UNDERSTANDING THE RELATIONSHIP BETWEEN SPIRITUAL STRUGGLES AND PHYSICAL HEALTH: A PHYSIOLOGICAL STUDY. Kavita M. Desai.

Transcription

1 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

2 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.

3 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

4 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!

5 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 CHAPTER II. METHODS Sample Characteristics Measures Procedure CHAPTER III. RESULTS General Analytic Plan Preliminary Analyses Main Analyses CHAPTER IV. DISCUSSION CHAPTER V. LIMITATIONS AND DIRECTIONS FOR FUTURE RESEARCH CHAPTER VI. CONCLUSION REFERENCES APPENDIX A. SCREENING STUDY APPENDIX B. SPIRITUAL STRUGGLES SEMI-STRUCTURED INTERVIEW APPENDIX C. LIFE STRUGGLES SEMI-STRUCTURED INTERVIEW... 73

6 vi LIST OF TABLES Table Page 1 Summary of Laboratory Study Descriptive Information for Screening and Demographic Questionnaires Descriptive Information for Difference Scores Descriptive Information by Order, Difference Scores Paired Samples T-tests Examining Differences between Spiritual Struggle First Order and Life Struggle First Order for Demographic and Screening Questionnaire (Condition) x 2 (Order) Mixed Model ANOVA Examining Interaction Effects for Condition and Order for Physiological Variables and Relevant Post-Hoc t-tests (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 (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 (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 Paired Samples T-tests Comparing Physiological Variables for Spiritual Struggles Condition and Neutral Condition for Spiritual Struggles First Order (Condition) x 2 (Order) Mixed Model ANOVA Examining Interaction Effects for Psychological Variables... 56

7 vii 12 Post-Hoc T-tests Examining Differences between Condition for SUDS, NA (Order) x 3(Condition) Simple Main Effects ANOVAs and Subsequent Post-Hoc Analyses Examining Differences between Conditions for Participants (Condition) x 2 (Order) x 4 (Control) ANCOVA Examining for Interaction between Condition and Order for Psychological Variables, while controlling for Potential Covariates Paired Samples T-tests Comparing Psychological Variables for Spiritual Struggles Condition and Neutral Condition for Spiritual Struggles First Order... 60

8 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

9 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

10 3 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

11 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

12 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 stressrelated 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.

13 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

14 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

15 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 potential 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 followup. 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

16 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

17 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

18 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

19 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

20 13 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

21 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

22 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.

23 16 The study investigated this question by comparing changes in cardiovascular reactivity and psychological distress associated with talking about spiritual struggles 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 struggle 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

24 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.

25 18 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 struggles. 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

26 19 fourths of the sample indicated previously talking about their life struggles with others (76.5%, n = 61). Measures Screening Questionnaire 2 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. Sixhundred 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 online 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.

27 20 difficulty with scheduling time for laboratory study and no longer needing the extracredit 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 struggles 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

28 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

29 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 struggles. 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 struggle 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

30 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).

31 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