topics, spiritual struggles, and life struggles. Cardiovascular distress, heart rate and blood pressure, were monitored continuously during the study while mood and subjective distress were assessed after each condition. The results partially supported the hypotheses, though significant order effects made it difficult to interpret the differences between spiritual struggles and life struggles. Nevertheless, the results suggest that spiritual struggles were related to increased cardiovascular reactivity, particularly blood pressure, when compared to baseline functioning.
Implications for future studies and limitations of this study are discussed. iii
To my parents, Harsha and Mahesh, and my sister, Armisha, who provided me with love and motivation, sprinkled with critical questions, to ensure that I found a meaningful career path iv
ACKNOWLEDGMENTS
First, I would like to express my deepest gratitude to my advisor, Dr. Kenneth Pargament, for your guidance and support during my years as a graduate student. Prior to starting graduate school, I did not truly understand the research process or the skills required to successfully complete research projects. The atmosphere of independence, coupled with your limitless patience, fostered my skills as a researcher. I am truly fortunate to have been able to have you as an advisor.
I would also like to thank the members of my committee, Dr. Anne Gordon, Dr. Annette
Mahoney, and Dr. William O’Brien. Your insight and expertise about the research process has given me invaluable experience as I continue on my path towards becoming a researcher. I am thankful for your participation and support over the years. In addition, I would like to thank Dr.
Strange, my graduate college representative, for agreeing to join my dissertation committee last minute. Your flexibility in joining my committee and scheduling was much appreciated.
Lastly, I would like to give personal thanks to my family and friends who have endured and supported me along the long journey towards the completion of my dissertation, and consequently, the completion of my doctorate. First, to my family, your questions and interest about my degree progress and my research demonstrated your support, love, and investment in all the endeavors that I undertake. Your love and support have enabled me to branch off the
“traditional” path, allowing me to follow my own inspiration and dreams. To my husband, Nirav, for providing a mixture of study breaks and motivation needed to complete this project. In addition, I would like to thank the new part of my family, my in-laws, for your support over the past two years. And, to Toral, my sister-in-law, who witnessed my dissertation meeting with excitement and enthusiasm, which helped make the entire process more meaningful.
Thank you all for your support, without it, this process may never have ended! v
TABLE OF CONTENTS
Page
CHAPTER I. INTRODUCTION ...... 1
Religious Coping Theory ...... 1
Outcomes of Spiritual Struggles ...... 4
Explaining Links between Spiritual Struggles and Poorer Health ...... 9
Present Study ...... 15
CHAPTER II. METHODS ...... 18
Sample Characteristics ...... 18
Measures ...... 19
Procedure ...... 26
CHAPTER III. RESULTS ...... 30
General Analytic Plan ...... 30
Preliminary Analyses ...... 31
Main Analyses ...... 32
CHAPTER IV. DISCUSSION ...... 36
CHAPTER V. LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH ...... 41
CHAPTER VI. CONCLUSION ...... 45
REFERENCES ...... 61
APPENDIX A. SCREENING STUDY ...... 67
APPENDIX B. SPIRITUAL STRUGGLES SEMI-STRUCTURED INTERVIEW ...... 71
APPENDIX C. LIFE STRUGGLES SEMI-STRUCTURED INTERVIEW ...... 73 vi
LIST OF TABLES
Table Page
1 Summary of Laboratory Study ...... 46
2 Descriptive Information for Screening and Demographic Questionnaires ...... 47
3 Descriptive Information for Difference Scores ...... 48
4 Descriptive Information by Order, Difference Scores...... 49
5 Paired Samples T-tests Examining Differences between Spiritual Struggle First
Order and Life Struggle First Order for Demographic and Screening Questionnaire ...... 50
6 3 (Condition) x 2 (Order) Mixed Model ANOVA Examining Interaction Effects
for Condition and Order for Physiological Variables and Relevant Post-Hoc t-tests ...... 51
7 1 (Order) x 3 (Condition) Simple Main Effects ANOVAs Examining Differences
between Conditions for Participants in Spiritual Strugg les First Order and Relevant Post-Hoc
T-tests ...... 52
8 1 (Order) x 3 (Condition) Simple Main Effects ANOVAs Examining Differences
between Conditions for Participants in Life Struggles First Order and Relevant Post-Hoc
T-tests ...... 53
9 3 (Condition) x 2 (Order) x 4(Controls) Mixed Model ANCOVA Examining Interaction
Effects for Condition and Order for Physiological Variables while Controlling for Inequalities
between Orders ...... 54
10 Paired Samples T-tests Comparing Physiological Variables for Spiritual Struggles
Condition and Neutral Condition for Spiritual Struggles First Order ...... 55
11 3 (Condition) x 2 (Order) Mixed Model ANOVA Examining Interaction Effects for
Psychological Variables ...... 56 vii
12 Post-Hoc T-tests Examining Differences between Condition for SUDS, NA ...... 57
13 1(Order) x 3(Condition) Simple Main Effects ANOVAs and Subsequent Post-Hoc
Analyses Examining Differences between Conditions for Participants...... 58
14 3 (Condition) x 2 (Order) x 4 (Control) ANCOVA Examining for Interaction between Condition and Order for Psychological Variables, while controlling for Potential
Covariates ...... 59
15 Paired Samples T-tests Comparing Psychological Variables for Spiritual Struggles
Condition and Neutral Condition for Spiritual Struggles First Order ...... 60
1
CHAPTER I: INTRODUCTION
Psychological research on religion has increased within the past few decades.
In the past, religion was assessed as a simple construct, using global indices such as
frequency of prayer and church attendance. More recently, however, research has demonstrated that religion is a complex, multi-faceted construct, a construct with richness that cannot be captured by global indices. Religious coping is one of the many facets of religion. Research demonstrates that individuals often turn to religion to help them cope
with stressful life events (refer to Pargament, 1997). Although religious coping strategies
are beneficial for individuals, there are times when these strategies are accompanied with strain and tension. These forms of religious coping, namely those indicative of spiritual struggles, have mixed implications for individuals. Within the religious and psychological realms, spiritual struggles have been connected to both growth and decline outcomes. However, for physical health, spiritual struggles have consistently been tied to negative outcomes. The mechanism underlying this latter relationship has not yet been explored. The purpose of this study was to clarify the physiological mechanism relating spiritual struggles and declines in physical health.
Religious Coping Theory and Spiritual Struggles
Individuals experiencing stressful events have been found to draw on their religious orientation system, a set of personal religious beliefs and values, to help navigate through life and cope with stumbling blocks along the way (Pargament, 1997).
The religious orientation system can be viewed as a “reservoir [that individuals] draw on during hard times” (Pargament, 1997, p. 100). Generally, the religious coping methods that arise from the orienting system are effective in helping people cope with life
2 stressors. However, the reservoir is not limitless. Sometimes, the religious orientation system is overtaxed by stressful life events. When this happens, coping methods that were previously successful may become “unworkable, [leaving individuals] befuddled”
(Pargament, 1997, p. 340) and disoriented. Spiritual struggles arise at the intersection of stressors and the religious orientation system (Pargament, Murray-Swank, Magyar, &
Ano, 2005). They are signs that the religious orienting system itself is under stress.
Defined, spiritual struggles refer to expressions of conflict, question, doubt, and tension about matters of faith, God, and religious relationships that occur as an individual attempts to conserve or transform a spirituality that has been threatened or harmed
(Pargament et al., 2005). Spiritual struggles can be triggered by a variety of stressors. For example, a single unexpected event, such as the untimely loss of a loved one, may overtax the orientation system and trigger a spiritual struggle. Conversely, the stressor might be the cumulative effect of normative developmental processes and transitions, such as moving away from home and starting college.
Types of Spiritual Struggles
Three types of spiritual struggles have been articulated: interpersonal, intrapsychic, and divine (Pargament, Murray-Swank, Magyar, & Ano, 2005).
Interpersonal spiritual struggles consist of conflict, tension, and strain within religious relationships, including relationships with family, friends, or congregation members.
Arguing with family members about the interpretation of religious beliefs, such as if homosexual behavior is sinful, would be an example of an interpersonal spiritual struggle. Intrapsychic spiritual struggles reflect internal turmoil, including doubts, questions, and uncertainty, regarding religious matters. Doubting the veracity of religious
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scriptures and questioning God’s existence (for individuals who reported previously
believing in a higher power) are examples of intrapsychic struggles. Divine spiritual
struggles reflect perceived conflict between an individual and the divine. Anger at God,
turning away from God, fearing God, and beliefs that the devil caused a negative event
are all ways that the relationship between an individual and God may be strained. These
categories are theoretically-based. Research suggests that certain types of spiritual
struggles, specifically intrapsychic and divine struggles, are related, but distinct concepts
(Desai, unpublished data; Pargament, 1997). It is possible that there are other forms of
spiritual struggles; however, this study focuses on these three types of struggles.
Prevalence of Spiritual Struggles
Spiritual struggles are relatively commonplace, with most individuals
experiencing them at some point during their lifetime. For example, a survey of
undergraduate students (n = 5,472) from 39 public and private colleges and universities
found that 44% of students endorsed current distress caused by “spiritual/religious”
concerns (Johnson & Hayes, 2003). After dividing the sample into two groups, the
researchers found that 32% of students seeking services from counseling centers and 57% of those not seeking services were at least “a little bit” concerned with religious/spiritual problems. These findings suggest that roughly half of a college sample, at any given time, may experience at least “a little bit” of distress caused by religious/spiritual issues.
Another study on college students lends more support to the idea that spiritual struggles are relatively commonplace in college (Desai, 2006). In this study, 68.9% of introductory psychology students indicated that they were currently experiencing at least “a little bit”
4
of spiritual struggles. Together, these findings suggest that, at any given time, more than
half of college students are experiencing some distress related to their religiousness.
Research on specific types of spiritual struggles, such as religious doubts and anger towards God, demonstrates that specific forms of spiritual struggles are also
commonplace. For example, 78% of seniors from parochial schools reported that they
were currently experiencing religious doubt (Kooistra & Pargament, 1999). In fact, only
9% reported that they had never experienced religious doubt. Anger at God has also been
found to be a common experience: 63% of adults from a probability sample in the United
States (data from the 1988 General Social Survey) indicated sometimes experiencing
anger towards God (Exline, 2003). Moreover, one-third of men sampled from homeless
shelters reported that becoming homeless elicited negative feelings in their personal
relationship with God (Exline, 2003). These studies suggest that most Americans will
experience a spiritual struggle at least once in their lifetime.
Outcomes of Spiritual Struggles
Psychological and Religious Outcomes
Empirical evidence suggests that spiritual struggles have mixed implications for
individuals. With regard to religious and psychological functioning, spiritual struggles are
related to growth and decline outcomes. For example, Koenig, Pargament, and Nielson
(1998) studied the impact of divine struggles (measured by the Negative Religious
Coping scale; NRCOPE) on depression, quality of life, stress-related growth,
cooperation, and spiritual growth in an elderly medically ill sample. Focusing on the
subscales of the NRCOPE indicative of divine struggles (i.e., Punishing Reappraisals,
Demonic Reappraisals, Reappraisal of God’s Power, and Spiritual Discontent; refer to
5
Table 1 for descriptions of these subscales), higher levels of divine struggles were consistently tied to higher levels of depression (correlations ranged from .15 to .25, p <
.01) and lower quality of life (correlations ranged from -.10 to -.19, p < .01). Divine struggles were inconsistently tied to growth measures. Specifically, greater endorsement of Punishing God Appraisals and Demonic Reappraisals were associated with greater stress-related growth (r = .14 and .17, respectively, p < .01). In contrast, higher scores on
Reappraisals of God’s Power were related to lower reports of stress-related growth (r = -
.09, p < .05). With respect to spiritual growth, greater reports of Demonic Reappraisals were linked to increased spiritual growth (r = .20, p < .01). Greater Reappraisals of God’s
Power were associated with lower levels of spiritual growth (r = -.24, p < .01). The results of this study demonstrate that spiritual struggles are associated with psychological and spiritual growth and decline.
Similar findings were reported by Pargament, Koenig, and Perez (2000). Their study assessed elderly medical patients coping with medical illnesses and undergraduate students coping with a variety of life stressors. The researchers found that higher scores on specific subscales of NRCOPE (i.e., Demonic and Punishing Reappraisals, Spiritual
Discontent, and Reappraisals of God’s Power) were related to higher levels of stress- related growth and spiritual growth (correlations ranged from .12 to .20, p < .05).
Interestingly, these same indices were also related to higher levels of distress and poorer mental health outcomes (correlations ranged from .08 to .19, p < .01). Thus, spiritual struggles appeared to be linked not only to higher levels of psychological and spiritual growth, but also to higher levels of psychological distress.
6
This pattern of findings was also demonstrated in a study by Pargament, Smith,
Koenig, and Perez (1998). They assessed divine struggles using the NRCOPE in three samples: elderly hospital patients, church members surrounding the Oklahoma City bombing area, and undergraduate students. In the hospitalized sample, struggles were related to poorer physical health and psychological outcomes, such as increased depression and decreased quality of life (magnitude of correlations ranged from .15 to
.31, p < .01). In response to the Oklahoma City bombing, church members’ experiences of divine struggles were correlated with increased posttraumatic stress symptoms and callousness (r = .39 and .36, p < .01, respectively). For college students coping with a recent negative life event, struggles were related to higher levels of current distress and poorer physical health (r = .18 and .13, p < .01, respectively). In all three samples, divine struggles were tied to measures of growth, such as stress related growth and religious growth (correlations ranged from .10 to .38, p < .01). This study examined psychological well-being, religious outcomes, and physical health. These results suggest that spiritual struggles are tied to psychological growth and decline, religious growth, and declines in physical health.
Physical Health Outcomes
Within psychological and religious domains, then, spiritual struggles appear to have mixed implications for individuals, with links to both growth and decline. Within the physical realm, however, the findings appear to be more straightforward: spiritual struggles are associated with declines in physical health. Although fewer studies have investigated this relationship, consistent ties have been reported between spiritual struggles and declines in physical health. A study of randomly selected adults
7 demonstrates this relationship (Pargament, Magyar, Benore, & Mahoney, 2005). In this study, participants identified the most negative life event that they had experienced within the past two years and completed a battery of questionnaires assessing spiritual appraisals of the event (appraising the event as a desecration or as a sacred loss), religious coping with the event, and the outcomes of the event. This study measured spiritual struggles using the NRCOPE scale. Results demonstrated that greater endorsement of spiritual struggles was related to more negative health symptoms, such as greater reports of cold or flu symptoms, headaches, nausea, or upset stomach (r = .34, p < .01).
Additionally, negative religious coping was the main mediator between spiritual appraisals (i.e. sacred loss and desecration) and negative outcomes. The authors concluded that spiritual struggles may be one mechanism through which spiritual appraisals relate to health outcomes.
Other studies have tied spiritual struggles to specific types of physical declines, including poorer somatic functioning and increased mortality. One such study investigated patients in a medical rehabilitation center (Fitchett, Rybarczyk, DeMarco, &
Nicholas, 1999). In this study, hospitalized individuals were assessed at admission and after four months. Baseline spiritual struggles, assessed using NRCOPE, were predictive of declines in somatic autonomy, even after controlling for baseline somatic autonomy, depression, social support, and demographic variables. One specific item from the
NRCOPE indicative of divine struggles, “anger at God,” was an especially powerful predictor. This item accounted for 9% of variance, in contrast to the full scale, which accounted for 5% of variance. The researchers concluded that specific spiritual struggles, namely anger at God, compromised recovery in medical rehabilitation patients. This is
8 especially noteworthy because struggles predicted declines in recovery better than variables generally associated with physical health, including demographics, social support, and baseline physical activity level.
Another study of an elderly (55 and older) hospitalized sample demonstrated the pot ential long-term impacts of spiritual struggles on physical well-being (Pargament,
Koenig, Tarakeshwar, & Hahn, 2001). In this study, spiritual struggles at baseline were used to predict health status after 2-years. Even though spiritual struggle was not frequently endorsed at baseline, it was still a significant predictor of mortality at follow- up. Specifically, higher levels of spiritual struggles at baseline were predictive of mortality at follow-up (M = 3.1 for baseline spiritual struggles for participants that were deceased at follow-up, M = 2.3 for baseline spiritual struggles for participants that were alive at follow-up). In fact, struggles were better predictors of mortality than were other typical “long life” variables such as race, diagnosis, cognitive functioning, depressed mood, quality of life, and independence in daily activities. Moreover, the researchers identified three specific items that were more predictive of mortality: alienation from
God, feelings of not being loved by God, and attributing the illness to the devil. These items were associated with an increased risk of mortality that ranged from 19% to 28%.
This study demonstrates how powerful, and harmful, even low amounts of spiritual struggle can be for physical health.
Taken together, these studies suggest that spiritual struggles may predict changes in health status better than more traditional variables, such as baseline physical functioning and demographic variables. This suggests that spiritual struggles are an important dimension to investigate when assessing risk factors for declines in physical
9 health. Given the prevalence of spiritual struggles and the connections between spiritual struggles and physical health, it is important to understand the mechanisms underlying this relationship.
Explaining the Links between Spiritual Struggles and Poorer Health
One possible explanation for this relationship is that spiritual struggles cause cardiovascular reactivity, which may, in turn, compromise physical health. In support of this assertion, stressful life events and environmental stressors have been linked to cardiovascular reactivity. Although reactivity helps prepare the body to cope with stressors, recurrent activation has been found to compromise physical health (e.g. Lepore,
Miles, & Levy, 1997; Taylor, 2006). One theory posits that certain people have exaggerated reactivity in response to stress, which makes those individuals more susceptible to developing cardiovascular disease (Manuck & Krantz, 1998). This model focuses on individual differences in stress-reactivity. However, Christenfeld, Glynn,
Kulik, and Gerin (1998) suggest that environmental and situational factors also have the potential to elicit an exaggerated stress response for individuals. In this vein, experiencing a stressful situation, such as a spiritual struggle, could result in cardiovascular reactivity, which could overtax and strain the body’s resources, resulting in declines in physical health. One study on concealment of sexual orientation by gay men lends support to this idea (Perez-Benitez, 2002). In this study, gay men who initially reported higher levels of concealment regarding their sexual orientation and who disclosed more during the experiment demonstrated greater cardiovascular reactivity. In this study, disclosure was considered a social stressor. Extrapolating these findings suggests that specific stressors, such as discussing sexual orientation for individuals who
10 are usually secretive about this, can be associated with exaggerated cardiovascular reactivity. Whether these findings would extend to the experience of spiritual struggles is unclear. There is no direct evidence of a relationship between spiritual struggles and cardiovascular reactivity; however, indirect evidence from studies on religiousness and physical health and from literature on secular stressors provides initial support for this assertion.
Links between Religion and Physiology
Research has demonstrated connections between religion and physiology.
Seeman, Dubin, and Seeman (2003) evaluated 31 studies that found links between religion/spirituality and biological pathways. The authors examined the strength of the relationship as well as the methodology used in each study using criteria outlined by
Miller and Thoresen (2003). The authors identified several methodological limitations, such as low statistical power, poor or no control group, and inconsistent assessment of religion and spirituality, in the reviewed studies. In spite of the limitations of the studies included in the review, Seeman et al. concluded that there is initial support to suggest a link between religion/spiritually and biological pathways, including cardiovascular, immune, and endocrine systems.
Two of these studies are particularly relevant to the present study because they investigated the relationship between religion/spirituality and cardiovascular reactivity.
The first study investigated the association between frequency of participation in religious activities and cardiovascular health, measured by blood pressure, in elderly (65 and older) community members (Koenig et al., 1998). In this study, blood pressure and religious participation was assessed for 3,963 community members who were
11 participating in a larger research project with three waves of data. Participants were divided into two categories: those who frequently attended religious services, prayed, and/or studied the Bible and those who infrequently engaged in these activities. Results from cross-sectional analysis suggested that infrequent religious participation was associated with higher blood pressure. In fact, there was a 40% greater chance of having diastolic blood pressure of 90 mmHG or greater for individuals who infrequently engaged in religious activities. However, in longitudinal analyses, significant relationships between religious participation and blood pressure were not found. This study demonstrates potential links between involvement in religion and better cardiovascular health, but the strength of these conclusions is limited by the failure to find significant results in the longitudinal analyses.
Another study investigated the differences in cardiovascular health between secular and religious Italian females over 30 years of age (Timio, et al., 1997). In this study, a group of female community members (n = 138) and a group of nuns (n = 144) were identified. The two groups had no significant differences at baseline for age, blood pressure, body mass index, race, ethnic background, or family history of hypertension.
Over time, significant differences emerged in blood pressure and in the number of fatal and non-fatal cardiovascular events between the two groups. Specifically, blood pressure for the secular group was significantly higher over time than for the nuns. Additionally, the secular group experienced more fatal and non-fatal cardiovascular events than did the nuns (21 versus 10 fatal and 48 versus 21 non-fatal, for community members and nuns respectively). This study demonstrates the potential longitudinal impacts of religious involvement on cardiovascular health. The results are noteworthy because there were no
12 significant differences between community members and nuns at baseline on certain risk factors for cardiovascular disease. It is possible that the difference in cardiovascular health between the two groups of women reflected differences between religious and secular lifestyles.
In addition to these studies, a recent meta-analysis investigated the relationship between religious involvement and all-cause mortality (McCullough, Hoyt, Larson,
Koenig, & Thoresen, 2000). The authors reviewed 29 studies that examined these two variables and found that greater religious involvement was related to a 29% lower risk of mortality. Some of the studies included in the meta-analysis controlled for the effects of other variables associated with decreased risk of mortality, including health status, health behaviors, social support, and demographic variables. When effect sizes were calculated only for the studies that controlled for other important covariates, the results were smaller, but still significant. Based on these findings, the authors suggested that there is enough evidence to demonstrate a relationship between religious involvement and mortality. They recommended that future research focus on identifying the potential mechanisms underlying this relationship.
These studies provide support for a relationship between religion and spirituality and cardiovascular health. However, these studies focus on the positive aspects of religion, particularly involvement in religious activities and following a religious way of life. It is important to investigate whether other, potentially more problematic aspects of religiousness, specifically spiritual struggles, are associated with compromised cardiovascular health. Researchers studying religion and spirituality have suggested that future studies utilize psychophysiological methods to investigate the relationship between
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religion and health more thoroughly (e.g. Moss, 2002; Pargament, Magyar, Benore, &
Mahoney, 2005). Moreover, a recent article proposed specific biological pathways that
could account for links between religion and health, including specific cardiovascular
pathways (Seybold, 2007). Seybold indicated that empirically testing these pathways was
an important next step.
Links between Stressful Life Events and Cardiovascular Reactivity
The adverse impact that stress has on physical health has been documented
(Tosevski & Milovancevic, 2006). Researchers have suggested that psychophysiological mechanisms, specifically cardiovascular reactivity, underlies the relationship between stress and adverse health (refer to Lovallo & Gerin, 2003 for detail about proposed physiological mechanisms; McEwen, 1998). A recent review found evidence supporting
the notion that higher levels of cardiovascular reactivity is related to risk factors for
cardiovascular disease (Treiber et al., 2003). Evidence from three large-scale epidemiological studies (with follow-ups longer than 20 years) found that greater cardiovascular reactivity is predictive of hypertension, a known risk factor for cardiovascular disease. Although results were mixed in studies with shorter follow-ups,
Treiber and colleagues argue that there is “reasonable evidence” suggesting that cardiovascular reactivity is predictive of preclinical cardiovascular disease.
Several laboratory studies have demonstrated that exposure to stressful life events
is related to increased cardiovascular reactivity. One study investigated cardiovascular
reactivity (assessed by heart rate) in two groups of female war veterans, those with and
without a diagnosis of Posttraumatic Stress Disorder (PTSD; Forneris, Butterfield, &
Bosworth, 2004). In their study, the authors found that veterans with PTSD had an
14 elevated mean heart rate level in comparison to veterans not diagnosed with PTSD
(F(1,91) = 4.87, p = .03). These results suggest that stressful events, stressful enough to result in Posttraumatic Stress Disorder, are associated with greater cardiovascular reactivity.
Another study demonstrated the relationship between stressful life experiences
(physical assault and car accidents) and cardiovascular reactivity (assessed by heart rate and skin conductance; Nixon, Byrant, Moulds, Felmingham, & Mastrodomencio, 2005).
In this study, heart rate and skin conductance were assessed during baseline, trauma exposure, and recovery periods. During the trauma exposure, individuals were instructed to describe their trauma experience in present tense. The researchers found that heart rate and skin conductance significantly changed between baseline and trauma exposure, indicating that trauma exposure was associated with greater cardiovascular reactivity.
Additionally, there was a significant difference between the recovery phase and baseline, demonstrating that participants remained objectively distressed, even after a 5-minute recovery period. This suggests that cardiovascular reactivity associated with trauma experiences is related to increased periods of physiological arousal.
As mentioned above, spiritual struggles may be triggered by stressful life events.
It is possible that stressful events are related to declines in physical health because they elicit struggles, both secular and spiritual in nature. Overtime, struggles may result in deteriorations in physical health because of recurrent cardiovascular reactivity. Spiritual struggles may be even more problematic for physical health because of the element of the sacred. Struggling with the sacred, which for religious individuals is considered to be
15
“the core of life” (Pargament et al. 2005, p. 688), may have different impacts on
individuals than secular struggles.
Preliminary evidence supports the assertion that spiritual struggles are related to
increased cardiovascular reactivity (Desai, unpublished data). In a pilot study, the
relationship between cardiovascular reactivity (heart rate and blood pressure) and current
spiritual struggles was assessed. For this study, cardiovascular reactivity was assessed
across four phases: baseline, talking about neutral topics, spiritual struggle reflection, and
talking about spiritual struggles. Results indicated that talking about spiritual struggles
caused significant increases in heart rate and blood pressure compared to baseline and
spiritual struggle reflection. These data provide preliminary evidence suggesting that
spiritual struggles are related to increased cardiovascular reactivity. However, the study
had several methodological limitations, including small sample size and no secular
struggle comparison; therefore, results should be interpreted cautiously.
Present Study
Previous research has identified a relationship between spiritual struggles and
declines in physical health; however, the mechanism underlying this relationship is unknown. Research has demonstrated that stressful life events are associated with increased cardiovascular reactivity, which in turn is related to declines in physical health.
Although the relationship between spiritual struggles and cardiovascular reactivity has not been formally evaluated, a pilot study provided some evidence of this relationship
(Desai, unpublished data).
The primary purpose of this study was to determine whether spiritual struggles
were associated with higher levels of cardiovascular reactivity and psychological distress.
16
The study investigated this question by comparing changes in cardiovascular reactivity
and psychological distress associated with talking about spiritual strugg les with those associated with talking about neutral events and life struggles. Drawing from the pilot study, it was hypothesized that spiritual struggles would be related to greater cardiovascular reactivity and psychological distress than neutral events. Previous research has not investigated the differences between spiritual struggles and life struggles.
However, it was hypothesized that talking about spiritual struggles would be tied to greater cardiovascular reactivity and psychological distress than talking about life struggles because spiritual struggles reflect tension within an individual’s core belief
system, while life struggles may reflect tension within an individual’s day to day life
experiences.
In addition, exploratory analyses controlling for two spiritual strugg le
characteristics, spiritual struggle severity and previous disclosure of spiritual struggles,
were conducted. These were only used when comparing spiritual struggles with neutral
events to better understand the relationship between spiritual struggles, cardiovascular
reactivity, and subjective distress. It was hypothesized that talking about spiritual
struggles would be tied to significant changes in cardiovascular reactivity and mood,
compared to talking about neutral events, even after controlling for these two
characteristics.
The sample was comprised of students from a secular university. A college
student sample is appropriate for this study because, for most students, college is a time
of flux in terms of religious and spiritual beliefs. This flux can be attributed to numerous
reasons, including distance from family and friends and interactions with non-religious
17 peers (Bryant, Choi, and Yasuno, 2003). Moreover, spiritual struggles are relatively common in this sample (e.g. Desai, 2005; Johnson & Hayes, 2002).
College students experiencing both spiritual and life struggles were identified using a screening questionnaire. Eligible participants completed the laboratory study in which they were required to talk about three different topics: neutral events, life struggles, and spiritual struggles. Cardiovascular reactivity (i.e. changes in heart rate, blood pressure, and mean arterial pressure) and psychological distress (i.e. changes in mood and subjective distress) were assessed multiple times during the study.
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CHAPTER II: METHODS
Sample Characteristics
The sample (n = 80)1 consisted of undergraduate students from a Midwestern university who participated in the study to receive extra credit for psychology classes.
The majority of participants were Caucasian (91%, n = 72) and female (54%, n = 54), with an average age of 20 years (ranging from 18 – 48). The sample reported being moderately religious (M = 2.2 on a 4-point Likert scale) and moderately spiritual (M =
2.54 on a 4-point Likert scale). With respect to religious affiliation, the majority of the sample identified as Christian or Catholic (74.7%, n = 59).
With respect to spiritual struggles, participants endorsed between a little bit and moderate degree of spiritual struggles (intrapersonal struggles: M = 2.33, divine struggles: M = 2.11, and interpersonal struggles: M = 2.03 on scale ranging from 1 to 5).
Participants responded to distinct items assessing each type of spiritual struggle.
Intrapersonal spiritual struggles were most frequently endorsed (75% of sample, n = 60), followed by divine spiritual struggles (67.5%, n = 54), and then interpersonal spiritual struggles (62.5%, n = 50). Participants’ rated their spiritual struggles as moderately distressing (M = 31.0, on scale ranging from 0-45). In addition, 56% (n = 45) of participants had previously talked to someone else about their spiritual strugg les.
The most frequently endorsed life struggles were academic problems (75%, n =
60), adjusting to college (67.5%, n = 54), and difficulties with a friend or roommate
(58.75%, n = 47). On average, participants indicated experiencing significant distress related to their life struggles (M = 37.3, on scale ranging from 0 – 45). More than three-
1 Demographic data, including gender, religiosity, spirituality, are only available for 79 individuals; Age is only available for 77 individuals
19 fourths of the sample indicated previously talking about their life struggles with others
(76.5%, n = 61).
Measures
Screening Questionnaire2
A screening questionnaire was used to identify individuals eligible for the laboratory study. Eligibility was determined by participants’ reports of current and distinct spiritual struggles and life struggles. In addition, the screening survey generated stimulus materials for the laboratory study and assessed specific struggle characteristics.
The screening survey was web-based and took approximately one hour to complete. Individuals earned research credit for completing the screening survey. Six- hundred and three participants completed the screening survey. Of these, 32.5% (n = 196) of participants were ineligible. These individuals were ineligible because of missing data
(n = 34), not experiencing a spiritual struggle (n = 103); not experiencing a life struggle
(n = 7); and spiritual and life struggles that were related (n = 47). Fourteen percent (n =
84) were qualified, but uninterested in participating in the laboratory portion of the study.
The remainder of the screening sample (n = 323) were eligible and indicated initial interest in participating in study. A quarter of participants who were qualified and interested actually participated in the study (n = 80). Although the attrition from the on- line study to the lab study was high, there were no significant differences in spiritual struggle severity or life struggle severity between the participants who were qualified and completed the laboratory study and those who were qualified but did not complete the laboratory study. The low response rate may be attributed to a variety of factors, such as
2 Refer to Appendix A for the screening questionnaire.
20 difficulty with scheduling time for laboratory study and no longer needing the extra- credit offered as incentive for participating in this study.
Identification of current spiritual struggles. Individuals experiencing current spiritual struggles were identified by their responses to single items assessing for intrapersonal, divine, and interpersonal spiritual struggles. Intrapersonal spiritual struggles were assessed using the following question: “Currently, to what extent are you experiencing personal conflict regarding your religious or spiritual beliefs, doubts about religion or spirituality, or questions about God.” To assess for divine spiritual struggles, participants were asked, “Currently, to what extent are you experiencing any tension in your relationship with God, such as feelings of confusion, anxiety, loneliness, frustration, anger, abandonment, or guilt.” Lastly, interpersonal spiritual strugg les were assessed by asking, “Currently, to what extent are you experiencing conflict, strain, or alienation in your relationships with friends, family, church members, and/or your religious community because of religious or spiritual issues.” Individuals rated how much they experienced each type of spiritual struggle using a 5 point scale, ranging from 1, not at all, to 5, extremely. Individuals who endorsed a 2 (a little bit) or more in response to any of the three questions were classified as having a current spiritual struggle and were subsequently asked to write a brief description of their struggle. These written descriptions were used as stimulus material for the laboratory study.
A modified version of the Negative Religious Coping scale (NRCOPE) scale was used to substantiate the responses to the single items (Pargament, Koenig, & Perez,
2000). The modified scale included two items from the Spiritual Discontent subscale, four items from the Punishing God Appraisals subscale, and seventeen additional items
21 were added to assess for spiritual struggles more thoroughly. When used in the pilot study, this scale demonstrated good reliability (Cronbach’s α = .83; Desai, unpublished data) and was able to differentiate strugglers from nonstrugglers. In the current study, this scale demonstrated adequate reliability (Cronbach’s α =.92). Moreover, the modified
NRCOPE differentiated between strugglers from nonstrugglers as identified using the single items (t(564) = 5.32; p < .01).
Identification of current life struggles. To assess for current life struggles, participants rated the degree to which they were currently struggling with a list of events commonly perceived as stressful by college students. The list reflects the most frequently endorsed stressors that were experienced across two samples of college students (Park,
Cohen, & Murch, 1996; Tedeschi & Calhoun, 1996). These include adjusting to college, academic difficulties, problems with romantic relationships, difficulties with a friend or roommate, victim to criminal activity, personal injury, divorce, pregnancy, and death of a loved one. The list is not exhaustive; therefore, participants had the option of listing two other secular events with which they were struggling. In the current study, only 25 participants (31%) wrote in additional life struggles.
Participants rated the amount they struggled with each event on a 5-point scale, ranging from 1, not at all, to 5, extremely. Participants also indicated if the life and spiritual struggles were related by answering “yes” or “no” to the following question “is this causing religious/spiritual tension or strain”. Events that were not related to spiritual struggles (response of “no”) that participants were struggling with at least a little bit
(response of 2) were identified as life struggles. From the screening sample, only 9% (n =
47) of interested participants from the screening sample were ineligible for the laboratory
22 study because their life struggle was related to their spiritual struggle. Participants who endorsed a life struggle that was not related to their spiritual struggle provided a brief description of their life strugg les.
Struggle Characteristics. The screening questionnaire also assessed two specific struggle characteristics that may influence the relationship between spiritual struggles and distress: spiritual struggle severity and prior disclosure of spiritual struggles. For descriptive information about the sample, these two variables were also assessed with respect to life struggles (i.e. life struggle severity and previous disclosure of life struggles). The Impact of Event Severity (IES) scale (Howorwitz, Wilner, & Alvarez,
1979) was used to assess the severity of spiritual struggles and life struggles. Participants completed the IES twice, once with respect to their spiritual struggles and once with respect to their life struggles. The directions for this scale were slightly modified for this study. Specifically, the questions referred to the type of struggle (i.e. spiritual strugg le or life struggle), instead of leaving the negative event vague, as in the original scale. For instance, an original item from the IES reads, “I thought about it when I didn’t mean to.”
In the current study, the word “it” was replaced with either “my spiritual struggle” or “my life struggle”. The instructions were modified to help participants differentiate between the two versions of the IES. Participants were asked to rate the frequency that they experienced the 15 items using a 4-point scale, ranging from 1, not at all, to 4, often.
The IES has 15 items that are divided into two subscales, the Intrusion subscale
(seven items) and the Avoidance subscale (eight items). This scale has demonstrated good psychometric properties. Specifically, the internal consistency coefficients for the
Intrusion and the Avoidance subscales are α = .79 and α = 0.82, respectively
23
(Howorwitz, Wilner, & Alvarez, 1979). For this study, the composite of these subscales
was used as a general indicator of struggle severity. Although the authors did not report on the reliability of the total scale, it has demonstrated good reliability (α = .88) in another study (Desai, 2006). In the current study, the IES demonstrated good reliability for both spiritual struggles (α = .90) and life struggles (α = .91).
Prior disclosure of spiritual struggles was another struggle characteristic
investigated. Research suggests that concealment of traumatic or personal events causes greater stress and adversely impacts health (Pennebaker & Beal, 1986; Pennebaker,
Hughes, & O’Heeron, 1987). Therefore, it is possible that previous disclosure of struggles may affect cardiovascular reactivity and psychological distress. To assess this
possibility, participants indicated whether they had or had not previously talked about
their spiritual struggles. This question was also posed with respect to life struggles (i.e.
whether participants had previously talked about their life struggles).
Laboratory Study
Demographic Information. To provide descriptive information about the sample,
participants completed a survey assessing demographic information. Participants
completed this questionnaire at the conclusion of the laboratory study.
Assessment of Cardiovascular Reactivity. Four indicators of cardiovascular
reactivity, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR),
and mean arterial pressure (MAP), were used. These measurements have been used in
other studies to assess cardiovascular reactivity in response to psychological stressors
(e.g. Forneris, Butterfield, & Bosworth, 2004; Nixon, Byrant, Moulds, Felmingham, &
Mastrodomencio, 2005).
24
To assess cardiovascular reactivity, a blood pressure cuff was positioned on the medial surface of the nondominant arm over the brachial artery. Inflation rates and deflation rates were automatically adjusted by the electronic blood pressure cuff. Systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate were recorded every minute for the duration of the experiment. To determine baseline cardiovascular reactivity, participants were instructed to “sit and relax” in the lab for 10 minutes. The first three recordings (i.e. data from the first three minutes) were discarded and the remaining recordings were averaged. From the subsequent phases of the lab study, peak ratings were identified and used in analyses. Even when exposed to prolonged stressors, physiological ratings naturally decline over time; therefore, peak ratings are preferable because they capture the magnitude of cardiovascular reactivity that was caused by each condition.
Assessment of Psychological Distress. Psychological distress was assessed using changes in subjective distress and mood. Subjective distress was obtained using subjective units of distress (SUDs) ratings (Wolpe, 1988). SUDS ratings have been used to assess subjective distress across a variety of populations, including people in treatment for clinical disorders and participants in laboratory studies (e.g. Exline, Smyth, Gregory,
Hockemeyer, & Tulloch, 2005; Rauch, Foa, Furr, & Filip, 2004). SUDs ratings are ideal for this experiment because they directly assess participants’ internal experience of distress, are sensitive to changes in distress levels caused by external situations, and can be administered repeatedly within a short time period.
Participants were asked to indicate their SUDs level immediately after each condition. Typically when using SUDs ratings, participants are asked to indicate their
25 current distress level from 0, completely at ease and comfortable, to 100, extremely distressed. This question was modified slightly for this study by asking participants to rate the highest level of distress they felt during the condition. The directions were modified to assess the extent of distress that was experienced during, not after, the condition.
Participants also rated their current affective state using the Positive and Negative
Affective Scale (PANAS; Watson, Clark, & Tellegen, 1988). The PANAS is a 20-item scale which is subdivided into two subscales: the PA, assessing positive affect, and the
NA, assessing negative affect. Depending on the instructions, the PANAS can be used to assess dispositional or situational affect. For this study, the PANAS assessed situational affect using a 5-point scale, ranging from 1, very slightly or not at all, to 5, extremely.
Similar to the SUDs ratings, the instructions for the PANAS were modified to assess for participants’ affect during, instead of after, each condition. Specifically, instead of asking participants to rate their affect “right now, that is, at this present moment,” participants were asked to indicate their affect “during the most intense moment of the past conversation.”
This scale has been used extensively in the literature and has been found to have good psychometric properties. In the development and validation of the PANAS, both subscales demonstrated good internal consistencies (α = .89 for Positive Affect; α = .85 for Negative Affect). Moreover, the authors found that the PANAS is sensitive to changes in affect when using the “right now” directions, which is particularly relevant for this study since participants were asked to rate their affect four times, once after each
26 phase. For the current study, this scale demonstrated adequate reliability (α ranging from
.64 for baseline Negative Affect to .90 for life struggles Positive Affect).
Procedure
Participants earned research credit in psychology classes for participation in the laboratory study. A two-hour appointment was scheduled for each eligible participant one to two weeks after completion of the web-based screening study. At the beginning of the appointment, the experimenter gave the participant a brief tour of the laboratory, explained the equipment that would be used in the study, and reviewed the informed consent. Then, the participant was instructed to sit in a comfortable chair while the blood pressure cuff was connected to his or her nondominant arm. After the blood pressure cuff was connected, the participant was given a packet that included the stimulus materials and questionnaires needed for the study.
This study utilized a 4 (condition) x 2 (order) mixed design. Each individual participated in the four conditions: baseline, neutral, spiritual struggle, and life struggle
(Table 1 for a summary of the conditions). For all participants, baseline and neutral conditions occurred first and second, respectively. The order of the spiritual struggle and life struggle conditions were counterbalanced, with participants randomly assigned to each order. Therefore, there were two orders: spiritual struggles first (spiritual struggles, then life struggles) and life struggles first (life struggles, then spiritual struggles).
Set-up for Laboratory Study
The laboratory study was conducted in a psychophysiology laboratory in the psychology department. Participants were seated in a reclining chair in a room with the physiological assessment equipment, a microphone, and a video camera. After
27 connecting the blood pressure cuff, the participant was left alone in the room. The experimenter conducted the study from the adjacent room, communicating with the participant via microphones. Additionally, the experimenter monitored participants’ affect using a closed-circuit television.
Baseline Condition
Participants completed a 10-minute baseline condition. During this condition, participants were asked to “rest and relax.” Physiological ratings were assessed every minute. The data from the first three minutes of this condition were discarded to allow participants to habituate to the lab environment. Data from the remaining seven minutes were averaged to obtain baseline physiological functioning.
Neutral Condition
During this condition, participants talked about neutral events for a minimum of five minutes. At the beginning of this condition, the experimenter prompted participants
“to bring to mind” what they were doing prior to the appointment and how they walked to the appointment in “as much detail as possible.” They were instructed to “describe, in detail” these activities after they had them clearly in their mind. The experimenter then prompted participants to elaborate on these topics. If participants could not describe these activities for five minutes, they were then asked to describe their activities for the remainder of the day, the next day, and/or to describe the layout of their room.
Struggle Conditions
For both the spiritual struggle and the life struggle conditions, participants were asked to talk about their struggles (i.e. spiritual struggles and life struggles) for a minimum of 10 minutes, while the interviewer prompted them using a semi-structured
28 interview (appendix B for spiritual strugg les; C for life struggles). Participants were randomly assigned to talk about either spiritual struggles first (SS1st) or life struggles first (LS1st). During these conditions, participants were first asked to reflect on their struggles by reading the descriptions they wrote during the screening questionnaire, which was included in the experiment packet. The experimenter prompted the participant
“to try to remember and re-experience” their struggles. Then, using semi-structured interviews, the experimenter prompted the participants to talk about their struggles for a minimum of 10 minutes.
The semi-structured interviews for spiritual struggles and life struggles were equivalent when possible. For example, the experimenter prompted participants to discuss intrapersonal spiritual struggles by asking, “Explain any conflict or tension you are experiencing about your personal religious beliefs.” To assess for similar struggles within the secular realm, the experimenter asked, “Explain any conflict or tension you are experiencing because of your life struggles.” Since there is no parallel dimension for divine struggles within the secular realm, this construct was assessed only in the spiritual struggles condition.
The semi-structured interview served as a guideline for the experimenter and was tailored to capture participants’ experiences. The experimenter used the descriptions of each participant’s distinctive struggles he/she had written on the screening questionnaire.
For example, if a participant wrote about a divine struggle with “a higher power,” the experimenter substituted “a higher power” for the word “God.” This protocol was successful and all participants were able to talk about struggles for at least 10 minutes.
29
After each of the four conditions, participants were asked to rate their psychological distress (i.e. SUDs, PA, NA). In addition, each talking condition was followed by a 5-minute rest period. During the rest period, participants were instructed to
“relax and try to clear your mind.” At the end of the study, participants completed the demographic questionnaire.
30
CHAPTER III: RESULTS
General Analytic Plan
First, difference scores were calculated for each dependent variable (SBP, DBP,
HR, MAP, SUDs, PA, and NA). Specifically, the mean values for the baseline condition were subtracted from the values for the other conditions (i.e. neutral condition, spiritual struggle talk, and life struggle talk). Therefore, three difference scores were calculated for each dependent variable: one comparing the spiritual struggl e condition to baseline; one comparing the life struggle condition to baseline; and one comparing the neutral condition to baseline. Difference scores were used in subsequent analyses. These scores are more meaningful than raw scores because they represent the total magnitude of change in a dependent variable with respect to baseline.
Means, standard deviations, actual and potential ranges, and reliability information were calculated, as appropriate, for the screening and demographic questionnaires and the laboratory study. Then, paired samples t-tests were conducted for the two orders (i.e. spiritual struggles first and life struggles first) to identify whether the two orders were different with respect to demographic information and struggle characteristics.
Separate 3 (condition) x 2 (order) mixed-model ANOVAs were conducted for each dependent variable, including: SBP, DBP, HR, MAP, PA, NA, and SUDs.
ANCOVA analyses were ran as needed to control for variables that were unequal between the two orders. Post-hoc tests, including paired samples t-tests and simple main effect ANOVAs, were conducted when appropriate.
31
Lastly, exploratory analyses were conducted to determine whether spiritual
struggle severity and prior disclosure of spiritual struggles impacted the relationship
between spiritual struggles, cardiovascular reactivity, and psychological distress.
Specifically, 2-way within subjects ANCOVAs comparing spiritual struggles and the
neutral condition were conducted for each dependent variable, while controlling for
spiritual struggle severity and previous disclosure of spiritual struggles. These analyses
were only conducted only for SS1st.
Preliminary Analyses
First, descriptive information and frequencies were calculated for the screening and demographic questionnaires (refer to Table 2) and variables assessed during the laboratory study (refer to Table 3 for aggregate results and Table 4 for results by order).
Then, paired samples t-tests were conducted to determine the difference between the two orders. Specifically, t-tests were used to examine differences between participants in the spiritual struggles first order (SS1st) and life struggles first order (LS1st) for demographic variables, endorsement of spiritual strugg les, and struggle characteristics
(i.e. struggle severity and previous disclosure; refer to Table 5). The two groups differed
on four variables: age, frequency of religious service attendance, religiousness, and
frequency of life struggle disclosure. Specifically, participants in SS1st were significantly
older (t(75) = 2.24, p < .05) and attended religious services more frequently (t(77) = 2.12,
p < .05) than participants in LS1st. Participants in LS1st were higher on self-rated
religiousness (t(77) = -2.10, p < .05) and had a higher frequency of disclosing their life
struggles (t(78) = -2.42, p < .02) than those in SS1st. These four variables were used in a
subset of analyses to control for inequalities between the SS1st and LS1st groups.
32
Main Analyses
Physiological Variables
The primary purpose of this study was to determine whether spiritual struggles
were related to significant elevations in cardiovascular reactivity when compared to
neutral, and life struggles. To evaluate this, separate 3 (condition) x 2 (order) mixed
model ANOVAs were conducted to determine whether there were any significant
interaction or condition effects, in the absence of control variables (refer to Table 6).
Diastolic blood pressure was the only physiological variable that had a significant main
effect for condition (F(2, 156) = 9.54; p < .01). Therefore, paired samples t-tests were
conducted to determine which conditions were significantly different from each other
(refer to Table 6). These results indicated that both spiritual struggles and life struggles
were tied to greater elevations in DBP than the neutral condition (t(79) = -4.50; p < .01;
t(79) = -2.86, p < .01; respectively). There was not a significant difference in DBP
between spiritual struggle and life struggle conditions.
There were significant interaction effects (condition x order) for the remaining
physiological variables. Specifically, there were significant interaction effects for SBP
(F(2, 156) = 6.58; p < .01), HR (F(2, 156) = 3.84; p < .01), and MAP (F(2, 156) = 3.56; p
< .05). Therefore, simple main effects ANOVAs for each order were conducted for these
variables to better understand the interaction effects. For SS1st, only SBP was significant:
F(2, 78) = 6.93, p < .01 (refer to Table 7 for these results). Follow-up paired-samples t- tests indicated that SBP was greater during the spiritual struggles condition when compared to neutral and to life struggles (refer to Table 7). For LS1st, SBP, HR, and
MAP were significant: F(2, 78) = 3.17, p < .05; F(2, 78) = 3.68, p < .05; and F(2, 78) =
33
4.27, p < .05, respectively (refer to Table 8). Post-hoc analyses for LS1st revealed that
SBP and MAP were significantly higher during the life struggles condition compared to the neutral condition (refer to Table 8). Surprisingly, heart rate was significantly greater for the neutral condition compared to the spiritual struggles condition.
Then, to control for inequalities between the two orders (i.e. SS1st and LS1st), separate 3 (condition) x 2 (order) x 4 (control) mixed model ANCOVAs were run for each physiological variable (refer to Table 9). In these analyses, condition (i.e. neutral,
SS, and LS) was the within subjects variable, while order (i.e. SS1st; LS1st) and controls
(age, religiousness, frequency of religious service attendance, and prior disclosure of LS) were the between subject variables. For these analyses, there were no significant main effects for condition for DBP. Therefore, the main effects found above for DBP could be a result of inequalities between the two orders. There were significant interaction effects
(condition x order) for SBP (F(2, 142) = 4.02, p < .05) and MAP (F(2, 142) = 3.12, p <
.05). Therefore, the order effects found above are not associated with inequalities in age, religiousness, frequency of religious service, and previous disclosure of LS between
SS1st and LS1st groups.
Due to significant interaction effects between order x condition, analyses were conducted only for SS1st to assess differences between spiritual struggles and neutral events. Paired samples t-tests were conducted for participants in SS1st between the neutral and spiritual struggles conditions. During the spiritual strugg les condition, participants exhibited significantly greater SBP and DBP than during the neutral condition (t(39) = -2.34, p < .05; t(39) = -3.02, p < .01, respectively). Results for MAP and HR were not significant (refer to Table 10 for these results).
34
Lastly, exploratory 2-way [neutral, spiritual struggles] within subjects ANCOVAs were run to control for spiritual struggle severity and previous disclosure of spiritual struggles for SBP and DBP, the physiological variables that were significantly different from neutral as noted above. These analyses were only conducted for SS1st and only
compared the spiritual struggl es condition with the neutral condition, making it a within
subjects analysis. Since there were significant interaction effects between the two orders,
only SS1st was used for these analyses. There were no significant differences between
the spiritual strugg les and neutral condition on the physiological variables when
controlling for spiritual struggle severity and previous disclosure of spiritual struggles.
Psychological Variables
Separate 3 (condition) x 2 (order) mixed model ANOVAs were conducted for
each psychological variable (Table 11). Significant main effects for condition were found
for SUDs and NA (F(2, 152) = 16.79, p < .01; NA, F(2, 156) = 35.06, p < .01,
respectively). Therefore, planned post-hoc analyses were conducted to determine which
conditions were significantly different. In each of these analyses, spiritual struggles and
life struggles showed increased SUDS and NA than the neutral condition (refer to Table
12). In addition, life struggles was tied to greater negative affect than spiritual struggles.
Significant interaction effects between variable and order were found for PA;
therefore simple main effects ANOVAs were calculated separately for each order (refer
to Table 13). These analyses were significant for both orders (for SS1st F(2,78) = 6.68, p
< .01; for LS1st F(2, 78) = 12.16, p < .01). Post-hoc analyses for SS1st revealed that the
life struggles condition was associated with significantly less positive affect when
compared to both neutral and spiritual struggles conditions. For LS1st, post-hoc analyses
35
found that both life struggles and spiritual struggles conditions were associated with less
positive affect than neutral. There were no significant differences between the life
struggles and spiritual struggles conditions for LS1st.
Next, 3 (condition) x 2 (order) x 4 (control) mixed model ANCOVAs were conducted to control for inequalities between the two order conditions. There were no
significant main effects or interactions in these analyses (Table 14). Therefore, the
significant results found for subjective distress variables could be a result of inequalities
between the two orders.
Like with the cardiovascular reactivity variables, significant interaction effects
between order x condition necessitated that analyses be conducted only for SS1st,
comparing the spiritual struggles and neutral events conditions. Paired samples t-tests
between the neutral and spiritual struggles conditions were conducted for participants in
the spiritual strugg les first condition. The spiritual struggles condition was significantly
greater than the neutral condition for NA and SUDS (t(39) = -3.54, p < .01; t(38) = -2.11,
p < .05, respectively). Results for PA were not significant (refer to Table 25 for these
results).
Lastly, exploratory analyses were run to control for spiritual struggle severity and
previous disclosure of spiritual struggles. Specifically, 2-way [neutral, spiritual strugg les]
within subjects ANCOVAs were run for SUDS and NA, while controlling for spiritual
struggle severity and previous disclosure of spiritual struggles. As for the physiological
variables, these analyses were only conducted for SS1st and only compared the spiritual
struggles condition with the neutral condition. No significant differences were found for
these analyses.
36
CHAPTER IV: DISCUSSION
The main purpose of this study was to determine the relationship between
spiritual struggles and cardiovascular reactivity. Previous research has demonstrated links between spiritual struggles and declines in physical health; however, the mechanism underlying this relationship has not been investigated. A pilot study shed some light on this relationship and suggested that spiritual struggles are associated with increased cardiovascular reactivity, namely greater heart rate and blood pressure. This study expanded on the pilot in several ways. First, a larger sample size was used. Second, the role that specific spiritual struggle characteristics (i.e. severity and previous disclosure) have on the relationship between spiritual struggles, cardiovascular reactivity, and psychological distress was investigated. Third, this study investigated whether there were differences between the effects of spiritual struggles and life struggles on cardiovascular reactivity.
For this study, individuals who were experiencing distinct spiritual and life
struggles were identified using a web-based survey. Appointments were scheduled for
individuals who met qualifying criteria. During the lab study, participants completed a
10-minute baseline phase followed by a 5-minutes talking about neutral events. Then,
participants were asked to reflect on and talk about their spiritual struggles and life
struggles. These two conditions were counterbalanced, with half of the sample talking
about spiritual strugg les then life struggles, and the other half talking about life struggles
then spiritual strugg les. Participants were randomly assigned to these two groups. Heart
rate, blood pressure, and mean arterial pressure were used to assess cardiovascular
37 reactivity. Psychological distress was assessed by evaluating changes in participants’ subjective distress, positive affect, and negative affect. It was hypothesized that spiritual struggles would be associated with greater cardiovascular reactivity and psychological distress than the neutral and life struggles conditions. Results supported the hypothesis that spiritual strugg les would be related to increased distress when compared to neutral events. However, results regarding the relationship between spiritual and life struggles were inconclusive because of significant interaction effects and group differences that negated the counterbalanced design.
The counterbalanced design for this study was negated for two reasons. First, there were carryover effects between order and condition. Specifically, the order that participants talked about spiritual struggles and life struggles (i.e. which struggle was talked about first) mattered, particularly for physiological variables. The pattern of interaction effects was interesting. Generally, for physiological variables, the first struggle condition was associated with greater (though not statistically significant) cardiovascular distress. This was found for systolic blood pressure, mean arterial pressure, and heart rate for both orders. For example, participants who talked about spiritual struggles first had greater cardiovascular reactivity while talking about spiritual struggles than when talking about life struggles. Since this was observed in both orders, it is reasonable to deduce that the rest period was too short to allow sufficient recovery for the cardiovascular system. Under this assumption, these results are consistent with previous literature and understanding about cardiovascular distress. Specifically, cardiovascular reactivity peaks when first encountering a stressor and then decreases over time, even when still faced with the stressor (refer to Clements & Turpin, 2000; Kelsey,
38
Soderlund, & Arthur, 2004). Extrapolating, then, it is logical that the first struggle condition elicited the greatest amount of reactivity. Although interaction effects made it difficult to understand the relationship between spiritual and life struggles, both conditions were associated with increased distress, which suggests that both types of struggles are capable of eliciting physiological distress.
Second, there were inequalities between the participants who talked about their spiritual struggles first and those who talked about their life struggles first with respect to age, religious service attendance, self-rated religiousness, and disclosure of life struggles.
Controlling for group differences affected physiological and psychological variables in distinct ways. For physiological variables, significant order effects remained after controlling for group inequalities for systolic blood pressure and mean arterial blood pressure. This suggests that systolic blood pressure and mean arterial blood pressure were still influenced by the order that participants talked about their struggles, irrespective of group differences. However, controlling for inequalities between the two groups eliminated the only main effects found for physiological variables: diastolic blood pressure being greater for spiritual and life struggles than for the neutral condition. This suggests that the main effects found between conditions for diastolic blood pressure were likely due to inequalities in control variables. For psychological variables, main effects found for subjective distress and negative affect were eliminated when controlling for inequalities between the two groups. In fact, when controlling for group differences, there were no significant main effects or interaction effects. Therefore, it is likely that differences in age, religious service attendance, self-rated religiousness, and disclosure of life struggles accounted for the differences that were found between the spiritual and life
39 struggles first conditions for subjective distress variables. In sum, this study was unable to investigate the relationships between spiritual and life struggles with cardiovascular and subjective distress. Therefore, the remaining analyses were conducted only for those participants in the spiritual strugg les first condition, comparing spiritual struggles condition to the neutral condition.
Looking only at the spiritual struggles first condition, spiritual struggles were associated with greater blood pressure, both systolic and diastolic, negative affect, and subjective distress compared to neutral condition. Although spiritual struggles were not tied to increased heart rate, the association with elevated blood pressure is clinically significant. Specifically, elevations in blood pressure cause increased risk for atherosclerosis, or plaque build up in arteries, which, in turn, causes peripheral resistance that is associated with an increased risk for cardiovascular disease. This is the same mechanism underlying the relationship between stress and cardiovascular problems (refer to Lovallo & Gerin, 2003 for a detailed explanation). The current study was unable to determine if there were differences between the effects of spiritual and life struggles on cardiovascular distress; however, it demonstrates that spiritual struggles are similar to stressful life events because spiritual struggles are associated with elevations in blood pressure, which has the potential to cause deteriorations in physical health.
It is also important to understand more about the qualities and characteristics of spiritual struggles that are tied to greater distress. This study investigated the effect of two potentially relevant variables, severity and previous disclosure, on the relationship between spiritual struggles and distress. When controlling for these variables, there were no significant differences between spiritual struggles and the neutral condition for
40 distress variables. This suggests that the severity of spiritual struggles and previous disclosure of struggles are two important components of the relationship between spiritual struggles and distress.
41
CHAPTER V: LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH
The study represents an important contribution to the literature because it demonstrates that spiritual struggles are in fact associated with greater cardiovascular distress and psychological distress when compared to a neutral talking condition.
Therefore, the distress associated with talking about spiritual struggles is not an artifact of talking during a laboratory study. There is a growing body of literature, correlational studies as well as theoretical explanations, which point to links between spiritual struggles and declines in physical health. Of particular relevance is an article by Seybold
(2007) which articulates a rationale for several potential biological mechanisms,
including cardiovascular pathways, which could link religion/spirituality and physical
health outcomes. Seybold offers theoretical evidence for the notion that spirituality may
effect health outcomes via cardiovascular processes.
However, there are important limitations to the current study. The most notable
limitation was the inability to investigate the relationship between spiritual struggles and
life struggles. Although the study utilized a counterbalanced design, order effects and
inequalities between groups made it difficult to draw conclusions about the relationships
between spiritual struggles and life struggles with distress variables. Future research
should attempt to discern whether spiritual struggles relate to distress in ways different
than life struggles. There are several ways that future studies could attempt to minimize
interaction effects. First, the recovery time between the two conditions could be increased
to allow sufficient time for cardiovascular functioning to return to baseline levels.
Second, relaxation methods, such as deep breathing or guided imagery, could be
employed to decrease heart rate and blood pressure between conditions. Third, the study
42 could be conducted across several days, having participants talk about each condition on separate days.
The study is also limited by potential experimenter bias. Specifically, the experimenter was the principal investigator of the study and was not blinded to study design or hypotheses. Several procedural safeguards were employed to minimize experimenter bias. First, a pre-developed structured interview was used to elicit both spiritual and life struggles. These interviews were employed to ensure consistency across the study. Additionally, the experimenter did not check data (cardiovascular reactivity variables and self-report measures) until after each participant was completed. This prohibited the experimenter from having direct knowledge of how participants were reacting physiologically and psychologically to the study.
In addition, the study is limited by the sample. Specifically, the sample consisted of college students who were primarily Caucasian, Christian, and female. Although college students represent an adequate sample for this study due to the high proportion of spiritual struggles, results may be different for individuals who are experiencing different life circumstances. Specifically, it is likely that participants of this study experienced spiritual struggles triggered by normative life transitions. These types of spiritual struggles may be vastly different from those that are triggered by negative life events.
Therefore, it is important to determine whether the triggering event (i.e. normative life transitions or discrete stressors) that initiates a spiritual struggle or the type of spiritual struggle (interpersonal, intrapersonal, or divine) affects the relationship between spiritual struggles and distress. Studies of the relationship between specific spiritual struggles and
43 cardiovascular distress might help practitioners pinpoint struggles that are the most likely to result in cardiovascular distress.
Lastly, the manipulation for this study could have been stronger. The current study is an expansion of a pilot study and these results are different from the pilot study.
Specifically, in the pilot study, spiritual struggles were tied to increases in heart rate, blood pressure, and mean arterial pressure. Additionally, participants in the pilot study were appeared more distressed during the study than the participants in the current study; however, there were no significant differences in experience of spiritual struggles (based on single items assessing for spiritual struggles and the composite NRCOPE score).
Therefore, differences found between the two studies may be attributed to procedural changes. For the pilot study, the experimenter followed guidelines when eliciting the spiritual struggles, instead of a semi-structured interview. This procedure was changed for the current study to decrease experimenter bias as well as to increase consistency between the spiritual strugg le and life struggle conditions. It is possible that the structured interview was not as successful in eliciting struggle experiences. Future studies should consider less structured interviews to elicit struggle experiences. When doing this, it may be beneficial to use an experimenter who is blinded to the study aims.
Given that spiritual struggles are tied to some forms of cardiovascular distress, additional research should focus on developing interventions to buffer the harmful effects of spiritual struggles. In recent years, several psychospiritual interventions have been developed addressing spiritual struggles in the context of specific stressors, including living with HIV/AIDS (Tarakeshwar, Pearce, & Sikkema, 2005), diagnosis of cancer
(Cole, 2005), and experience of sexual abuse (Murray-Swank & Pargament, 2005). These
44 interventions have had promising findings. Future research should expand on these and develop interventions that address spiritual struggles generally, instead of addressing the triggering event. In this vein, a group intervention was developed for college students experiencing a variety of spiritual struggles and had promising results.
45
CHAPTER VI: CONCLUSION
In conclusion, this study adds to the existing literature on spiritual struggles and physical health. Previous research has demonstrated that spiritual struggles are associated with declines in physical health. Although physiological mechanisms have been offered as theoretical explanations for these effects, this is the first study to investigate one
specific physiological pathway that could explain the links between struggles and health.
Specifically, spiritual struggles could be related to increased cardiovascular reactivity,
which in turn, could tax the cardiovascular system, leading to declines in cardiovascular
health. This is the same mechanism underlying the relationship between life stressors and
declines in cardiovascular health. This study demonstrated that spiritual struggles have the potential to significantly raise blood pressure, which may explain at least in part the
relationship between spiritual struggles and declines in physical heath.
46
TABLES Table 1 Summary of Laboratory Study Condition Time Instructions Cardiovascular Psychological Distress Reactivity Baseline 10 minutes “Relax and get used to the - Systolic Blood - Subjective Distress (discard first room” Pressure (SBP) (SUDS) three minutes) - Diastolic Blood - Positive Affect (PA) Pressure (DBP) - Negative Affect (NA) - Heart Rate (HR) - Mean Arterial Pressure (MAP) Neutral Event Minimum 5 “Try to remember and re- - SBP - SUDS Talk minutes experience the path you took - DBP - PA to get here.” - HR - NA - MAP “Describe, in detail, the path you took to get to the lab.”
Rest 5 minutes “Try to clear your mind as much as possible; rest and relax for the next few moments”
Spiritual Minimum 10 “Try to remember and re- - SBP - SUDS Struggle* minutes experience your spiritual - DBP - PA struggle.” - HR - NA - MAP “What was going through your mind when you reflected on your spiritual struggle?”
Rest 5 minutes “Try to clear your mind as much as possible; rest and relax for the next few moments”
Life Struggle* Minimum 10 “Try to remember and re- - SBP - SUDS minutes experience your life - DBP - PA struggle.” - HR - NA - MAP “What was going through your mind when you reflected on your life struggle?”
Rest 5 minutes “Try to clear your mind as -Demographic much as possible; rest and Questionnaire relax for the next few moments”
Note. * Spiritual Struggles and Life Struggles were counterbalanced.
47
Table 2 Descriptive Information for Screening and Demographic Questionnaires
Variable n Mean SD Potential Actual Range Reliability Range
Screening
Intrapersonal SS1 80 2.33 1.06 1 – 5 1 – 5
Divine SS 80 2.11 1.07 1 – 5 1 – 5
Interpersonal SS 80 2.03 1.02 1 – 5 1 – 4
NRCOPE Sum 80 38.85 12.08 23 – 92 24 – 71 .92
SS Distress 80 31.10 10.12 15 – 60 15 – 56 .90
LS2 Distress 80 37.30 8.79 15 – 60 18 – 55 .91
Demographic
Age 77 19.87 3.75 18 + 18 – 48
Year in College 79 1.80 1.09 1 – 5 1 – 5
Attendance of 79 5.59 2.18 1 – 9 2 – 9 Services
Prayer 79 4.65 2.57 1 – 9 1 – 9
Religiousness 79 2.2 0.95 1 – 4 1 – 4
Spirituality 79 2.54 0.95 1 – 4 1 – 4
Note. 1 SS refers to Spiritual Struggles; 2 LS refers to Life Struggles
48
Table 3 Descriptive Information for Difference Scores (baseline values partialled out) for Laboratory Study
Variable n Mean SD Potential Actual Reliability Phase Range Range
Psychological Variables Subjective Distress Neutral 80 -2.68 8.73 -100 – 100 -25 – 30 SS1 79 5.56 19.27 -100 – 100 -57 – 60 LS2 78 8.62 19.15 -100 – 100 -45 – 60 Positive Affect Neutral 80 -0.76 4.27 -40 – 40 -9 – 12 .84 SS 80 -3.26 6.21 -40 – 40 -20 – 22 .89 LS 80 -3.26 5.40 -40 – 40 -19 – 22 .90 Negative Affect Neutral 80 -1.80 2.48 -40 – 40 -10 – 3 .64 SS 80 1.72 5.85 -40 – 40 -10 – 26 .84 LS 80 2.74 5.66 -40 – 40 - 8 – 20 .86
Physiological Variables Systolic Blood Pressure Neutral 80 15.64 9.16 -3.2 – 50.14 SS 80 18.72 11.15 0.25 – 54.00 LS 80 16.83 10.65 -5.86 –55.14 Diastolic Blood Pressure Neutral 80 13.57 7.81 -13.63 – 30.60 SS 80 18.19 9.55 -1.00 – 52.83 LS 80 16.50 8.77 -6.29 – 36.71 Mean Arterial Pressure Neutral 80 11.33 6.02 -10.60 – 29.57 SS 80 13.23 8.26 -1.33 – 41.83 LS 80 12.71 7.87 -7.71 – 32. 57 Heart Rate Neutral 80 12.23 6.39 0.83 – 30.89 SS 80 11.14 9.02 -7.86 – 43.14 LS 80 10.54 8.53 -13.57 – 44.50
Note. 1 SS refers to Spiritual Struggles; 2 LS refers to Life Struggles
49
Table 4 Descriptive Information by Order (Spiritual Struggles first; Life Struggles First) for Difference Scores (baseline values partialled out) for Laboratory Study
Order
Variable Spiritual Struggles (SS) First Life Struggles (LS) First Phase n Mean SD n Mean SD PA Neutral 32 -0.97 4.4 34 0.88 4.29 SS 32 -1.94 5.79 34 -3.03 5.25 LS 32 -3.5 6.14 34 -4.44 6.43 NA Neutral 32 -1.91 2.82 34 -1.91 2.22 SS 32 0.38 6.49 34 2.50 4.72 LS 32 2.19 6.13 34 2.40 5.50 SUDS Neutral 32 -3.09 8.51 34 -4.06 7.55 SS 32 2.03 21.27 34 9.47 15.91 LS 32 8.48 23.17 34 7.62 19.98 SBP Neutral 33 16.04 9.53 32 15.12 9.28 SS 33 20.13 11.88 32 17.09 9.38 LS 33 14.52 10.23 32 20.49 11.68 DBP Neutral 33 15.66 6.63 32 12.36 8.24 SS 33 20.51 9.44 32 17.56 9.95 LS 33 17.12 9.26 32 16.29 7.91 MAP Neutral 33 12.96 4.29 32 10.35 6.98 SS 33 14.99 8.57 32 12.50 7.78 LS 33 12.50 9.16 32 14.10 6.55 HR Neutral 33 12.31 5.57 32 12.79 7.06 SS 33 13.37 6.82 32 9.60 11.76 LS 33 10.61 9.55 32 11.44 9.10
Note. PA = positive affect, NA = negative affect, SUDS = subjective distress, SBP = systolic blood pressure, DBP = diastolic blood pressure, MAP = mean arterial pressure, HR = heart rate
50
Table 5
Paired Samples T-tests Examining Differences between Spiritual Struggle First Order and Life Struggle First Order for Demographic and Screening Questionnaires
Variable Order Paired Sample T-test
SS1 First LS2 First n M SD n M SD t df p Screening Intrapersonal SS 40 2.33 1.19 40 2.33 9.44 0.00 78 .99
Divine SS 40 2.13 1.14 40 2.10 1.03 0.10 78 .92
Interpersonal SS 40 2.15 1.05 40 1.90 0.98 1.10 78 .28
NRCOPE Sum 40 39.39 13.24 40 38.32 10.95 0.40 78 .69
SS Distress 40 30.44 9.92 40 31.76 10.39 -0.58 78 .56
LS Distress 40 38.48 8.00 40 36.12 9.46 -1.47 78 .15
SS Disclosure 40 1.63 0.49 40 1.78 0.42 1.21 78 .23
LS Disclosure 40 1.65 0.48 40 1.88 0.33 -2.42 78 .02 Demographic Age 38 20.82 5.09 39 18.95 1.05 2.24 75 .03
Ethnicity 39 6.46 1.39 40 6.85 0.95 -1.45 77 .15
College Year 39 1.97 1.22 40 1.63 0.93 1.43 77 .16
Gender 39 1.69 0.47 40 1.68 0.47 0.16 77 .87
Attendance 39 6.10 2.26 40 5.09 2.00 2.12 77 .04
Prayer 39 4.92 2.71 40 4.38 2.44 0.95 77 .35
Religiousness 39 1.97 0.87 40 2.41 0.98 -2.10 77 .04
Spirituality 39 2.46 0.99 40 2.63 0.90 -0.77 77 .45
Note. 1SS refers to Spiritual Struggles; 2 LS refers to Life Struggles
51
Table 6
3 (Condition) x 2 (Order) Mixed Model ANOVA Examining Interaction Effects for Condition and Order for Physiological Variables and Relevant Post-Hoc T-tests
Variable Interaction Effects Main Effect: Condition Main Effect: (variable * order) (within subjects) Order (between Condition subjects)
F(df) Effect F(df) Effect F(df)
t (df)
Systolic Blood 6.58** .08 3.71* .05 0.00 (1, 78) Pressure (2, 156) (2, 156) .11 Diastolic Blood 0.75 .01 9.54** 0.94 (1, 78) Pressure (2, 156) (2, 156)
Neutral vs SS -4.50 (79)**
Neutral vs LS -2.86 (79)**
LS vs SS -1.47 (79)
.02 Heart Rate 3.84* .05 1.93 0.11 (1, 78) (2, 156) (2, 156) .04 Mean Arterial 3.56* .04 2.82 0.55 (1, 78) Pressure (2, 156) (2, 156)
Note. The three conditions are neutral, spiritual struggles, life struggles; the two orders are: spiritual strugg les condition first; life struggles condition first. Italics represent post- hoc t-tests. Means for DBP Conditions are: Neutral M = 13.57; LS M = 16.50; SS M = 18.19. p* < .05; p** < .01
52
Table 7
1 (Order) x 3 (Condition) Simple Main Effects ANOVAs Examining Differences between Conditions for Participants in Spiritual Struggles First Order and Relevant Post-Hoc T- tests
Post-Hoc Analyses Variable F (df) Effect
N Mean LS Mean SS Mean t (df)
Systolic Blood 6.93** .15 Pressure (2, 78)
N vs. SS1 16.14 14.56 20.49 -2.34 (39)*
N vs. LS2 16.14 14.56 20.49 1.09 (39)
LS vs. SS 16.14 14.56 20.49 -3.65 (39)**
Heart Rate 2.11 .05 (2, 78) Mean Arterial 2.29 .06 Pressure (2, 78)
Note. Conditions are: neutral, spiritual strugg les, life struggles in that order (i.e. spiritual struggles are first). Italics represent post-hoc tests. N refers to neutral condition, LS refers to life struggles condition, and SS refers to spiritual struggles condition p* < .05; p** < .01
53
Table 8
1 (Order) x 3 (Condition) Simple Main Effects ANOVAs Examining Differences between Conditions for Participants in Life Struggles First Order and Relevant Post-Hoc T-tests
Variable Means F (df) Effect Phase Neutral LS1 SS2 t(df)
Systolic Blood 3.17* .08 Pressure (2, 78)
Neutral vs. LS 15.14 19.09 16.95 -2.6 (39)*
Neutral vs. SS 15.14 19.09 16.95 -1.09 (39)
LS vs. SS 15.14 19.09 16.95 1.401 (39)
Heart Rate 3.68* .10 (2, 78)
Neutral vs. LS 12.8 10.85 9.50 1.70 (39)
Neutral vs. SS 12.8 10.85 9.50 2.23 (39)*
LS vs. SS 12.8 10.85 9.50 1.37 (39)
Mean Arterial Pressure 4.27* .09 (2, 78)
Neutral vs. LS1 10.22 13.48 12.06 -3.76 (39)**
Neutral vs. SS1 10.22 13.48 12.06 -1.52 (39)
LS vs. SS 10.22 13.48 12.06 1.15 (39) Note. Italics represent post-hoc analyses; 1 LS refers to Life Struggles; 2 SS refers to Spiritual Struggles *p < .05; p < .01
54
Table 9
3 (Condition) x 2 (Order) x 4 (Controls) Mixed Model ANCOVA Examining Interaction Effects for Condition and Order for Physiological Variables, while Controlling for Inequalities between Orders
Variable Interaction Effects Main Effect: Condition Main Effect: Order (variable * order) (within subjects) (between subjects)
F(df) p Effect F(df) p Effect F(df) p Effect
Systolic Blood 4.02 .02 .05 2.61 .08 .05 0.02 .89 .00 Pressure (2, 142) (2, 142) (1, 71)
Diastolic Blood 0.89 .41 .01 0.66 .52 .01 0.08 .77 .00 Pressure (2, 142) (2, 142) (1, 71)
Heart Rate 2.40 .09 .03 0.29 .75 .00 0.01 .91 .00 (2, 142) (2, 142) (1, 71)
Mean Arterial 3.12 .05 .04 0.96 .39 .01 0.00 .97 .00 Pressure (2, 142) (2, 142) (1, 71)
Note. Total n for these analyses is 77 due to missing demographic data; Spiritual Struggles first condition n = 38; Life Struggles first condition, n = 37; Conditions are: neutral, spiritual struggles, life strugg les; Orders are: spiritual strugg les first; life struggles first; and controls are life struggles disclosure, age, religiousness, and frequency of religious service attendance.
55
Table 10
Paired Samples T-tests Comparing Physiological Variables for Spiritual Struggles Condition and Neutral Condition for Spiritual Struggles First Order
Variable Means t(df)
Neutral Spiritual Struggles
Systolic Blood Pressure 16.14 20.49 -2.34 (39)*
Diastolic Blood Pressure 14.79 19.19 -3.02 (39)**
Heart Rate 11.65 12.78 -1.18 (39)
Mean Aterial Pressure 12.44 12.78 -1.18 (39)
Note. *p < .05; **p < .01
56
Table 11
3 (Condition) x 2 (Order) Mixed Model ANOVA Examining Interaction Effects for Psychological Variables
Variable Interaction Effects Main Effect: Condition Main Effect: Order (variable * order) (within subjects) (between subjects)
F (df) p Effect F(df) p Effect F(df) p Effect
Subjective 0.75 .47 .01 16.79 .00 .18 0.74 .39 .01 Distress (2, 152) (2, 152) (1. 76) (1, 76)
Positive 2.97 .05 .04 15.83 .00 .17 0.66 .42 .01 Affect (2, 156) (2, 156) (1, 78) (1, 78)
Negative 0.78 .46 .01 35.06 .00 .31 0.26 .61 .00 Affect (2, 156) (2, 156) (1, 78) (1, 78)
Note. Subjective Distress: n = 78 due to missing data for SS first (n = 38); there is no missing data for Positive Affect and Negative Affect ( total n = 80)
57
Table 12
Post-Hoc T-tests Examining Differences between Condition for SUDs, NA
Variable Means Phase t(df) p Neutral LS SS Subjective Distress
Neutral vs. LS1 -2.78 8.62 5.57 -5.72 (78) .00
Neutral vs. SS1 -2.78 8.62 5.57 -4.07 (78) .00
LS vs. SS -2.78 8.62 5.57 -1.48 (77) .14
Negative Affect
Neutral vs. LS -1.80 2.74 1.72 -7.33 (79) .00
Neutral vs. SS -1.80 2.74 1.72 -6.2 (79) .00
LS vs. SS -1.80 2.74 1.72 -1.98 (79) .05
Note. 1 LS refers to Life Struggles; 2 SS refers to Spiritual Struggles
58
Table 13
1 (Order) x 3 (Condition) Simple Main Effects ANOVAs and Subsequent Post-Hoc Analyses Examining Differences between Conditions for Participants
Variable Means F(df) Phase t(df) p
Neutral LS SS
Spiritual Struggles First
Positive Affect 6.68 (2,78) .002
Neutral vs.SS -.63 -3.28 -2.13 1.803 (39) .08
Neutral vs. LS -.63 -3.28 -2.13 3.31 (39) .002
LS vs. SS -.63 -3.28 -2.13 2.29 (39) .03
Life Struggles First
Positive Affect 12.16 (2, 78) .00
Neutral vs. SS -.90 -3.25 -4.4 4.27 (39) .00
Neutral vs. LS -.90 -3.25 -4.4 4.07 (39) .00
LS vs. SS -.90 -3.25 -4.4 -1.53 (39) .13
Note. Italics represent post-hoc tests; for Spiritual Struggles First Order, conditions are: neutral, spiritual struggles, then life struggles; for Life Struggles First order, conditions are: neutral, life struggles, then spiritual struggles
59
Table 14
3 (Condition) x 2 (Order) x 4 (Control) ANCOVA Examining for Interaction between Condition and Order for Psychological Variables, while controlling for Potential Covariates
Variable Interaction Effects Main Effect: Condition Main Effect: Order (variable * order) (within subjects) (between subjects)
F(df) p Effect F(df) p Effect F(df) p Effect
Subjective 0.43 .65 .01 1.52 .22 .02 .44 .51 .006 Distress (2, 138) (2, 138) (1, 69)
Positive Affect 2.03 .14 .03 1.08 .34 .02 .22 .64 .003 (2, 142) (2, 142) (1, 71)
Negative Affect 0.48 .62 .01 0.33 .72 .01 .33 .57 .005 (2, 142) (2, 142) (1, 71)
Note. The number of subjects changes based on the measure: for spiritual struggles first condition, n = 38 for PA & NA, n = 36 for SUDS; for life struggles first condition, n = 39 for PA & NA, n = 39 for SUDs. The differences were caused by missing data on the demographic questionnaire.
60
Table 15
Paired Samples T-tests Comparing Psychological Variables for Spiritual Struggles Condition and Neutral Condition for Spiritual Struggles First Order
Variable Means t (df) p
Neutral Spiritual Struggles
Subjective Units of -2.63 3.18 -2.11 (38) .04 Distress
Positive Affect -0.63 -2.13 1.80 (39) .08
Negative Affect -1.73 1.10 -3.54 (39) .001
Note. For subjective units of distress, n = 39 due to missing data.
61
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APPENDIX A: SCREENING SURVEY
A-1: Assessment of Spiritual Struggles
A-2: Assessment of Life Struggles
68
Appendix A-1: Assessment of Spiritual Struggles
Please circle the response that best fits you.
1. Currently, to what extent are you experiencing personal conflict regarding your religious or spiritual beliefs, doubts about religion or spirituality, or questions about God?
1 2 3 4 5 Not at all A little bit Moderately Quite a bit Extremely
2. Currently, to what extent are you experiencing any tension in your relationship with God, such as feelings of confusion, anxiety, loneliness, frustration, anger, abandonment, or guilt?
1 2 3 4 5 Not at all A little bit Moderately Quite a bit Extremely
3. Currently, to what extent are you experiencing conflict, strain, or alienation in your relationship with friends, family, church members, and/or your religious community because of religious or spiritual issues?
1 2 3 4 5 Not at all A little bit Moderately Quite a bit Extremely
The questions above ask about personal feelings or questions that individuals may experience. These feelings, which will be called spiritual struggles for the rest of this survey, are relatively common feelings for individuals to experience. Please be open and honest when you are answering the questions. Remember, when a question asks about your spiritual struggle, it is referring to feelings that were asked about above.
1. Describe your spiritual struggle in as much detail as possible. Explain the conflicts and tensions that you are currently experiencing.
2. Describe the event or events that triggered your spiritual struggle.
3. Describe the thoughts and/or words that are associated with your spiritual struggle.
4. Describe the feelings and emotions associated with your spiritual struggles.
5. Describe the images, colors, and/or pictures that appear when reflecting on your spiritual struggle.
6. Have you talked about the things you just described with anyone in the past? Yes No
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Appendix A-2: Assessment of Life Struggles
Below is a list of events that are commonly experienced by college students. There are two questions for you to answer for each event. First, indicate how much you are currently struggling with each event. Second, indicate if each event is causing conflict, question, doubt, or tension about spiritual/religious beliefs. There are two blank spaces were you can add events or situations that you are currently struggling with.
Not at all at Not A little bit little A Extremely Quite a Bit a Quite Moderately 1. Adjusting to college a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing tension or strain within your religious/spiritual beliefs? NO YES 2. Academic problems a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 3. Problems with romantic relationship a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 4. Problems with friend or roommate a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 5. Criminal victimization a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 6. Personal injury/accident a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 7. Parents’ separation or divorce
70 a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 8. Unwanted pregnancy a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 9. Recent death of loved one a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 10. (OTHER): a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES 11. (OTHER): a. How much are you struggling with 1 2 3 4 5 this event? b. Is this causing religious/spiritual tension or strain? NO YES
For this part of the survey (meaning, the questions 1 – 11 that you just answered), I am only interested in the events that are currently struggling with that ARE NOT causing religious/spiritual tension or strain. These are the events that you answered the first question (a) with a response of 2 or more and the second question (b) with a response of NO. These events, which will be called life struggles for the rest of this survey, are relatively common for individuals to experience. Please be open and honest when you are answering the questions. Remember, when a question asks about your life strugg le, it is referring to events that were asked about above.
7. Please describe your life struggles in as much detail as possible. Explain the conflicts and tensions that you are currently experiencing. 8. Describe the event or events that triggered your life struggles. 9. Describe the thoughts and/or words that are associated with your life struggles. 10. Describe the feelings and emotions associated with your life struggles. 11. Describe the images, colors, and/or pictures that appear when reflecting on your life struggles. 12. Have you talked about the things you just described with anyone in the past? YES NO
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APPENDIX B: SPIRITUAL STRUGGLES SEMI-STRUCTURED INTERVIEW
[Have participants read their description of their spiritual struggles and try to imagine their struggles, brief]
Online, you wrote about the spiritual struggles that you are currently experiencing. Take a few minutes to read and reflect on what you wrote. [pause for a 15-30 seconds].
[Use the participants words as much as possible- for example, instead of referring to it as a spiritual struggle, use whatever word the participant used to describe the event]
I would like you to try to remember and re-experience the struggle for the next few minutes as you sit in this room. Bring your spiritual struggle to mind. Try to remember the struggle as fully as you can. Listen for any words and thoughts associated with your spiritual struggle. [brief pause].
Let yourself truly experience your struggles. [brief pause]
[Verbal description of spiritual struggle; prompt so participants talks for at least 10 minutes]
What was going through your mind when you reflected on your spiritual struggle? [If participant has difficulty answering, follow up with following questions]
Help me understand your spiritual struggle. Explain the thoughts, feelings, and conflicts that you are experiencing. • (Intrapersonal struggles) Explain any conflict or tension you are experiencing about your personal religious beliefs. o Tell me about any doubts about religion even if they are minor. o Tell me about any questions about religion or about God that are unanswered, even if they are minor.
• (Divine struggles) Tell me about any conflict or strain in your personal relationship with God or your idea of the Divine, even if it is minor. o Prompt with the following feelings if participant does not respond or says no: . Have you felt anger towards God recently? [If yes, ask to elaborate] . Any frustration? [If yes, ask to elaborate] . Do you ever feel like God isn’t always there for you? [If yes, ask to elaborate]
• (Interpersonal struggles): Tell me about any conflict or strains in your relationship with your family, friends, or others because of your religious beliefs, even if they are minor. [Provide examples if needed]:
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. For example, do you fight with your parents or friends about differences in religious viewpoints? . Do you ever feel alienated from others in your community because of your spiritual struggles?
When you think about your struggle, what’s going through your head? • Ask the following if participant does not respond: o What would I hear if I could hear your thoughts? o Are there voices or dialogue running through your mind when thinking about struggles? What is this like? Tell me what the dialogue or thoughts are saying. • When you think about your struggle, what is the hardest part for you to face? To come to grips with?
What do you feel when reflecting on your spiritual struggle? Specifically, what emotions are you experiencing?
What are the sensations associated with your spiritual struggle? Are there any colors, sounds, words, or phrases that pop into your mind when imaging your struggle?
[If participant has talked for at least 10 minutes, skip the next two sections] History • Think back—what triggered your spiritual struggles [try to use participant’s phrasing from on-line description or from earlier]. o Ask specific details about how the struggle developed—ask about the event or about the thoughts that preceded the struggles • Have you experienced these thoughts and feelings consistently in your life?
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APPENDIX C: SEMI-STRUCTURED INTERVIEW FOR LIFE STRUGGLES
[Have participants read their description of their life struggles and try to imagine their struggles, brief]
Online, you wrote about the life struggles that you are currently experiencing. Take a few minutes to read and reflect on what you wrote. [pause for a 15-30 seconds].
[Use the participants words as much as possible- for example, instead of referring to it as a life struggle, use whatever word the participant used to describe the event]
I would like you to try to remember and re-experience your life struggles for the next few minutes as you sit in this room. Bring your life struggles to mind. Try to remember the struggles as fully as you can. Listen for any words and thoughts associated with your struggles. [brief pause].
Let yourself truly experience your life struggles. [brief pause]
[Verbal description of life struggles; prompt so participant talks for at least 10 minutes]
What was going through your mind when you reflected on your life struggles? [If participant has difficulty answering, follow up with following questions]
Help me understand your life struggles. Explain the thoughts, feelings, and conflicts that you are experiencing. • (Intrapersonal struggles) Explain any internal conflict or inner turmoil that you are experiencing because of your life struggles
• (Interpersonal struggles) Tell me about any conflict or strains in your relationship with your family, friends, or others because of your life struggles: o Have you felt anger towards anyone recently? [If yes, ask to elaborate] o Any frustration? [If yes, ask to elaborate] o Do you ever feel like others aren’t there for you? [If yes, ask to elaborate] o Do you ever feel alienated from others because of your life struggles?
When you think about your life struggles, what’s going through your head? • Ask the following if participant does not respond: o What would I hear if I could hear your thoughts? o Are there voices or dialogue running through your mind when thinking about struggles? What is this like? Tell me what the dialogue or thoughts are saying. • When you think about your life struggles, what is the hardest part for you to face? To come to grips with?
What do you feel when reflecting on your life struggles? Specifically, what emotions are you experiencing?
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What are the sensations associated with your life struggles? Are there any colors, sounds, words, or phrases that pop into your mind when imaging your struggle?
[If participant has talked for at least 10 minutes, skip the next two sections] History • Think back—what triggered your life struggles [try to use participant’s phrasing from on-line description or from earlier]. o Ask specific details about how the struggle developed—ask about the event or about the thoughts that preceded the struggles • Have you experienced these thoughts and feelings consistently in your life?