Special Issue: Spirituality and HealthCarl E. Thoresen, Editor
Spirituality and Health: Is There a Relationship?
Carl E. Thoresen
Stanford University
The role of spiritual and religious factors in health, viewed from a scientific perspective, has been yielding interesting if not intriguing results. In general, studies have reported fairly consistent positive relationships with physical health, mental health, and substance abuse outcomes, mostly using cross-sectional or prospective designs. Some spiritual or religious factors, however, have failed to demonstrate in some studies significant outcomes (e.g., gender differences). Empirical relationships have been commonly based on only a few questionnaire items. Adequate controls for possible confounding or moderating factors that could explain health outcomes have often been missing. A healthy skepticism seems called for, given the need to clarify and refine concepts, such as spirituality, develop comprehensive assessments, and conduct experimentally designed studies. Still, the overall evidence is promising enough to warrant careful and expanded study. Need for a methodological pluralism in research and for cultural sensitivity is recommended.
The notion that the body works in close collaboration with mind to influence health and disease has been increasingly accepted as this century comes to a close (e.g, Goleman & Gurin, 1993). Cognitive processes appear to convey information to an impressive array of physiological functions, such as the immune system, via the central, autonomic and neuroendocrine pathways (Coe, 1997; McEwen, 1998). Some of the most impressive evidence to date may come from experimental studies with humans and non-human primates demonstrating that perceived social stressors (e.g., threat, challenge, helplessness) apparently initiate a cascade of neuroendrocrine-related changes, such as elevated glucocorticoids (e.g., cortisol) (Sapolsky, Krey, & McEwen, 1986). Such changes have been found, for example, to increase atherosclerosis (coronary artery disease) (Manuck, Kaplan, Adams & Clarkson, 1988) and respiratory infections (Cohen, Doyle, Stoner, Rabin & Gwaltney, 1997; Cohen, Smith & Tyrrell 1991).
Social environmental and cultural factors also appear to influence health and disease status. That is, particular social settings create living contexts, rich in cultural "rules" and constructions of what is real, appropriate, meaningful and desirable.
Kleinman and Becker (1998) and others have labeled these social and cultural influences on health and disease as the field of "sociosomatics."
With transactional perspectives of health and disease in mind, viewing health as far more than just physiology, recent interest in spiritual and religious factors in health and disease seems understandable (e.g., Koenig, 1997; Pargament, 1997; Richards & Bergin, 1997). Long known has been the fact that some religious groups (e.g., Mormons, Adventists) live longer with less chronic disease than other religious or non-religious groups (Cochran, Beeghley, & Block, 1988; Richards & Bergin, 1997). Perhaps they do because healthier habits and practices (e.g., no smoking, no alcohol) are strongly sanctioned and perhaps because of extensive family support programs. But differences in health status may not be simply explained by better health practices or family social support. As will be discussed, trying to clarify why a spiritual or religious factor, among other factors, may influence health presents a genuine challenge.
It is interesting to recall that at the turn of the last century spiritual and religious factors in health were clearly recognized. William James (1902), a father of American psychology, wrote on religious experiences, noting how such experiences could influence overall health and well being. Sir William Osler, founder of modern cardiology, if not modern clinical medicine, wrote a series of articles early in this century about religious factors in medical care for the British Medical Journal (Osler, 1910). Yet the advent of germ theory with the development of vaccines, new pharmaceuticals, and highly advanced surgical techniques all but eclipsed concern for personal and social cultural factors, such as religious beliefs or spiritual practices (Chatters, Levin & Ellison, 1998).
As this century closes, interest in spiritual and religious issues in health has rebounded, but in ways distinctly different from earlier periods. Along with growing public interest, an emerging empirical literature is beginning to document significant relationships between religious factors and health status (e.g., Larson, Swyers & McCullough, 1998, Levin, 1994). The recent publication of articles has been noted in prestigious scholarly journals (e.g., American Journal of Public Health, Journal of the American Medical Association, Journal of Consulting and Clinical Psychology, and Journal of Personality and Social Psychology. Special issues on spirituality, religion and health in journals, such as this issue, and in other journals have or will be appearing (Chatters, Levin & Ellison, 1998). In addition, a chapter on spirituality and health (Thoresen & Harris, in preparation) will appear in the forthcoming Handbook of Health Psychology (Raczynski, Leviton & Bradley, in preparation) to be published by the American Psychological Association. (Also see McCullough, Pargament & Thoresen, in press; Richards & Bergin, 1997).
Currently a religious or spiritual gap may exist between those with health problems and health professionals who conduct research or who provide service. For example, between 1 and 5 percent of the American public described themselves as agnostic or atheist compared to 50 percent of health professionals (Gallup, 1985). This gap could contribute to several possible problems, starting with the lack of professional training about possible roles that religious and spiritual factors can play in health, and the common omission of any religious or spiritual assessments in research studies or in taking medical histories and planning treatment (e.g., Barnard, Dayringer & Cassel, 1995).
Several reasons appear plausible within the American culture and possibly in other highly industrialized cultures. These include the following:
Several other emerging social and cultural problems and developments could be possible reasons, such as growing inner-city violence, poverty, alcohol and substance abuse, job strain, and work addiction.
Clearly the term spirit has evolved over the centuries, yet the underlying essence of spirituality still alludes to a search or quest for the sacred in life and beyond, a seeking of answers to life’s most meaningful and vital questions. As such, a crisp, tightly bounded definition that readily captures the breath and depth of spirituality is difficult. Aldridge (1993), for example, presented 13 definitions focused primarily on spirituality and healing. Most definitions cited mentioned or alluded to the following: 1) Need to transcend or rise above everyday material or sensory experience; 2) One’s relationship to God or some other higher universal power, force or energy; 3) Search for greater meaning, purpose and direction in living; and 4) Healing by means of non-physical kinds of intervention (e.g., prayer, meditation, religious beliefs).
Others however have defined spirituality as clearly a part of organized religion, for example, the Judeo-Christian tradition that includes both institutional as well as personal factors (e.g., Koenig, 1993). From this perspective, religion is the more inclusive concept (Larson, Swyers and McCullough, 1998).
If we accept the latent, multidimensional nature of spirituality as a concept, that it has many facets of which some may not be readily observable, and if we accept the fact that some persons may agree on some of these facets but not on others, then we can seek different ways to describe and understand it. We can also realize that a comprehensive assessment of spirituality requires multifaceted approaches, making it difficult to capture spirituality, for example, in a simple, brief questionnaire (Miller & Thoresen, in press). This does not preclude, however, attempts to create a relatively brief set of items that could reveal at least some but not all features of spirituality (Gorsuch & Miller, in press).
Religion as with spirituality is multidimensional. Most agree that it involves a social institution with an organized system of beliefs, practices, rituals, and symbols designed to facilitate a relationship to and understanding of a deity (or deities). Religions seek to promote understanding and harmony of a person’s relationship to oneself and to others in living together in community and to a transcendent power in the universe. Religions also involve many practices and procedures than can have either positive and negative effects on health (see Richards & Bergin, 1997, for further discussion).
Here only highlights can be mentioned (see Ellison & Levin, 1998; Koenig, 1997; Larson, Swyers & McCullough, 1998; Levin, 1994 for further information). Basically, empirical evidence based on over 300 studies have demonstrated in many but not all cases that a positive relationship exists between spiritual or religious factors and health. This relationship appears valid, in general, and is not fully explained by other health-related factors (e.g., by level of social support, by specific health behaviors or beliefs, or sociodemographic factors). However, causal evidence is clearly lacking (e.g., that religious beliefs cause better health) since prospective studies have not adequately assessed the multidimensionality of religion or spirituality to clarify possible mechanisms. Furthermore, prospective studies have not accounted for many psychosocial and sociocultural factors that could explain health outcomes. With rare exception, experimentally designed studies (e.g., randomized clinical trials) have not been conducted (Harris, Thoresen, McCullough & Larson, 1999, this volume; Thoresen, et al, 1998).
The logic of science anticipates that humans will generally err in their conjectured beliefs and selective interpretations about how nature works, including their explanations of causality (e.g., Murphy, 1972, Suppe, 1977). Any claim of causality about spirituality and health, often based on cross-sectional or prospective studies, must be viewed very cautiously (Miller & Thoresen 1997; Popper, 1965). Without evidence from replicated, experimentally designed studies, matters of causality remain unclear.
With that caveat in mind here are some tentative comments about the evidence linking spiritual and religious factors to physical health (see Levin, 1994 for detailed discussion). Note that in the studies examined, religious factors have been assessed in very limited ways, typically by one or a few items in a questionnaire used on only one occasion. Typical items have asked about a person’s religious affiliation, attending religious services, use of prayer or belief, or about how important the person viewed their religious beliefs. In general:
The studies have included the following characteristics:
A recent panel of behavioral and social scientists as well as religious scholars essentially have echoed the above comments, but have also reviewed evidence relating spiritual and religious factors to mental health and alcohol and other drug abuse (Larson, Swyers & McCullough, 1998; also see Worthington, Kurusu, McCullough & Sandage, 1996). The following highlight findings for those persons who were more spiritually or religiously involved:
While the overall picture suggests a positive relationship, a healthy skepticism in much in order. Statistically significant correlations or explained variances are not valid substitutes for evidence from experimentally-based studies. Feinstein (1988), a noted epidemiologist, has argued persuasively that epidemiological studies commonly rely upon prediction, not experimentation, and most as such cannot strongly confirm explanations. He also noted the common error in published studies of authors implying causality. Miller (1997) cogently argues that prospectively designed studies using modern statistical methods (e.g., logistic regression, structural equation models) cannot adequately clarify explanations about possible causes due to temporal confounding of predictors used. Too often the explanatory contribution of a particular factor has been obscured because it may occur before or after other factors.
Levin (1996) has urged caution in overinterpreting or misrepresenting findings in this area of inquiry. He discussed several myths that may put findings into a more proper perspective. Figure 1 summarizes some of these misunderstandings. Others have questioned, in general, studies showing a spiritual and religious connection to health (e.g., Sloan, Bagiella & Cooper, 1999).
In effect, the literature supports, with exceptions, a modest relationship between various measures of religiousness (e.g., church attendance) and disease indicators, including mortality. What the literature does not provide, however, are answers on health outcome to the following questions about health outcomes:
Research focused on these kinds of questions, and several others, will begin to clarify and expand our understanding of the spiritual and religious relationships with health. Harris, Thoresen, McCullough & Larson (1999, this issue) discuss some of these questions in greater detail (also see Thoresen et al, 1998).
How might the often found relationship between spiritual and religious factors with health outcomes be explained? By what sequence of processes could, for example, feeling a strong sense of strength and comfort from one’s religious beliefs predict death six months after coronary surgery (e.g., Oxman, Freeman & Manheimer, 1995)? It is important to keep in mind that understanding the processes by which things actually happen is for many the ultimate scientific goal. Yet such understanding may be long in coming and requires careful consideration of many factors, especially when a spiritual or religious factor may most likely be one of several factors that explain health outcomes (Harris, Thoresen, McCullough & Larson, 1999, this issue).
Keep in mind that evidence offering a possible explanation for why a spiritual and religious factor might influence health can be viewed in at least 3 different ways (D. Oman, personal communication, 2/23/99). Each way of framing possible combinations of factors may lead to different interpretation of findings.
Unfortunately, failure to clarify these different frameworks can create confusion and disagreement in how evidence is evaluated (e.g., Sloan, Bagiella & Powell, 1999). Also keep in mind that a factor may be found to be useful within an intervention without fully understanding how or why it is effective. The successful treatment of many health problems has occurred, such as hypertension, without knowing exactly how the treatment works or why people have the problem (Engel, 1998; Cooper, Rontini & Ward, 1999).
Promising Physiological Possibilities
Several possibilities of mechanisms can be classified into three major categories: physiological, psychosocial, and sociocultural. Scheidt (1996), for example, provided an array of possible physiological mechanisms that could explain coronary heart disease risk. Several cited could conceivably relate to how a religious or spiritual factor, such as meditation or forgiving others, could help explain reductions in disease risk. Of the 12 possibilities, Scheidt (1996) identified excessive sympathetic nervous system (SNS) arousal, coupled with hypothalamic-pituitary-adrenal (HPA axis) arousal, as the most evidence-based possibility. Common sources of SNS and HPA axis arousal that produce, for example, excessive levels of norepinephrine (noradrenalin) and cortisol, are chronic negative emotional states (e.g., anger, fear, depression) as well as certain cognitions that construe current or anticipated situations and events as very dangerous, threatening or challenging.
McEwen (1998) recently outlined different physiological problems associated with chronic distress. The term "allostatic load" describes the health costs of physiological changes that seek to restore and maintain physiological stability in the face of perceived demands. (Allostasis is defined as the ability of the body to achieve stability through changing to meet perceived demands). McEwen notes that the body’s capacity to recover stability in response to long-term distress may be gradually lost (e.g., the person may experience more and more prolonged arousal and thus delayed recovery or the person may lose the overall ability to respond physiologically to demands). This, in turn, leads over time to major disruptions in cardiovascular, metabolic, immune and brain functions (e.g., Seeman & McEwen, 1996).
Perceived loss of control, lack of social emotional support, poverty, and low social status have been suggested as examples of sources that contribute to excessive and chronic allostatic load. Conceivably those more religiously involved or spiritually active may benefit greatly in drawing upon the resources provided by others in religious organizations and/or by their own spiritually enhancing beliefs, and practices and experiences. Doing so could reduce the level of allostatic load, thus enhancing overall physiological functioning.
Promising Psychosocial Possibilities
Psychosocial mechanisms that could possibly explain a religious-health connecting are several (Pargament, 1997). These could be described under categories of cognitive/motivational, behavioral, interpersonal, and sociocultural processes (Miller & Thoresen, in press). Examples of more specific processes that could influence health, (i.e., could mediate or moderate health outcomes) include a variety of health behaviors and habits (e.g., avoiding cigarettes, balanced diet, physical activities). Cognitive processes could include self-perception of worth, including perceived acceptance and approval by others and/or God or Divine Spirit, perceived self-efficacy beliefs about competence to take action needed to accomplish goals, (e.g., making friends, giving unselfishly to others, attributions about life satisfaction, and beliefs about love and compassion as life’s major guiding principles). Possible interpersonal resources include, for example, having friends who share spiritual or religious beliefs and practices, group meditation skills, and understanding interpersonal forgiveness.
Sociocultural factors, such as beliefs and symbols about illness and suffering, connected to spiritual and religious factors may also help create the kind of social context that promotes health-enhancing behavior, cognitions and interpersonal relationships (Kleinman & Becker, 1998). Such contexts may diminish, for example, the excessive individualistic if not narcissistic styles often associated with adverse health and quality of life (Emmons, in press).
A promising example of how cultural norms may influence health within a religious setting is found within many African Americans churches in the United States (e.g., McCrae & Carey, 1998). For some African Americans, the church offers a safe and caring context, one that encourages making behavior and cognitive changes in health-related beliefs and habits. Thus the cultural norms and values associated with some Black churches may foster effective church-based health programs concerning physical and mental health.
Given the early state of the scientific literature on spiritual and religious factors, methodological if not conceptual pluralism in research seems especially important. No one level of magnification provides the best lens to see all vistas clearly. The vast majority of prospectively designed epidemiological studies, as noted, have relied solely on one or a few "religious" items on one occasion (Gorsuch & Miller; 1999). We have essentially no information on how, if at all, people change in this area over time. If religious and spiritual factors were all unquestionably fixed traits or characteristics, then one assessment would suffice. But if these factors change over time, then assessments are need to capture the degree and the direction of change, if any, over time. Some factors may indeed function as enduring characteristics, such as religious affiliation, but others may indeed change, such as beliefs about forgiveness or use of meditation.
Questionnaires do offer an inexpensive and convenient way to gather information. However, given the early stages of theoretical development in this area, a variety of research methods spanning quantitative and qualitative research designs could offer the kind of information needed to build theory and inform practice (Cook, 1985). That is, a mix of methods and modes seems called for, whereby a specific research problem or question guides decisions about what combination of methods are best suited. As Kaplan (1964), a noted philosopher of science, once noted, too often researchers attempt to study various problems with the same tool, much like the young boy who, having discovered a hammer, decides everything in sight needs hammering. An impressive array of assessment tools are available, from ambulatory monitors of physiology and ambulatory cueing devices to prompt cognitive and behavioral self-monitoring (e.g., Newman, Kenardy, Herman & Taylor, 1997) to software programs to quantify narrative themes transcribed from in-depth interviews (Denzin & Lincoln, 1994).
Westen (1999) recently discussed evidence that people commonly remain quite unaware of most of their daily experiences, unless in some way specifically prompted or assisted. For example, Keefe et al, (1997) recently used brief daily self-monitoring of mood, physical symptoms, pain level and coping methods with excellent compliance over 30 days among chronic pain patients. Such information added a great deal to standardized questionnaire data in clarifying how daily patterns influenced pain and psychosocial factors. Interesting, spiritual coping was found to be a powerful predictor of pain during the following 24 hour period. Davidson, Stuhr & Chambers (in press) found that standard questionnaire reports of anger were often misleading, given the common unawareness of many about their own level of anger. A brief, highly structured interview was found to be more successful in predicting diastolic blood pressure recovery rates after stressful events when compared to anger questionnaires which failed to predict recovery rates. These two examples suggest that a variety of assessment measures and modes are needed and can be adapted to explore more fully spiritual and religious factors related to health.
This Special Issue features several studies that touch upon some of the spiritual and religious factors related to health. In many ways the findings reported offer a glimpse of the current state of what we know and, more importantly what we need to find out. Developmentally, empirical research in this area may be at the toddler level, with some almost balanced movement forward, but falls aplenty. While some speech is available, it’s not always understood. There’s also much to be curious about and lots to get into, sometimes in ways that may not be appreciated. Still, evidence is available that something called spiritual and/or religious seems to be often related positively to health status.
The articles selected represent the best of those submitted but are not in any way comprehensive of possible spiritual and religious factors nor health and disease issues. Hopefully these articles will stimulate readers to explore this exciting and controversial topic. As has been noted, spiritual and religious factors represent part of the rapidly expanding alternative and complementary medicine perspective, at times called unconventional practices (Eisenberg, et. al., 1993).
There is much to be skeptical about in this developmentally young area of empirically-based theory and research. Little is currently known with confirmed confidence. Trying to clarify concepts, such as spirituality, trying to improve assessments, such as moving beyond one or a few questionnaire items, and trying to conduct experimental studies, such as those exploring possible mediating or moderating variables, will all greatly clarify what is known.
Some ethical issues in this area may remain, even if findings are empirically replicated. For example, should physicians and other health care professionals assess and use spiritual and religious factors in their practice? What if the health professional is non-spiritual or non-religious? Does such a person still have responsibility to consider the topic? Sloan, Bagiella & Powell (1999), for example, mention the inappropriateness of any physician using a social demographic factor, such as marital status, economic status, or religious status in a "medical intervention," even if such factors are known to influence health or disease. Would it be unethical for any physician or other health professional, such as a health psychologist, to assess spiritual or religious factors and use that information in planning a treatment?
Such questions illustrate the type of concerns that have been raised. They deserve careful consideration. Yet such questions need not prevent the conduct of well-controlled empirical studies. Careful review by appropriate institutional review boards concerned with research involving human subjects, along with informed written consent can provide safeguards against unethical inquiry. Hopefully, a group of established empirical researchers in this area along with health ethicists will collaborate with health care practitioners from various disciplines to consider major ethical issues and practice guidelines.
I was very impressed when Robert Sapolsky, a distinguished biologist, authored a paper in Science entitled, "Why Stress is Bad for Your Brain" (Sapolsky, 1996). In it he reviewed evidence that chronic stress, such as long-term clinical depression and the post-traumatic stress disorder, predicted permanent damage in the hippocampus. Perhaps someone in time in reviewing the evidence may be able to write an article for Science entitled, "Why Spirituality is Good for Your Body." Given the fact that so much of the impossible has actually become possible in this century, the scientific basis for such an article may be a real possibility for the 21st century.
(Adapted from Levin, 1996)
|
Popular Myth |
Empirical Reality |
|
1. Religious involvement promotes healing |
No, may prevent morbidity |
|
2. Religious people don’t get sick |
No, associated with lower risk or odds of morbidity |
|
3. Spirituality is a protective factor |
No, not yet studied independent of religion |
|
4. Prayer heals |
No, epidemiological evidence lacking; experimental designs needed |
|
5. Religion is the most important factor in health |
No, may be one significant factor among many others preventing/coping with disease |
|
6. Supernatural powers influence health |
No, scientific evidence not available |
|
7. Other factors explain away all religion-health relationships |
No, religious factors as possible indirect cause, not just confounding or proxy variable |
Albom, M. (1997). Tuesdays with Morrie. New York: Doubleday.Aldridge, D. (1993). Is there evidence for spiritual healing? Advances, 9, 21.
Armstrong, K. (1993). A history of God. New York: Knopf.
Bellah, R.N., Madisen, R., Sullivan, W., Swidler, A., & Tipton, S. (1985). Habits of the
heart: Individualism and commitment in American life. Berkeley, CA: University
of California Press.
Chatters, L.M., Levin, J.S. & Ellison, C.G. (1998). Public health and health education in
faith communities. Health Education and Behavior, 25, 689-699.
Cochran, J.K., Beeghley, L. & Block, E.W. (1988). Religiosity and alcohol behavior: An
exploration of reference group therapy. Sociological Forum, 3, 256-276.
Coe, C. (1997). Sociality and immunological health revisited. Psychosomatic Medicine,
59, 222-223.
Cohen, S., Doyle, W.J., Stoner, D.P. , Rabin, B.S. & Gwaltney, J.M.Jr. (1997). Social
ties and susceptibility to the common cold. Journal of the American Medical
Association. 277, 1940-1944.
Cohen, S., Smith, A.P. & Tyrrell, D.A.J. (1991). Psychological stress and susceptibility
to the common cold. New England Journal of Medicine, 325, 606-612.
Coles, R. (1997). The moral intelligence of children. New York: Random House.Cook, T.D. (1985). Postpositivist critical multipilism. In. R.L. Shotland & M.M. Marks
(Eds.), Social Science and Social Policy (pp. 21-62). Beverly Hills, CA: Sage.
Cooper, R.S., Rotimi, C.N. & Ward, R. (1999). The puzzle of hypertension in African-
Americans. Scientific American, 280, 56-62.
Damon, W. (1995). Greater expectations. New York: Free Press.Davidson, K., Stuhr, J. & Chambers, L. (in press). Constructive anger behavior as a
stress buffer. In K.D. Craig & K.S. Dobson (Eds.). Stress, vulnerability and
resiliency. Thousand Oaks, CA: Sage.
Denzin, N.K. & Lincoln, Y.S. (Eds.)(1988). Handbook of Qualitative Research.
Thousand Oaks, CA: Sage.
Eisenberg, D.M., Kessler, R.C., Foster, C., Norlock, F.E., Calkins, D.R., & Delbanco,
T.L. (1993). Unconventional medicine in the United States: Prevalence, costs,
and pattern of use. New England Journal of Medicine, 328, 246-252.
Ellison, C.G. & Levin, J.S. (1998). The religion health connection: Evidence, theory and
future directions. Health Education and Behavior, 25, 700-720.
Emmons, R.A.. (in press). Personality and forgiveness. In M.E. McCullough, K.I.
Pargament & C.E. Thoresen (Eds.) Forgiveness: Theory, research and practice.
New York: Guilford Press.
Engel, B.T. (1998). An historical and critical review of the articles on blood pressure
published in Psychosomatic Medicine between 1939 and 1997. Psychosomatic
Medicine, 60, 682-696.
Erickson, E.H., Erickson, J,M. & Kivnick, H.W. (1986). Vital involvement in old age.
New York: Norton.
Feinstein, A.R. (1988). Scientific standards in epidemiological studies of the menace of
daily living. Science, 242, 1257-1263.
Gallup, G. (1985). Religion in America, 50 years: 1935-1985. Princeton, NJ: Princeton
Religious Research Center.
Gallup, G. (1995). The Gallup Poll: Public opinion 1995. Wilmington, DE: Scholarly
Resources.
Goleman, D. & Gurin, J. (1993). Mind body medicine: How to use your mind for better
health. New York: Consumer Union.
Gorsuch, R.L. & Miller, W.R. (in press). Measuring spirituality. In W.R. Miller (Ed.)
Integrating spirituality into practice: Resources for practitioners. Washington, D.C.: American Psychological Association.
Harris, A.H.S., Thoresen, C.E., McCullough, M.E. & Larson, D.B. (1999).
Spiritually and religiously oriented health interventions. Journal of Health Psychology, XX, XX-XX.
House, J.S., Landis, K.R. & Umbertson, D. (1988). Social relationships and health. Science, 241, 540-545.Kaplan, A. (1964). The conduct of inquiry. San Francisco: Chandler.
Keefe, F.J., Affleck, G., Lefebvre, J.C., Starr, K., Caldwell, D.C. & Tennen, H. (1997).
Pain coping strategies and coping efficacy in rheumatoid arthritis: A daily process analysis. Pain, 69, 35-42.
Kleinman, A. & Becker, A.E. (1998). "Sociosomatics": The contributions of
anthropology to psychosomatic medicine. Psychosomatic Medicine, 60, 389-393.
Koenig, H.G. (1992). Aging and God: Spiritual pathways to mental health in midlife and
later years. New York: Haworth.
Koenig, H.G. (1997). Is religion good for your health? Effects of religion on mental and
physical health. New York: Haworth Press.
Larson, D.B., Swyers, J.P. & McCullough, M.E. (Eds.)(1998). Scientific research on
spirituality and health: A consensus report. Rockville, MD: National Institute.
Levin, J. (1994). Religion and health: Is there an association, is it valid, and is it causal? Social
Science and Medicine, 38, 1475-1484.
Levin, J.S. (1996). How religion influences morbidity and health: Reflections on natural
history, salutogenesis and host resistance. Social Science & Medicine, 43,5,
849-864.
Levin, J.S., Larson, D.N. & Puchalski, C.M. (1997). Religion and spirituality in medicine: Research and education. Journal of the American Medical Association, 278, 792-793.Manuck, S.B., Kaplan, J.R., Adams, M.AR., Clarkson, T.B. (1988). Studies of
psychosocial influences on coronary artery atherogenesis in cynomolgus
monkeys. Health Psychology, 7, 113-124.
Matthews, D.A., Larson, D.B. & Barry, C. (1993). The faith factor: An annotated
bibliography of clinical research on spiritual subjects. Rockville, MD: National
Institute for Healthcare Research.
McCrae, M.B. & Carey, P. (1998). Black churches as therapeutic systems: A group
process perspective. Health Education and Behavior, 25, 760-778.
McCullough, M.E., Pargament, K.I., & Thoresen, C.E. (in press). The psychology
of forgiveness: History, conceptual issues and overview. In M.E. McCullough,
K.I. Pargament and C.E. Thoresen (Eds.), Forgiveness: Theory, research and
practice. New York: Guilford Press.
McEwen, B.S. (1998). Protective and damaging effects of stress mediators. New
England Journal of Medicine, 338, 171-179.
McNichol, T. (April, 1996). The new faith in medicine. USA Today, April 7, 1996.Miller, W.R. & Thoresen, C.E. (in press). Spirituality and Health. In W. Miller (Ed.). Integrating spirituality into treatment: Resources for practitioners. Washington, D.C.: American Psychological Association.
Miller, T.Q. (1997). Statistical methods for describing temporal order in longitudinal
research. Journal of Clinical Epidemiology, 50, 1115-1168.
Murphy, E.A. (1972). The logic of medicine. Baltimore, MD: Johns Hopkins University
Press.
Newman, M.G., Kenardy, J., Herman, S. & Taylor, C.B. (1997). Comparison of palmtop
computer-assisted brief cognitive-behavioral treatment to cognitive-behavioral
treatment for panic disorder. Journal of Consulting and Clinical Psychology, 65,
178-183.
Oman, D. (1999, February 22). Personal communication, Stanford University.Osler, W. (1910). The faith that heals. British Medical Journal,1470-1472.
Oxman, T.E., Freeman, D.H. & Manheimer, E.D. (1995). Lack of social participation or
religious strength and comfort as risk factors for death after cardiac surgery in the
elderly. Psychosomatic Medicine, 57(1), 5-15.
Pargament, K.I. (1997). The psychology of religion and coping: Theory, research, and
practice. New York: Guilford.
Peck, M.S. (1978). The road less traveled. New York: Bantam.Popper, K.R. (1965). Conjectures and refutations. New York: Harper Collins.
Raczynski, J.M., Leviton, L.L., Bradley, L. (Eds.)(in preparation). Handbook of health
psychology (Vol. II). Washington, D.C.: American Psychological Association.
Richards, P.S. & Bergin, A.E. (1997). A spiritual strategy for counseling and
psychotherapy. Washington, D.C.: American Psychological Association.
Roof, W.C., Carroll, J.W. & Roozen, D.A. (1995). Conclusion: The postwar generation –
the carriers of a new spirituality. In W.C. Roof, J.W. Carroll & D.A. Roozen
(Eds.) The postwar generation and establishment religion: Cross-cultural
perspectives. Santa Barbara, CA: Westport Press.
Sapolsky, R.M. (1996). Why stress is bad for your brain. Science, 273, 740-741.Sapolsky, R. M., Krey, L.C. & McEwen, B.S. (1986). The neuroendocrinology of stress
and aging: The glucocorticoid cascade hypothesis. Endocrinology Review, 7, 284-
301.
Scheidt, S. (1996). A whirwind tour of cardiology for the mental health professional. In
R. Allan & S. Scheidt (Eds.), Heart and mind: The practice of cardiac psychology
(pp. 15-124). Washington, D.C.: American Psychological Association.
Seeman, T.E. & McEwen, B.S. (1996). The impact of social environment characteristics
on neuroendocrine regulation. Psychosomatic Medicine, 58, 459-471.
Sloan, R.P., Bagiella, E. & Powell, T. (1999). Religion, spirituality and medicine.
Lancet, 353, 664-667.
Suppe, F. (1977). The structure of scientific theories. (2nd ed.) Urbana, IL: University of
Illinois Press.
Thoresen, C.E. & Harris, A.H.S. (in preparation). Spirituality and health. In J.M.Raczynski, L.L. Leviton & L. Bradley (Eds.) Handbook of Health Psychology
(Vol. II). Washington, D.C.: American Psychological Association.
Thoresen, C.E., Worthington, E.L., Swyers, J.P., Larson, D.B., McCullough, M.E. &Miller, W.R. (1998). Religious and spiritual interventions. In D.B. Larson,
Swyers, J.P. & McCullough, M.E. (Eds.) Scientific research on spirituality and
health: A consensus report (pp. 104-129). Rockville, MD: National Institute for
Healthcare Research.
Westen, D. (1998). The scientific legacy of Sigmund Freud: Toward a
psychodynamically informed psychological science. Psychological Bulletin, 124,
333-371.
Worthington, E.L. Kurusu, T.A., McCullough, M.E. & Sandage, S.J. (1996). Empirical
research on religion and psychotherapeutic processes and outcomes: A 10-year
review and research prospectus. Psychological Bulletin, 119, 448-487.