Transcript of "Religion And Disability Clinical, Research And Training Considerations For Rehabilitation Professionals"
Disability and Rehabilitation, August 2007; 29(15): 1153 – 1163
Religion and disability: Clinical, research and training
considerations for rehabilitation professionals
BRICK JOHNSTONE1, BRET A. GLASS2 & RICHARD E. OLIVER3
Department of Health Psychology, 2Department of Educational, School, and Counseling Psychology, and 3School of Health
Professions, University of Missouri-Columbia, Columbia, Missouri, USA
Accepted July 2006
Purpose. This article (i) reviews existing research on the relationships that exist among spirituality, religion, and health for
persons with disabilities; and (ii) compares different theoretical coping models (i.e., spiritual vs. psychoneuroimmunological).
Background. Over the past decade interest has increased in relationships among spirituality, religion, and health in both
the mainstream media (e.g., Newsweek) and scientiﬁc literature (e.g., Koenig). In general, research has concluded that
religion and spirituality are linked to positive physical and mental health outcomes. Most religion and health research
has focused on populations with life-threatening diseases (e.g., cancer, cardiovascular disorders, AIDS) with minimal
attention to persons with chronic, life-long disabling conditions such as brain injury, spinal cord injury, and stroke. However,
religion is used by many individuals with disabilities to help them adjust to their impairments and to give new meaning to
Conclusions. Religion and spirituality are important coping strategies for persons with disabilities. Practical suggestions for
rehabilitation professionals are provided regarding: (a) strategies to enhance religious coping; (b) methods to train
rehabilitation professionals about religious issues; and (c) issues to consider regarding future research on rehabilitation and
Keywords: Religion, disability, rehabilitation, psychology, health
Religion and health
Passion of the Christ, Luther). Traditional beliefs about
Over the last decade laypersons and health profes- separation of church and state have even changed
sionals have become increasingly interested in the over the past several years, as evidenced by the faith-
relationship between health and religion. This has based health initiatives that have been promoted by
been due in part to the growing religious diversity in President Bush in the US.
the United States  and increased attention to Although the impact of religion on health has been
different faiths since September 11, 2001. Although infrequently researched in the past, several promi-
the relationship between religion and health has been nent psychological and rehabilitation journals have
minimally discussed in the mainstream media in the recently published special journal issues/sections on
past, Newsweek recently published a special issue the subject. These include the American Psychologist
entitled, ‘God & health: Is religion good medicine? (‘Spirituality, religion, and health’; ), the Journal
Why science is starting to believe’ . In addition, of Rehabilitation (‘Spirituality and disability’; ),
over the past ten years television programs with a and the American Psychological Association’s Monitor
religious theme have proven to be very popular (e.g., (‘Spirituality and health’; ). Even the Journal of the
Touched by an Angel) and recent movies with a American Medical Association published the proceed-
religious focus have generated much discussion ings of two conferences that addressed spirituality
regarding the role of religion in society (e.g., The and health . Furthermore, the National Institutes
Correspondence: Brick Johnstone, PhD, Department of Health Psychology, DC116.88, University of Missouri-Columbia, Columbia, MO 65212, USA.
Tel: þ1 573 882 6290. Fax: þ1 573 882 3518. E-mail: firstname.lastname@example.org
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd.
1154 B. Johnstone et al.
of Health (NIH) has funded numerous projects succinctly deﬁne and measure these differing con-
investigating the impact of religion on health over the structs.
past decade, and private foundations, such as the
John Templeton Foundation, are providing signiﬁ-
Religion and health research
cant ﬁnancial support to research the relationship
between religion and health. As previously indicated, there has been increasing
This new attention to healthcare and religion research regarding religion and health over the past
stems from the central role religion plays in the lives decade. Some researchers have focused on the
of most individuals. For example, recent Gallup polls impact of religion on persons with various diseases,
indicate that religion is a ‘very important’ part of the including kidney disease , cancer , heart
lives of 55% of the American public and is ‘fairly disease , lung disease , HIV/AIDS ,
important’ to another 29% . Over 90% of cystic ﬁbrosis , diabetes , sickle cell disease
individuals polled in 2003 reported believing in a , and ALS . Other research has focused
‘God’  and 66% reported being a member of a on the efﬁcacy of speciﬁc religious beliefs and
church or synagogue . In another national survey practices in promoting health, including traditional
McCaffrey et al.  estimated that one third of Judeo-Christian and Eastern religious practices such
adults used prayer for health concerns, and indicated as Zen, yoga, and meditation .
that people who prayed reported high levels of A review of the literature by Koenig and colleagues
perceived helpfulness. Newsweek  further indi-  identiﬁed 724 quantitative studies of religion
cated that 84% of Americans think that praying and health published during the 20th century, and
for people who are ill improves their chances of reported that 66% found a statistically signiﬁcant
recovery, and 72% state they would welcome the relationship between religion and better mental
opportunity to discuss their religious beliefs with health, greater social support, and less substance
their physician. abuse. Although the existing research suggests that a
It is clear that laypersons, health professionals, and positive relationship exists between religion and
researchers are interested in addressing the impor- health, some professionals have argued that this
tance of religion in society and in health care. research is plagued by methodological problems. For
However, if we are to use religion effectively to example, it is frequently argued that the positive
improve the health of individuals, there is a need to relationships that are commonly observed between
better educate current rehabilitation professionals increased religiosity and health are more likely
and students about religion, to critically evaluate the attributable to the lifestyle behaviors of religious
existing literature on disability and religion, and to individuals rather than religion per se, e.g., less
develop practical suggestions for rehabilitation pro- alcohol consumption and better dietary habits ,
fessionals to appropriately use religion to promote increased social support associated with religious
positive health outcomes. congregations , and a positive worldview which
promotes well-being .
In order to determine the validity of existing
Deﬁnitions of spirituality and religion
religion and health studies, Powell, Shahabi, and
In order to understand the relationships that exist Thoresen  completed a literature review to
among religion, spirituality, and health it is ﬁrst critically evaluate the most popular hypotheses made
necessary to deﬁne ‘religion’ and ‘spirituality’. These regarding the connection between religion/spirituality
terms can be both complementary and contradictory, and physical health (i.e., church attendance dec-
but they are often used interchangeably. Spirituality reases mortality, prayer improves recovery, etc.).
is recognized as an internal experience of personal The authors concluded that there is ‘persuasive’
cultivation motivated by interest in meaning, pur- evidence that church service attendance is asso-
pose, and signiﬁcance while religion is recognized as ciated with declined mortality, that there is ‘some’
an external experience of formal expression with evidence that religion and spirituality protect
associated systems of worship, traditions, practices, against cardiovascular disease, that being prayed
doctrines, beliefs, moral codes, and accompanying for improves physical recovery from illness, and
dogmas that represent speciﬁc ideologies shared by a that religion/spirituality may impede recovery from
faith-based group [11 – 13]. Regardless of the deﬁni- illness.
tions ascribed to spirituality and religion, it is evident
that spirituality is applicable to all persons, whether
Religion and chronic disabling conditions
religious, atheist, agnostic, or uncategorical [14 –
18]. Although ambiguity exists in the current To date research on religion and health has primarily
literature regarding ‘religion’ and ‘spirituality’ it focused on persons with life threatening diseases and
is important for future research in this area to conditions such as cancer , heart disease ,
Religion and disability 1155
lung disease , HIV/AIDS , kidney disease indicated that spirituality is positively correlated with
, cystic ﬁbrosis , diabetes , sickle cell psychosocial adjustment.
disease , and ALS . Persons facing impen- Powell et al.  examined three studies to
ding death may use religion to help them accept their determine if depth of religiousness and church/
condition, come to terms with unresolved life issues, service attendance provided any degree of protection
and prepare for death. from acquired disability deﬁned as required institu-
However, it is arguable that religion may be an tionalization or required assistance with daily living
equally if not more important coping mechanism for skills [37,38]. The reviewers suggested there was no
persons with chronic disabilities such as traumatic evidence to suggest that religious/spiritual involve-
brain injury, spinal cord injury, stroke, arthritis, ment protects an individual from acquiring a
epilepsy, etc. These individuals may expect to live for disability. However, Powell et al.  did ﬁnd that
years, even decades, after the onset of their injury or studies by Haley, Koenig, and Bruchett  and
disease and may use religion to help them cope with Idler and Kasl  reﬂected a positive relationship
their disability, give new meaning to their lives based between religious practice and disability, i.e., as
on their newly acquired disabilities, and help them to physical disability became more prevalent, personal
establish new life goals. For example, a middle age religious practices became more frequent. This sug-
man who primarily derives self-esteem from his gests that those experiencing disabling conditions of
identiﬁcation as a masculine, physically ﬁt laborer increasing severity may have a tendency to engage in
may need to redeﬁne himself and set new goals if he religious activities more often.
experiences a spinal cord injury. Similarly, a severe Unfortunately, there have been few empirical
traumatic brain injury may cause a young, intelligent studies with large samples to evaluate the relation-
woman studying to be an attorney to develop a new ship between religion and health outcomes for
self-concept, as well as to develop new life goals. persons with chronic disabling conditions. The need
Religion is likely to be a signiﬁcant resource for such still exists to determine how individuals with chronic
individuals to help them cope with the signiﬁcant disabilities, compared to life threatening diseases,
changes they will experience in their lives. Although use religion to help them cope with and prepare for
many individuals with disabilities turn to religion to lifelong handicaps.
help them deal with their situations, to date religion
is infrequently discussed in rehabilitation settings
Religion as a method to cope with disability
and is rarely investigated in rehabilitation research.
To better meet the needs of persons with disabilities, In addition to improving the functional abilities of
this needs to change. persons with disabilities, one of the primary goals of
The minimal research that has been conducted on rehabilitation professionals is to facilitate individuals’
religion and rehabilitation populations to date has adjustment to their disability. There has been
generally included only anecdotal case studies , considerable research on the different ways in which
descriptive information about the religious practices individuals cope with disabilities, which indicates
of persons with disabilities (e.g., how many persons that persons generally cope with stress by changing
with TBI use religion to cope), or correlational the environment, changing themselves, or changing
analyses (e.g., more spirituality is correlated with the meaning of the event/issue of relevance. Tradi-
better outcomes). For example, The Journal of tional psychological research on the coping strategies
Rehabilitation published a special issue on ‘Spiritual- of persons with disabilities has attempted to identify
ity and disability’ in 2001 , although ﬁve of the six how individuals search for meaning in their disability
articles were non-empirical narrative articles, and the  and how they integrate their disabilities into
only empirical study reported the validation of a their self-concept . Several studies have indi-
measure of spirituality (i.e., the Spiritual Transcen- cated that many individuals cope by relying on
dence Scale) based on undergraduate students (and cognitive strategies that promote favorable beliefs
not persons with disabilities). Similarly, Boswell et al. about the self in difﬁcult situations , while other
 conducted a qualitative assessment of the studies have shown that people tend to engage in
spiritual beliefs and practices of six women with protective and self-enhancing behaviors in order to
physical disabilities and, as expected, reported that maintain consistent and positive thoughts of them-
spirituality and disability were associated for this selves . For example, some individuals may cope
small sample. McColl et al.  conducted a similar with disability and promote self-esteem by providing
qualitative evaluation of spiritual issues for 16 rationalizations for their inability to perform some
persons with either TBI or SCI and developed a activity, or they may attempt to direct themselves and
matrix of common religious themes reported by this others away from problematic situations and toward
group. McNulty et al.  evaluated spiritual well- situations that lead to positive outcomes. In addition,
being in 50 persons with multiple sclerosis and many individuals with disabilities cope by increasing
1156 B. Johnstone et al.
the values they place on personal skills and traits suggests that spirituality (i.e., individual belief in a
(e.g., intelligence, social skills) and personal relation- higher power) is a fourth, relatively less considered
ships they may have previously minimized , while coping mechanism which is necessary to address
simultaneously decreasing their emphasis on physical when evaluating and treating patients with health
attributes or characteristics . disorders.
In addition to these psychological coping strate-
gies, many individuals with disabilities use spiritual
How does religion facilitate coping?
coping strategies to assist them in adjusting to their
disabilities. In fact, religious coping has been shown For many religious individuals, including laypersons
to add unique power to the prediction of positive and professionals, the speciﬁc manner or mechanism
adjustment for persons with disabilities after con- by which religion facilitates adjustment to disability
trolling for the effects of traditional coping strategies is relatively unimportant. Individuals have their
[47 – 49]. Although rehabilitation professionals work own personal faith and religious practices, and that
with patients with disabilities to promote adjustment is all that matters. Conversely, rehabilitation profes-
to disability, the use of religious coping strategies for sionals and patients who are not religious may
persons with disabilities is not even mentioned in not want to discuss religion because they may not
rehabilitation psychology training guidelines  or believe that it is a valid method by which to cope
in standard rehabilitation medicine and rehabilita- with disability, that it is not an appropriate subject to
tion psychology textbooks [51,52]. discuss in rehabilitation, or that it is a subject
Standard strategies used in rehabilitation to assist with which they are not comfortable addressing. In
individuals in coping with their disabilities include fact, some health professionals believe that religion
psychological counseling, medications, support and healthcare should remain separate given the
groups, and family/peer support. However, many personal nature of religion, and that the impact of
individuals also report relying on religious beliefs, religion on health cannot be scientiﬁcally validated
practices and supportive relationships to help them [55,56].
cope with their disabilities. For example, Cigrang From a rehabilitation perspective, the speciﬁc
et al.  reported that 26% of patients with chronic mechanisms by which religion facilitates adjustment
physical illnesses reported using prayer and religion to disability is of relatively minimal importance,
as a way to cope with their disability. Unfortunately, whether it is through divine intervention, the power
rehabilitation professionals rarely ask about a per- of repetitive religious practices (e.g., individual or
son’s religion or religious coping strategies, and group prayer, chanting, laying on of hands, yoga,
usually only brieﬂy when taking a patient’s history anointing ceremonies, sand paintings, etc.), or a
(e.g., asking about their religious afﬁliation). Some placebo affect (which may be the perspective of non-
patients may be referred to a hospital chaplain, religious rehabilitation professionals). If religion
encouraged to pray, or referred back to their religious helps an individual cope with a disability in a positive
networks after discharge. Given the signiﬁcant manner, it should be used accordingly. Regardless of
number of individuals who report using religion to one’s personal religious beliefs, it is possible to
cope with daily problems, it seems appropriate for understand how religion is used to cope with illnesses
rehabilitation professionals to increase their attention and disabilities based on two different models of
to this subject. coping: spiritual (faith based) vs. psychoneuroimmu-
Recent articles, in fact, propose that rehabilitation nological (physiologically based).
professionals and researchers need to consistently
consider the religious beliefs and practices of indi- Spiritual model of religious coping. For most religious
viduals with illness and disability. Speciﬁcally, Ray individuals, their faith in a higher power is sufﬁcient
 proposes that religious beliefs should be one of for them to deal with their disability. In explaining
four components to be considered when evaluating how spirituality may be used to cope with illness
the coping skills of individuals with illnesses or and disability, Koenig  suggests that many persons
disabilities. The three commonly accepted coping with illnesses feel helpless and not in control of
mechanisms used by persons to deal with stressors, their condition, but that religion provides them an
which should be uniformly considered by rehabilita- indirect form of control in that their problem is
tion professionals, include: (a) knowledge of their turned over to a higher power to handle. He also
condition (i.e., the more one knows about conditions states that prayer can give individuals the belief that
and treatments, the more likely it can be managed), they are directly controlling their outcome by pray-
(b) inner resources (e.g., individual beliefs and ing or meditating about it, and that prayer can
personality traits, such as optimism vs. pessimism), improve adjustment to health problems by producing
and (c) social support (i.e., the more the social a state of relaxation similar to stress management
support the better the outcome). However, Ray also techniques.
Religion and disability 1157
Psychoneuroimmunological model of religious coping. before Passover and increased by 24% the week after.
Many rehabilitation professionals may not be com- They found no change in the death rates of Jewish
fortable considering the use of religion as a means to women, Jewish children, Black adults, or Asian
cope with disability, and particularly if they are adults during the same time periods, suggesting that
trained in the scientist-practitioner model. As scien- these elderly men were able to delay their deaths due
tists they are trained to consider issues of causality to their will to live. Ray cited a similar study in which
and empirical evidence. However, it is impossible to the death rates of elderly Chinese women were
directly prove the effect of divine intervention or the investigated the week before and after the Chinese
power of prayer, as these constructs and behaviors Harvest Moon Festival, a holiday that holds special
are hard to conceptualize, quantify, and measure, religious signiﬁcance for elderly Chinese women
although the measurement of spirituality is improv- . The ﬁndings indicated that the death rates of
ing . For those rehabilitation professionals who Chinese women age 75 and older declined by over
may not feel comfortable using religion to assist one third the week before the holiday, but rose by
individuals in coping with their disabilities, it is also 35% the week after the holiday. No differences in
possible for them to reframe religious coping in death rates were found for younger Chinese women.
terms of psychoneuroimmunological models. These studies clearly illustrate that the will to live
In general, psychoneuroimmunology is based on (i.e., the mind) is very powerful in determining life,
the belief that the mind (i.e., thoughts) can directly death, health, and well-being. Ray concluded that
inﬂuence the body and how we adapt to stress. Psy- health clinicians and researchers need to promote the
choneuroimmunology can be deﬁned as the study of investigation of mind-body relationships and develop
four bodily systems that interact to promote health treatment and research models that incorporate
and assist the body in handling stress, including psychological, medical, and religious components.
(a) the mind, (b) endocrine system, (c) central ner-
vous system, and (d) immune system . In fact,
Speciﬁc religious coping methods
several studies have shown that the nervous, endo-
crine, and immune systems all have receptors on Before religious coping strategies are used with
critical cells that can receive information from each patients it is necessary to determine their religious
of the other systems [58,59]. Clear relationships bet- afﬁliation, their beliefs and practices, and the speciﬁc
ween psychological stress and health outcomes have manner in which they may use religious coping
been demonstrated, including studies which have methods (e.g., prayer, reframing of disability, etc.).
shown that increased stress is associated with respi- Some patients may have little or no desire to use
ratory tract infections [60 – 63] and cancer outcomes religion to cope with their disability, and not all
. Other studies have shown that clear relation- individuals with disabilities may feel comfortable
ships exist between religion and cardiovascular, discussing their religious beliefs with their health care
neuroendocrine, and immunological functions, in- providers. Other patients may have strong religious
cluding traditional Judeo-Christian and Eastern beliefs and coping strategies that promote adjust-
religious practices such as Zen, yoga, and meditation ment, while some may have religious beliefs and
. Just as biofeedback, stress management thera- coping strategies that negatively impact their health
pies, and mindfulness meditation have been shown (e.g., beliefs that their illness/disability is a reﬂection
to lead to greater control over bodily functions and of God’s punishment ). Before encouraging
the ability to cope with stress [65,66], it is also likely religious coping, rehabilitation professionals need
that other religious beliefs and practices can lead to to determine sensitively which people are most
decreased stress, increased immunological function- appropriate to beneﬁt from religious coping.
ing, and better physical and mental health. Pargament and Brant  have stressed that
Ray  argues that thoughts, feelings, and beliefs religion can be an effective or ineffective coping
can be conceptualized as chemical and electrical mechanism, depending on the individual and situa-
activities in our brains, and that these thoughts (i.e., tion. For example, many people draw strength from
chemical/electrical activities) can change our biology, their religion for coping purposes, while others have
health, and longevity in some cases. As an example, negative views of religion or previous negative
Ray cited a study  that evaluated the death rates religious experiences that hinder successful adapta-
of elderly Jewish men the week before and after tion to disability. Several studies suggest that
Passover. Theoretically, the death rates should not religious coping may be used most often by females,
differ statistically, although the researchers hypothe- older individuals, and persons of low income , as
sized that they might given that Passover has well as African Americans, persons with less educa-
particular religious signiﬁcance for elderly Jewish tion, widows and widowers, churchgoers, and
men. In fact, the study indicated that the death rates fundamentalists [72 – 74]. Other research suggests
of elderly Jewish men declined by 24% the week that religion is most appropriate to use at times of
1158 B. Johnstone et al.
high stress . Religious coping can be passive (i.e., has abandoned them in their illness or
a person turns their problems over to God) or active disability, which may subsequently lead to
(i.e., increase in prayer or religious rituals). For some hopelessness, despair, and resentment. Such
individuals religious coping can be personal (i.e., hopelessness is associated with poorer health
direct appeals to God for intervention) or inter- outcomes and is difﬁcult to overcome, even
personal (i.e., seeking support from clergy and with the help of religious and behavioral
congregation). In addition, religious coping can be health specialists.
problem focused (i.e., developing speciﬁc problem- (b) Negative religious reframing. In contrast to
solving strategies to overcome their illness/disability benevolent religious reframing, some indivi-
or adapt to it) or emotion focused (i.e., seeking duals may believe that their illness/disability is
emotional reassurance from God to gain acceptance a reﬂection of negative karma or of God’s
of their illness/disability). punishment. As may be expected, these
Pargament suggests that there are three types of individuals may have signiﬁcant difﬁculties
positive religious coping mechanisms to help persons adjusting to their problems, or being moti-
adjust to stress, including: vated to do something about them, believing
that God is purposely causing their illness/
(a) Spiritual religious support. In this manner of disability.
religious coping, individuals generally per-
ceive that they have the support of a higher In addition to taking into account the attitudes and
power (i.e., they trust that God would not let beliefs that may adversely affect the outcomes of
anything bad happen to them) and/or that persons with disabilities, it is also necessary for
they will receive guidance from God (i.e., rehabilitation professionals to consider how one can
God will show them how to deal with a inappropriately promote religion with patients. Spe-
difﬁcult situation). ciﬁcally, there is the possibility that overly religious
(b) Clergy and congregational support. Many indi- professionals may invade the privacy of patients, as
viduals turn to religious leaders to assist them religion is a matter of conscience and thus very
in coping with difﬁcult situations, including private for many individuals. Some health profes-
priests, pastors, ministers, rabbis, imams, sionals may proselytize and attempt to impose their
shamans, etc., as they are the most appro- religious beliefs on their patients, thereby coercing
priate professionals to provide spiritual sup- patients to engage in religious practices (e.g.,
port. Similarly, many individuals turn to praying) that they may not wish to do. Many patients
fellow members of their congregations (e.g., may also feel the need to follow the religious advice
temples, dharma centers, mosques, churches), of the rehabilitation ‘expert’, given the differences in
as these people have similar religious beliefs authority/power that may be perceived by the patient.
and are the individuals with whom they Furthermore, some patients from minority religions
practice their religion. may feel compelled to discuss religious matters even
(c) Benevolent religious reframing. People use this if they do not want to, perceiving that they may
type of cognitive reframing to attribute nega- experience religious discrimination if they are not
tive life events to karma or to the will of God members of the majority religion .
(i.e., acceptance that God will work with them
in their difﬁcult time for a speciﬁc reason),
making it easier for them to accept their fate.
It is encouraging that religious issues are being more
Although religion may be used by many indivi- frequently addressed by healthcare professionals and
duals to cope with their problems, not all persons are that there is increased research on the mechanisms
comfortable discussing their religious beliefs with by which religious coping strategies can positively
their health professionals. For example, in one poll inﬂuence health outcomes. Unfortunately, to date
28% of persons stated that religion and medicine most religion and healthcare text books and articles
should be separate (Newsweek ). In fact, not all provide little if any practical information about how
people use effective religious strategies to cope with religious coping can be appropriately promoted in
adversity. Pargament and Brant  reported several rehabilitation. Similarly, most religion and health
negative religious attitudes and beliefs that can research has used only correlational analyses to show
adversely affect the ability of persons to cope with that increased religion is generally associated with
illness and disability, including: better health outcomes, which is of limited practical
value. In order to most effectively use religion in
(a) Discontent with God, a higher power, or their rehabilitation, speciﬁc training modules in religion
congregation. Many persons may feel that God are necessary for health professionals and speciﬁc
Religion and disability 1159
religion-based interventions need to be developed, the religious beliefs and practices of patients so that
evaluated, and implemented. Following are several team members can best meet the needs of patients.
practical suggestions for rehabilitation professionals It is most appropriate to address religious issues
to: (a) utilize religious coping strategies with patients with patients in an initial interview, if the patient is
in rehabilitation; (b) educate students regarding comfortable in doing so. In this situation, it is
basic beliefs and practices of different religions and recommended that the following information be
their relation to healthcare; (c) develop research determined:
programs which systematically investigate the rela-
tionship between religion and rehabilitation out- . Comfort level in discussing religion
comes; and (d) identify appropriate funding sources . Religious afﬁliation
for religion and rehabilitation research. . Any speciﬁc religious practices/customs that
need to be observed (e.g., the need to pray at
certain times each day, dietary restrictions,
Clinical service issues
restrictions on physical touching by other
Before using religion or spirituality based coping genders, etc.)
strategies in rehabilitation, it is important for . Speciﬁc religious beliefs regarding their dis-
rehabilitation professionals to be aware of and to ability (e.g., God’s will or punishment), and
monitor their own religious beliefs and potential . Any religious coping methods they use (e.g.,
prejudices, and to understand how these potential prayer, rituals, benevolent or negative refram-
prejudices may affect interactions with patients. ing, etc.)
Rehabilitation professionals also need to become
comfortable in addressing religion with their patients Koenig  provides other suggestions for speciﬁc
and each other, rather than viewing religion as a religion-related questions to ask patients, including:
taboo subject. Although some professionals may feel
uncomfortable obtaining information about patients’ . Do your religious or spiritual beliefs provide
religious beliefs, it is no different than inquiring comfort and support or do they cause stress?
about their sexual, psychological, substance use, and . How would these beliefs inﬂuence your medical
legal histories. In fact, it can be argued that religion is decisions if you became really sick?
such an important part of many individuals’ total . Do you have any beliefs that might interfere or
being that it is inappropriate not to address it, even if conﬂict with your medical care?
brieﬂy. Similarly, rehabilitation professionals will . Are you a member of a religious or spiritual
work most effectively with individuals with disabil- community and is it supportive?
ities when they have an understanding of the indi- . Do you have any spiritual needs that someone
vidual’s worldview, including their religious beliefs should address?
and practices. Ignoring these cultural and religious
factors can have serious implications regarding the After gathering this basic information about
individual’s willingness to adhere to or comply with religion, it may then be determined how rehabilita-
treatment recommendations. tion professionals can assist their patients in using
On inpatient rehabilitation units, it may be best to appropriate religion-based coping strategies, if de-
designate one person to initially address the religious sired by the patient. Praying with patients may be
beliefs and practices of patients to assure that appropriate based on the comfort levels of both the
patients are not inundated with religious inquiries patient and the provider. Some professionals, parti-
from all rehabilitation professionals. Many disci- cularly psychologists and physicians, are increasingly
plines, including psychologists, physicians, rehabili- praying with their patients [77,78]. This is an issue
tation therapists, social workers, case managers, or which individual providers will need to consider
chaplains, could potentially be responsible for based on their own beliefs. However, the need exists
addressing these issues, depending on individual to be sure that there is no coercion, proselytizing, or
practitioners’ beliefs and comfort level with religious religious activities based on unrecognized assump-
issues. Chaplains are arguably the most important tions. Other religious practices important to indivi-
religious resources in most hospitals, and it may be duals can also be encouraged, including yoga,
helpful to have them regularly meet patients who reading of religious texts, meditation, laying on of
express strong religious beliefs, so that they can hands, etc.
address their spiritual needs and serve as the contact Rehabilitation psychologists, counselors, and cha-
person for the patient’s religious leaders in their plains should also work together to initiate forgive-
home communities. Similarly, it may be helpful to ness interventions with patients with disabilities
have hospital chaplains attend rehabilitation team when appropriate, and particularly those patients
meetings to assist team members in understanding who were injured as the result of the actions of others
1160 B. Johnstone et al.
(e.g., car accidents, violence, etc.). Many religious services (e.g., expectations for some health services
traditions have explicit ceremonies of forgiveness for to be provided only by same gender individuals),
oneself and forgiveness of others. When this is the dressing and hygiene customs (e.g., requirements to
case the rehabilitation professional should seek the wear certain clothes or headdresses at all times),
guidance of a religious leader. beliefs regarding death and an afterlife, etc. Booklets
When patients are discharged from inpatient have been written for medical professionals to inform
rehabilitation units, it may be appropriate to refer them of speciﬁc religious and cultural practices
them to their existing religious support systems, that should be considered when offering health care.
including their religious organization (i.e., church, For example, Sikhs have speciﬁc religious beliefs
synagogue, dharma center, mosque) or religious and customs pertaining to personal hygiene, daily
leaders and congregations. Unfortunately, many prayers, dietary requirements, reproductive issues,
health professionals rarely make referrals to clergy and beliefs about birth and death . Many Sikhs
. Just as it is common for patients to be referred wear a steel bracelet (Kara) to signify their unity with
to their respective community-based resources and God, as well as shorts (Kaccha) which signify sexual
social networks (e.g., spouse, parents, friends, co- morality. Their uncut hair (Kesh) symbolizes spiri-
workers, clubs, support groups, advocacy agencies, tuality, so healthcare professionals need to explain
etc.), rehabilitation professionals need to increase carefully why Sikh patients may need to remove their
their interaction with these community-based reli- turban, and allow them to do it themselves. The
gious resources. This may include making contact reference section of this article provides a list of
with the religious colleagues of the patient (with their relevant readings regarding religion and disability, as
permission) to inform them of the patient’s need for does the following website: www.disabilitystudies.
spiritual support, both during hospitalization and com/religion.htm.
Professional training issues
Future rehabilitation research will need to determine
On a professional level there are an increasing the efﬁcacy of religious beliefs, behaviors, and coping
number of health professional training programs methods on the physical and mental health of
(e.g., medical, nursing, psychology, counseling, etc.) persons with disabilities. In addition, as is the case
that offer courses or training modules on religion, for all rehabilitation research, the need exists to
which is particularly important given the increasing determine the relationships among these religious
religious diversity in America. In fact, Newsweek  variables and community based outcomes such as
reported that although only three medical schools the ability to live independently, work, and partici-
offered courses in health and spirituality three pate in recreational activities. Of primary impor-
decades ago, more than half of the medical schools tance, researchers will need to determine the speciﬁc
do so today. Similarly, Cashwell and Young  religious rituals (e.g., individual prayer, intercessory
indicate that psychological counseling programs are prayer, ritual participation) and coping mechanisms
offering more classes on spirituality, and that the (e.g., benevolent reframing, prayer, etc.) that are
counseling accrediting body (Council for Accredita- most appropriate to use with different individuals
tion of Counseling and Related Educational Pro- (e.g., persons with strong faiths, persons who
grams ) is giving increased attention to become religious after the onset of their disability,
spirituality and religion in training requirements. It atheists or persons with little religious conviction,
is suggested that rehabilitation professional training etc.), different populations (e.g., gender, race, age,
programs include academic coursework, didactic etc.), and different disability groups (e.g., physically
training, and/or professional supervision in religious vs. cognitively impaired, etc.). Although the con-
issues, including introductory information regarding ceptualization and measurement of religious beliefs
the most common religions, beliefs, practices, and and behaviors have been criticized in the past, Hill
customs. For example, students should be taught and Pargament  have reviewed several of the
the basic beliefs of Christianity, Judaism, Islam, more commonly used and validated religion and
Buddhism, Hinduism, Native American religions, spirituality measures that can be used by future
etc., and their relevance to healthcare. It is very religion and health researchers.
important that rehabilitation professionals and stu- Consistent with the recommendations of Ray ,
dents be aware of the different religious customs that rehabilitation professionals are strongly encouraged
should be considered when evaluating and treating to investigate mind-body relationships and develop
individuals in healthcare settings, including informa- treatment and research models that incorporate
tion regarding the appropriateness of physical touch- psychological, medical, and religious components.
ing by others, preferences regarding gender speciﬁc Investigation of the relationships that exist among
Religion and disability 1161
religious beliefs and rituals, religious coping strate- 12. McColl M, Bickenbach J, Johnston J, Nishihama S,
gies, psychoneuroimmunological functions, and Schumaker M, Smith K, et al. Spiritual issues associated with
traumatic-onset disability. Disabil Rehabil 2000;22(12):555 –
health outcomes will likely produce the most useful 564.
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professionals in the future. Relatedly, rehabilitation religiousness and spirituality and the lives of persons with
professionals need to collaborate with faith-based disabilities: A commentary. Am J Phys Med Rehabil 1997;
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