Religious coping styles and recovery from serious mental illnesses.
The idea that recovery from serious mental illnesses is a viable prospect has been promoted within the mental health field in the last decade contrasting sharply with the traditional view that they are chronic and intractable. The emergence of narratives written by individuals with severe mental illnesses describing their experiences of recovery and empirical research demonstrating the reality of positive outcomes in this population converged in the 1980s and gave birth to the recovery vision (Anthony, 2000). Anthony (1993) has defined recovery as a process of transformation, adaptation, and self-discovery involving changes in attitudes, values, and goals towards oneself and one's illness. Recovery does not refer to an end product, a linear process, or an absence of pain or setbacks. Relatedly, Deegan (1988) viewed recovery as the lived experience of individuals as they accept and overcome the challenge of their illness.
An integral part of recovery is empowerment, which involves consumers of mental health services taking responsibility and control over all aspects of their lives, including the treatment for their disorders (Corrigan, Faber, Rashid, & Leary, 1999). Traditionally, the mental health system has encouraged dependency and has restricted opportunities for choice and self-determination by regarding people who have mental illnesses as "passive recipients of treatment rather than as active agents in the recovery process" (Heinssen, Levendusky, & Hunter, 1995, p. 522). In contrast, Heinssen et al. (1995) have demonstrated that interventions are more effective when their recipients perceive choice, have a personal investment in the recovery process, and are treated as collaborators by mental health professionals. Additionally, activities, places, and people not related to the mental health system, such as lay social support networks, sports, clubs, and religious institutions, have been shown to be essential to many individuals' recovery (Anthony, 1993; Corrigan et al., 1999; Murnen & Smolak, 1994). Indeed, research has demonstrated that spiritual and religious involvement plays an important role in promoting and supporting recovery efforts (i.e., Fitchett, Burton, & Sivan, 1997; Koenig, Larson, & Weaver, 1998; Lindgren & Coursey, 1995; O'Rourke, 1997; Sullivan, 1999; Young & Ensing, 1999).
Even more neglected has been the study of the effects of religious beliefs and practices on the functioning of people who have serious mental illnesses (Crossley, 1995; Koenig, Larson, & Weaver, 1998). On the other hand, most personal accounts of recovery highlight spirituality. Religion and spirituality are seen as offering great help by providing coping and problem-solving strategies, a source of social support, and a sense of meaning in the midst of tragedy and confusion (Sullivan, 1999). Unfortunately, most of the current work on this matter is qualitative in nature and limited in scope.
The intersection of religion and coping has recently been identified as a rich area for scientific investigation (Pargament, 1997). One's method of religious coping has been found to relate to a number of psychosocial outcomes, such as the degree of adjustment to negative events and psychological resourcefulness. Pargament et al. (1988) identified three major approaches to religious coping with adversity: self-directing, deferring, and collaborative. The collaborative style reflects the joint responsibility for problem solving by God and the individual, while the deferring style implies placing all responsibility for problem solving on God while passively waiting to receive solutions. The self-directing approach emphasizes the individual's personal responsibility and active role in problem solving and excludes God from the process (Hathaway & Pargament, 1990).
Both self-directing and collaborative problem-solving styles have been linked to greater general psychological competence, while the deferring religious coping method has been related to lower levels of psychological resourcefulness (Hathaway & Pargament, 1990). However, in several studies the self-directing approach has also been associated with negative outcomes, such as anxiety and depression (Bickel et al., 1998; Schaefer & Gorsuch, 1991). Specifically, Bickel et al. (1998) found an increase in depressive affect under conditions of high stress with the reported use of the self-directing religious coping style. The use of the collaborative coping style, on the other hand, produced a decrease in depression under the same conditions.
Although generally not an effective problem-solving method, the deferring coping style has been found helpful in those situations where the individual has very little control over the stressful circumstances (Pargament, 1997). In these uncontrollable situations, delegating responsibility to what many view as a mighty and loving Being can be quite empowering, whereas assuming all responsibility for problem-solving may lead to great distress. Thus, a consistent pattern of positive outcomes emerges only for the collaborative coping style, while the other two styles yield mixed outcomes (Pargament, 1997). When applied to the recovery context, significant aspects of severe mental illness lend themselves to little control on the part of the person coping with it. Examples of this may include the presence of cognitive impairments, medication side effects, poverty, and discrimination.
Pargament and his colleagues (Pargament et al., 1990) also postulated the existence of an additional religious coping style, termed Plead, in which the individual petitions for God's miraculous intervention to bring about personally desirable outcomes, both refusing to accept the status quo and wishing for the world to change through God. In several studies, the use of pleading and bargaining for a miracle has been linked to greater distress and is generally considered a maladaptive religious style of coping (Pargament, Koenig, & Perez, 2000; Park & Cohen, 1993; Thompson & Vardaman, 1997).
Goals and Hypotheses
The major purpose of this project was to ascertain empirically the role of religion and religious coping in the process of recovery from serious mental illness. A more specific goal of this study was to increase our understanding of which religious methods of coping, if any, facilitate the recovery process most effectively. It was assumed that if certain approaches to religious problem-solving are indeed more efficacious in promoting individuals' psychosocial functioning, sense of empowerment, and recovery, mental health professionals and clergy working with these individuals would be in a better position to encourage the development and reliance upon these particular coping styles.
Three hypotheses were tested in this study.
Hypothesis 1: Higher scores on religious alience and attendance at religious services were expected to be linked to a better quality of life and fewer symptoms of distress.
Hypothesis 2: Mental health consumers' reliance on Self-directing and Collaborative religious problem-solving styles was predicted to be associated with a greater sense of personal empowerment and more extensive involvement in various aspects of recovery. By contrast, dependence on Deferring and Plead religious coping styles was expected to be associated with a lower sense of empowerment and reduced participation in the recovery process. The religious problem-solving styles were hypothesized to explain significant incremental variance in dependent variables beyond demographic factors.
Because recovery from serious mental illnesses is a complex and multidimensional process, some of its elements are within individuals' control and thus demand a fair degree of personal responsibility and action, while others are unchangeable and, to a large extent, simply require acceptance.
Hypothesis 3: Use of the Collaborative religious problem-solving style was predicted to be associated with a better ability to deal with the complexities of the recovery process, as defined by improved quality of life and reduced symptom distress, than reliance primarily on Deferring, Plead, and Self-directing styles. Individuals in the three latter categories were viewed as being more likely to focus on some aspects of recovery (i.e., outside their control) to the exclusion of others and thus would experience more frustrations and a decreased quality of life in the process.
In addition to these hypotheses, another goal of this study was to ascertain the factor structure of the Religious Problem-Solving Scale (RPSS; Pargament et al., 1988) in a sample of individuals who have serious mental illnesses. Moreover, given the previously demonstrated utility of examining one's pattern of religious coping, a cluster analysis on participants' styles of religious coping was planned.
One hundred seventy-eight individuals diagnosed with serious mental illnesses and receiving services in the public sector mental health system were recruited into the study. Data from 27 participants (15.2% of the total sample) were excluded because they did not meet minimum criteria for inclusion based on their score on a screening instrument or if they gave duplicate, incomplete, or unusable responses. The final sample consisted of 151 individuals.
The demographic characteristics of the sample are displayed in Table 1 and approximate those of individuals with serious mental illnesses in Hamilton County, Ohio on the basis of gender. However, the percentage of ethnic minority individuals is underrepresented in this sample, as compared to county-level data. The diagnostic information from participants' charts was obtained for 137 participants. However, because more than one diagnosis was recorded for several individuals, the total frequency displayed in Table 1 exceeds 137.
Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975). This brief cognitive screening instrument measures attention, learning/memory, language, and visuo-constructive abilities. The MMSE was used to screen potential participants for their ability to process information at hand and respond in a meaningful manner. The typical cutoff point used is 23 out of 30 possible correct responses. Cronbach alpha for the scale ranges from .77 to .84 and average test-retest reliability is .80.
Demographic questionnaire. Participants were asked to provide information regarding their age, sex, race, educational background, diagnosis, marital and employment status, and religious affiliation. All respondents were asked if they believe in God or a similar Higher Power. The possible response alternatives included Yes, No, and Unsure. Additionally, probes with respect to participants' view of themselves as having a mental illness and as recovering were included.
General religious questions. Religious salience or the importance of religion to the individual was assessed by three 4-point items developed by Roof (1978). Respondents were asked to report the extent to which they base important decisions in life on religious faith, perceive faith to be important to their lives, and find that faith provides them with meaning. Answers were coded on a range from 1 (seldom, not at all important, and strongly disagree, respectively) to 4 (always, extremely important, and strongly agree, respectively). The frequency of participants' religious service attendance was measured by means of one item, ranging from 1 (never) to 5 (two or more times a week).
Religious delusions. Several questions were added to the study protocol to explore potential effects of the presence of religiously delusional thinking on participants' responses. Because no standardized measure of religious delusions was available, ad hoc questions that seemed to capture the most obvious examples of religiously delusional thinking were developed. Participants were asked to provide "yes" or "no" responses to the following questions: (1.) and (2.) Have you in the past thought/Do you currently think that you are God? (3.) and (4.) Have you in the past thought or felt/Do you currently think or feel that you have God-like supernatural powers/abilities? (5.) Has God ever told you to harm yourself/others? Affirmative responses to questions 1, 3, and 5 were counted as indicators of past religious delusions; whereas affirmative answers to questions 2 and 4 were considered to be reflective of current religious delusions.
The short form of the Religious Problem-Solving Scale (RPSS; Pargament et al., 1988). This instrument, consisting of three correlated subscales, Collaborative (C), Self-directing (S), and Deferring (D), as well as the Plead (P) subscale taken from the Religious Coping Activities Scale (Pargament et al., 1990) were used in the study. Internal consistency reliability for the subscales are .93 for Collaborative, .91 for Self-Directing, .89 for Deferring, and .86 for Plead. Subscales of the RPSS correlate with measures of religiousness and psychosocial competence and predict degrees of distress, well-being, and other outcomes of negative life events (Pargament et al., 1988, 1990, 1994).
Participants were asked to report the frequency with which each statement applies to their recovery from mental illness on a 5-point scale ranging from 1 (Never) to 5 (Always). Although the majority of participants in this study were expected to represent traditional theistic religions (i.e., Christianity, Judaism, and Islam), in the instructions to scale completion, a qualification was added stating that people define God in different ways and that if participants use another term (e.g., Higher Power, the Transcendent), they can substitute that term for "God" in the questionnaire items.
Personal Vision of Recovery Questionnaire (PVRQ; Ensfield, 1998). This 24-item instrument measures the beliefs of individuals who have serious mental illnesses about what they can do to promote their own recovery. Responses are measured on a 5-point Likert-type scale ranging from 1 (Strongly disagree) to 5 (Strongly agree). Both in previous research and current study, internal consistency reliability indices for the five factors underlying the multidimensional structure of the questionnaire fell below generally accepted standards. However, in keeping with the principles of participatory action research (e.g., inclusion of mental health service consumers in all phases of research) on which the construction of this instrument was based (Ensfield, 1998), PVRQ was chosen over other measures of recovery for use in this study. As a result, a total score was utilized as an index of broad recovery-related activities participants engaged in.
The Ohio Mental Health Outcomes Survey Adult Consumer Form (ODMH, 1996-1997) was used to measure participants' level of global functioning and sense of empowerment. This self-report instrument is part of the outcome measure developed by the Ohio Mental Health Outcomes Task Force. The Consumer Form includes items from a variety of scales. The Quality of Life component of the scale consists of 10 items from the Quality of Life Questionnaire (Greenley, Greenberg, & Brown, 1997), two items from the Quality of Life Interview (Lehman, 1988), one item assessing physical health, one assessing medication concerns, and two for perceptions of stigma in the agency and community.
The Symptom Distress component of the instrument, Symptom Distress Scale (MHSIP Task Force on Consumer-Oriented Mental Health Report Card), is based on the Symptom Checklist and five additional items from the SCL-90 "Anxiety" dimension (Derogatis & Cleary, 1977) to form a 15-item scale. The responses are scored on a 5-point scale ranging from 0 (not at all) to 4 (extremely), and are summed to obtain a total symptom distress index.
Another part of the instrument, the Making Decisions Empowerment Scale (Rogers, Chamberlin, Ellison, & Crean, 1997) consisting of 28 items, was used to measure the construct of empowerment as defined by individuals who have serious mental illnesses. The instrument has adequate internal consistency (Cronbach alpha = .86) and some degree of construct validity as it relates positively to quality of life, social support, and self-esteem and negatively to the use of traditional mental health services. Responses are made on a 4-point Likert-type scale ranging from 1 (strongly agree) to 4 (strongly disagree). All the items are summed and averaged to arrive at an overall empowerment score.
Participants were sought from three major case management agencies in Hamilton County, Ohio. The principal investigators (PIs) and 4 research assistants (RAs) solicited individuals' participation in the study by approaching them, in person, at the agencies and explaining to them the nature of the study. Participants who provided written informed consent were tested individually and a standard research protocol was followed. The Mini-Mental State Exam was administered to ensure participants' ability to complete the interview process. Those individuals who scored below the cutoff point on the MMSE received $5 and were excluded from the rest of the interview. All other individuals who scored above the cutoff point on MMSE were asked to proceed with the interview. The questionnaires, in counterbalanced order, were read aloud to the participants. Upon completion of the study, the respondents were asked to provide a written release of information for diagnostic data. The participants were compensated with $20 for their time and effort if they fully completed the questionnaires.
Descriptive statistics for all variables in the study are shown in Table 2. Additionally, the following summary statistics were computed. Of the total sample, 95.4% reported belief in God/Higher Power, 2% said that they did not and 2.6% stated that they are unsure. When asked if they considered themselves to have a mental illness, 87.4% of the sample responded in the affirmative, while 12.6% denied it; 75.5% of respondents acknowledged to be recovering, 15.2% denied the experience and 9.3% stated that they consider themselves to be recovering sometimes; 34.4% of the sample (N=52) endorsed at least one religious delusion in the past, and 17.2% (N=26) agreed with at least one question on current religious delusions. Twenty-three of 26 (88%) participants who acknowledged current delusions also reported having experienced them in the past.
Kendall's tau-b was used to examine the directionality and strength of associations between religious attendance and religious salience, and other variables, because the normality assumption was not met for these two variables (Kolmogorov-Smirnov tests of normality were significant at p<.0001). Hypothesis 1, which predicted positive associations between religious salience/religious attendance and quality of life and negative relations between religious salience/religious attendance and symptom distress, was not supported. While the association between religious salience and quality of life approached significance (Kendall's tau-b=.11, p = .07), importance of religion was not related to level of symptom distress (Kendall's tau-b=-.03, p > .05). Neither was frequency of religious attendance associated with participants' level of functioning.
However, significant positive associations emerged between the two religious variables (service attendance and salience) and involvement in recovery-related activities (Kendall's tau-b=.24 and .23, respectively, p < .0001), as well as between religious salience and empowerment (Kendall's tau-b=.22, p < .0001). Additionally, as expected, use of various recovery strategies was positively related to one's level of empowerment (r = .29, p < .0001), and empowerment, in turn, was positively associated with quality of life (r = .31, p < .0001) and negatively with level of symptomatology (r = -.35, p < .0001). Associations between the four religious coping styles and other variables will be discussed separately.
Multiple regression analyses
A series of hierarchical regression analyses, with quality of life, symptom distress, level of empowerment, and recovery as criterion variables, were performed to test Hypotheses 2 and 3. Where appropriate, correlation matrix was also examined to clarify associations among the variables. To test Hypothesis 2, the predictor variables of sex, race, age, and presence of religious delusions were entered in the first block to control for them. Deferring, Plead, Collaborative, and Self-Directing coping styles were entered in the second block. The procedure was repeated with empowerment and recovery as criterion variables, respectively. Stepwise method was used within each block. In support of Hypothesis 2, the RPSS Collaborative factor predicted higher Personal Vision of Recovery Questionnaire (PVRQ) ([R.sup.2] change = .17, F change [1, 143] = 29.4, p < .0001) and empowerment scores ([R.sup.2] change = .05, F change [1, 143] = 7.9, p < .01) with demographic factors controlled for. When the effects of the Collaborative style were controlled for, higher scores on the Deferring RPSS accounted for lower total scores on the PVRQ ([R.sup.2] change = .03, F change [1, 142] = 4.8, p < .05), and higher scores on the Plead RPSS predicted lower scores in empowerment ([R.sup.2] change = .05, F change [1, 142] = 8.6, p < .01). Both findings are consistent with Hypothesis 2. Contrary to Hypothesis 2, the Self-Directing RPSS did not enter either prediction equation. However, examination of the correlation matrix revealed that a negative association emerged between PVRQ and this coping style (r = -.19, p < .05).
To test Hypothesis 3 that Collaborative RPSS predicts incremental variance beyond each of the three coping styles, three separate hierarchical regression analyses were conducted. In each analysis, demographic variables were entered in block 1. Block 2 consisted of Self-Directing, Deferring, and Plead RPSS, respectively, in each of the three separate analyses in order to control for each coping style individually. Collaborative coping style was then entered in block 3 in each analysis. Consistent with Hypothesis 3, Collaborative problem-solving strategy explained incremental variance in quality of life when Plead ([R.sup.2] change = .05; F change [1, 143] = 6.9, p < .05) and Self-Directing ([R.sup.2] change = .03; F change [1, 143] = 4.0, p < .05) styles were controlled for, respectively. Additionally, as predicted, reliance on the religious coping style of Plead accounted for 4% of the variance in higher symptom distress ([R.sup.2] change = .04; F change [1, 144] = 5.9, p < .05). However, contrary to expectation, use of the Deferring problem-solving style significantly predicted participants' improved quality of life before Collaborative RPSS was entered, explaining 5% of the variance ([R.sup.2] change = .05; F change [1, 144] = 8.0, p < .01). The Self-Directing RPSS did not enter the regression equations in accounting for variance in symptom distress or quality of life.
Factor and cluster analyses on RPSS
Principal axis factor analysis followed by an oblique rotation was used to ascertain that the original factor structure of RPSS replicated in the population of people who have severe mental illnesses. Eigenvalues greater than 1.0 and the scree plot were used to determine the number of factors to extract. The examination of the scree plot and meaningfulness of the item loadings on each of the factors (using the cutoff of .30 or higher) led to the retention of two correlated factors, with the first one including Collaborative, Deferring, and Plead items (45% of variance) and the second consisting of Self-directing items (10% of variance). The correlation between factors 1 and 2 was -.41. The scree plot is shown in Figure 1, and pattern loadings can be seen in Table 4. The factor structure of the RPSS in this data set markedly deviates from the original factor structure of the instrument reported by Pargament, Kennell, et al. (1988). This discrepancy should be explored in future studies.
Previous research has demonstrated that most individuals rely on more than one method of religious coping, and that examining one's pattern of religious problem-solving has utility (e.g., Bickel et al., 1998; Sears, Rodrigue, Greene, Fauerbach, & Mills, 1997). Thus, Ward's minimum variance method was used to perform three-, four-, five-, and six-solution cluster analyses, to determine the religious coping profiles of participants in this study. The three-cluster solution (Collaborative/Deferring/Plead [N = 35], Self-directing [N = 30], and Eclectic [N = 82]) provided the most parsimonious profiles. The first cluster included participants who scored high on Collaborative, Deferring, and Plead but lower on Self-directing coping styles. The second one consisted of individuals who scored high only on the Self-directing problem-solving style and low on Collaborative, Deferring, and Plead. Finally, the third cluster represented persons whose responses fell in the average range on all three religious coping styles.
This cluster solution is similar to the one reported with other populations, such as physically ill individuals and college students, where Self-directing, Deferring/Collaborative, and Eclectic religious coping profiles were found (i.e., Kolchakian & Sears, 1999; Sears et al., 1997). Figure 2 demonstrates these religious coping profiles, where numbers on the Y-axis represent standard deviations of each point in the cluster from the mean of the particular religious coping style.
[FIGURE 1 OMITTED]
In this sample, the percentage of participants who reported a belief in God/Higher Power is quite comparable to national statistics, reflecting favorably upon the generalizability of the current findings. On average, respondents in this study endorsed high levels of religious salience ([chi] = 8.9 out of 12 possible scale points) and bimodal religious service attendance, with "never" and "once a week" emerging as most frequent responses. This finding provides quantitative support to results from previous qualitative investigations that stressed the importance of religious faith to the population of people who have serious mental illnesses.
Hypothesis 1 predicted positive relations between religious salience and attendance and quality of life and negative associations between the two religious variables and symptomatology. This hypothesis was not supported by the data. However, religious salience was positively related to empowerment, and religious service attendance was tied to increased use of recovery-promoting activities. The lack of support for Hypothesis 1 is consistent with past research indicating that general religious variables are poorer predictors of psychological adjustment than more specific styles of religious coping (e.g., McIntosh, Silver, & Wortman, 1993; Pargament et al., 1990; Schaefer & Gorsuch, 1991). Although not directly linked with the degree of one's symptomatology and life satisfaction, greater religious commitment and involvement may represent one of several manifestations of an empowered stance one can take towards recovery as a whole.
Hypothesis 2 proposed positive associations between reliance on Self-directing and Collaborative religious problem-solving styles and participants' sense of personal empowerment and involvement in recovery. Dependence on Deferring and Plead religious coping styles was expected to predict a lower sense of empowerment and reduced participation in recovery. In support of Hypothesis 2, use of the Collaborative coping style made a significant positive contribution to variance in empowerment and various recovery-enhancing activities. However, contrary to Hypothesis 2, the Self-directing problem-solving style was negatively correlated with involvement in recovery although it did not enter either regression equation. When statistically separated from the Collaborative RPSS, consistent with Hypothesis 2, use of the Deferring RPSS predicted less active pursuit of recovery. Similarly, when variance shared with the Collaborative RPSS was removed, the religious coping style of Plead was associated with lower levels of empowerment. Thus, it appears that coping strategies that involve collaboration with God are most consistent with an active pursuit of recovery and an empowered stance, whereas exclusive reliance on one's own coping resources may be a deterrent of recovery or a by-product of decreased efforts to engage in it. Additionally, deferment and plead in relationship with God, when relied upon apart from a collaborative strategy, predict fewer recovery-promoting efforts.
Hypothesis 3 predicted that reliance on the Collaborative problem-solving style would be tied to lower levels of symptom distress and better quality of life. Both Self-directing and Deferring coping styles were expected to relate to decreased quality of life, whereas Plead was predicted to account for increased levels of symptomatology. The results lent support to the associations between Plead and higher symptom distress as well as between the Collaborative and Deferring approach to problem-solving and improved quality of life. These findings are largely consistent with previous research indicating the superiority of the Collaborative approach to coping and mixed implications for reliance on Self-directing and Plead styles. However, these results also extend recent research evidence indicating that deferment in relationship with God is not only used more often by people with serious mental illnesses than by individuals with other chronic medical illnesses such as diabetes (Taylor, 1999), but that it also has positive associations with life satisfaction in this population.
[FIGURE 2 OMITTED]
Taken together these findings indicate that, contrary to commonly held stereotypes that view religious faith and religious service attendance as passive coping strategies, these activities are associated with a higher sense of personal empowerment and greater adherence to various components of recovery. Moreover, in this sample, use of the Collaborative strategy emerged as a method of religious coping associated with the greatest level of empowerment and involvement in recovery-promoting activities. While deferring to God's wisdom, at the exclusion of other coping options, was tied to higher life satisfaction, it was connected with a more passive stance towards recovery. Additionally, pure reliance on Plead, as expected, was associated with increased levels of symptomatology and decreased sense of empowerment. Thus, Plead may have negative consequences as a method of religious coping in this population along with other previously researched groups. Alternatively, these results could be interpreted to indicate that individuals who are highly symptomatic tend to be more helpless and thus are apt to cry for help and plead for deliverance more than higher functioning persons. Similarly, it can be argued that consumers who are more satisfied with the quality of their lives and are more confident in their ability to overcome challenges confronting them are able to relate to God/Higher Power in more secure ways, by establishing a collaborative or deferring relationship.
Overall, the Self-directing religious coping style was tied to decreased use of recovery-related activities in this study. Previous research focusing on higher functioning individuals found the Self-directing coping style to be associated with increased levels of psychosocial competence in the context of largely controllable problems, yet higher levels of psychological distress in the context of uncontrollable problems (e.g., Bickel et al., 1998). The finding that this style was tied to the use of fewer recovery-enhancing activities could be a function of the emphasis of PVRQ on interpersonal relationships and help-seeking as essential ingredients of recovery. Thus, self-directing individuals' view of God as uninterested in their well-being or as a punishing being not to be trusted could also be manifested in a pattern of social avoidance in their everyday lives.
The fact that use of the Deferring style was positively related to life satisfaction and Self-directing strategy almost reached significance in negatively associating with quality of life can be tentatively interpreted as an indication that self-sufficiency does not promote life satisfaction in this population. This explanation would be consistent with much research indicating the critical role social and spiritual support play in recovery from serious mental illnesses. It is equally possible, however, that individuals who have found meaning and satisfaction in their lives have done so partly as a function of drawing on the awareness of Divine care and protection. Moreover, those who are unhappy with their circumstances may have abandoned their spiritual or religious commitments due to anger at God or despair and developed a more isolationist stance. Difficulty forgiving God has been found to be a strong and distinct predictor of negative emotion among college students (Exline, Yali, & Lobel, 1999). Future research should examine potential associations between disappointment and anger at God and recovery from severe and persistent mental illness.
The consistency of religious coping profiles found in this sample with those reported in previous studies indicates that the ways in which people who have serious mental illnesses cope do not differ from the general population of physically ill individuals or college students. The first cluster, consisting of individuals who scored high on Collaborative/Deferring/Plead and lower on Self-directing items, seems to represent those who are willing to engage in any coping strategy that involves God or Higher Power. This pattern may be similar to the phenomenon of indiscriminate proreligiousness, first coined and studied by Allport and Ross (1967). While Allport conceptualized indiscriminately proreligious persons as having both intrinsic and extrinsic attitudes towards religion, Cluster 1 members of this sample share with the original formulation a tendency to endorse all statements "that to them seem favorable to religion in any sense" (Allport & Ross, p. 437). It is also possible, however, that this cluster represents individuals who adjust their religious coping strategy based on the type and demands of the situation at hand.
Cluster 2 consists of persons who rely exclusively on their own resources to cope with adversity and who forgo sharing responsibility for problem-solving with a Higher Power. As mentioned previously, while most of these individuals endorse a theoretical belief in God, the coping strategies they choose better tap their underlying view of Deity as distant, uninvolved, or perhaps malignant and punishing. Finally, the third cluster includes participants who use a variety of coping styles in their recovery process. Because the present study did not investigate potential relations between the type of situation one confronts (i.e., in terms of appraisal of controllability) and the corresponding religious coping style used, it is difficult to ascertain whether distinguishable patterns can be found in this eclecticism.
A consistent finding in the religious coping literature has been the superiority of possessing a repertoire of coping styles to deal with a variety of problems over relying exclusively on a single coping style (e.g., Pargament et al., 1999). Because the effective-ness of a particular approach to problem-solving depends on the appraisal of controllability of the problem, the latter becomes a crucial variable of interest. In this study, the assumption was made that recovery from serious mental illness includes components that are generally viewed as uncontrollable as well as those that are within one's power to change. Therefore, it was hypothesized that the Collaborative problem-solving style would prove most flexible and effective in helping one deal with the complexities of recovery. However, the participants were asked to respond to questions regarding their religious coping in the context of recovery as a whole, rather than specific aspects of the process. It is likely that assessing the respondents' appraisals of controllability over specific situations relevant to recovery and the corresponding strategies used to cope with them would provide more direct answers to the research questions.
The issue of religious delusions deserves special attention and discussion in this study. Due to the lack of precise and agreed-upon definition and measurement system, the questions designed to tap the presence of religious delusions in this study were likely not comprehensive. However, in this sample, the presence of religious thinking of a delusional nature had the implication of heightened religiosity, but was not linked with functional or other recovery-related outcomes. Overall, a better measurement tool is necessary to draw more definitive conclusions regarding the role of religious delusions in the spiritual and psychosocial well-being of mental health consumers.
Another potential limitation of these findings is the researchers' complete reliance on self-report. The presence of cognitive deficits, common to this population, in addition to social desirability considerations and lack of insight may have affected not only the overall accuracy of some participants' responses, but their answers to questions of religious and spiritual nature in particular. Consequently, a social desirability measure should be included in future research in this area.
Overall, this study provided preliminary information on the nature of religious and spiritual beliefs and coping strategies and their association with recovery and level of functioning in the population of severely mentally ill. In summary, future research should measure participants' appraisal of controllability over various aspects of recovery and its association with particular religious coping styles. Second, the issue of religious delusions and their impact on mental health consumers' religious experiences and adjustment needs to be investigated further. Third, longitudinal studies assessing potential changes in participants' reliance on various religious coping methods, at different points in their illness, are necessary. Finally, it is recommended that future research examine associations between religious coping clusters and one's experience of relationship with God. For instance, the notion that individuals in Cluster 2 view God as an aloof figure would benefit from empirical investigation.
While further research is needed to replicate and broaden current findings, several recommendations based on the results can be made. First, mental health service consumers' reliance on religious faith and service attendance cannot and should not be dismissed as a symptom of their underlying psychopathology. Instead, it can be viewed as an empowering and recovery-promoting coping strategy and, thus, actively encouraged as part of treatment for those so inclined. Second, to those individuals who are open to exploring their spiritual and religious journeys, treatment can focus on discussing the benefits and liabilities of relying on various religious coping styles in the context of general problem-solving strategies. Both recommendations call for the need to bridge a gap between mental health and religious communities, as they work towards meeting the needs of this population.
Table 1 Demographic Characteristics of the Sample Frequency % Frequency Sex Male 74 49.0 Female 77 51.0 Race White, non-Hispanic 99 66.0 African American 46 30.7 Other 5 3.3 Marital Status Single 103 68.7 Married 8 5.3 Separated/divorced 38 25.3 Widowed 1 0.7 Education Less than high school 44 29.3 High school 58 38.7 Some college 38 25.3 Bachelor's degree 3 2.0 Graduate degree 7 4.7 Age Mean SD Range: 18-71 41.6 10.6 Employment* Unemployed 104 68.8 Employed part-time 34 22.5 Employed full-time 4 2.6 Volunteer 27 17.8 In school 12 8.0 Other 4 2.7 Diagnoses* Schizophrenia 48 29.6 Schizoaffective d/o 29 17.9 Bipolar disorder 24 14.8 Major depression 13 8.0 Substance abuse 12 7.4 Personality disorder 17 10.5 Other 19 11.7 Religious preference Protestant 69 45.7 Catholic 33 21.9 Jewish 4 2.6 No preference 31 20.5 Other 14 9.3 Other 14 9.3 *based on overlapping categories Table 2 Descriptive Statistics for All the Variables Variable Mean SD Religious salience 8.9 2.4 Collaborative RPSS 20.1 6.5 Self-directing RPSS 16.1 5.6 Deferring RPSS 18.4 6.3 Religious attendance Median = 3, Modes = 1, 4 Plead RPSS 15.9 5.4 Symptom Distress 37.9 13.4 Quality of Life 34.2 7.9 Total PVRQ 90.9 8.3 Total Empowerment 3.4 0.4 Table 3 Correlations between RPSS Factors and Other Variables Variable Factor 1 Factor 2 Factor 3 (Collaborative) (Deferring) (Self-directing) Age 0.03 0.06 0.10 Religious attendance 0.30** 0.23** 0.20** Religious salience 0.49** 0.36** 0.36** Symptom Distress 0.09 0.13 0.02 Quality of Life 0.22** 0.23** 0.16 Total Empowerment 0.21** 0.13 0.12 Total PVRQ 0.42** 0.23** 0.19* Variable Factor 4 (Plead) Age 0.02 Religious attendance 0.24** Religious salience 0.20** Symptom Distress 0.20* Quality of Life 0.09 Total Empowerment 0.20* Total PVRQ 0.27** *p < .05 **p < .01 Table 4 Pattern Loadings on RPSS Factor 1 Factor 2 Initial eigenvalues 10.3 2.3 RPSS 1 C 0.61 RPSS 5 C 0.65 RPSS 9 C 0.69 RPSS 13 C 0.73 RPSS 17 C 0.66 RPSS 21 C 0.71 RPSS 3 D 0.68 RPSS 7 D 0.67 RPSS 11 D 0.63 RPSS 15 D 0.73 RPSS 19 D 0.76 RPSS 23 D 0.67 RPSS 4 P 0.62 RPSS 8 P 0.70 RPSS 12 P 0.73 RPSS 16 P 0.73 RPSS 20 P 0.69 RPSS 2 S 0.50 RPSS 6 S 0.67 RPSS 10 S 0.70 RPSS 14 S 0.34 RPSS 18 S 0.66 RPSS 22 S 0.58 C -- Collaborative D -- Deferring P -- Plead S -- Self-Directing
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YANGARBER-HICKS, NATALIA: Address: Department of Psychology, Wheaton College, Wheaton, IL 60187. Title: Assistant Professor of Psychology. Degrees: MA, PhD, University of Cincinnati. Specializations: Severe mental illnesses; psychodynamic theory and therapy; psychology of the Holocaust; and Messianic Jewish identity.
Project funded by research grant #00.1154 from Ohio Department of Mental Health. Correspondence concerning this article may be sent to Natalia Yangarber-Hicks, PhD, Department of Psychology, Wheaton College, Wheaton, IL 60187. Email: Natalia.YangarberHicks@wheaton.edu