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Disability and Rehabilitation, August 2007; 29(15): 1153 – 1163


Religion and disability: Clinical, research a...
1154      B. Johnstone et al.

of Health (NIH) has funded numerous projects                 succinctly define and measure t...
Religion and disability     1155

lung disease [22], HIV/AIDS [23], kidney disease            indicated that spirituality ...
1156      B. Johnstone et al.

the values they place on personal skills and traits          suggests that spirituality (i....
Religion and disability      1157

Psychoneuroimmunological model of religious coping.          before Passover and increa...
1158      B. Johnstone et al.

high stress [75]. Religious coping can be passive (i.e.,          has abandoned them in the...
Religion and disability    1159

religion-based interventions need to be developed,            the religious beliefs and p...
1160      B. Johnstone et al.

(e.g., car accidents, violence, etc.). Many religious      services (e.g., expectations for...
Religion and disability           1161

religious beliefs and rituals, religious coping strate-              12. McColl M,...
1162        B. Johnstone et al.

35. Boswell BB, Knight S, Hamer M, McChesney J. Disability              58. Dantzer R. Ca...
Religion and disability         1163

81. Council for Accreditation of Counseling and Related Educa-   83. Templeton      ...
Religion And Disability   Clinical, Research And Training Considerations For Rehabilitation Professionals
Religion And Disability   Clinical, Research And Training Considerations For Rehabilitation Professionals
Religion And Disability   Clinical, Research And Training Considerations For Rehabilitation Professionals
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Religion And Disability Clinical, Research And Training Considerations For Rehabilitation Professionals


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Transcript of "Religion And Disability Clinical, Research And Training Considerations For Rehabilitation Professionals"

  1. 1. Disability and Rehabilitation, August 2007; 29(15): 1153 – 1163 REVIEW Religion and disability: Clinical, research and training considerations for rehabilitation professionals BRICK JOHNSTONE1, BRET A. GLASS2 & RICHARD E. OLIVER3 1 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 Abstract 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 their lives. 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 religion. 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 [1] 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’; [3]), the Journal Why science is starting to believe’ [2]. In addition, of Rehabilitation (‘Spirituality and disability’; [4]), 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’; [5]). 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 [6]. 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: ISSN 0963-8288 print/ISSN 1464-5165 online ª 2007 Informa UK Ltd. DOI: 10.1080/09638280600955693
  2. 2. 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 [19], cancer [20], heart lives of 55% of the American public and is ‘fairly disease [21], lung disease [22], HIV/AIDS [23], important’ to another 29% [7]. Over 90% of cystic fibrosis [24], diabetes [25], sickle cell disease individuals polled in 2003 reported believing in a [26], and ALS [27]. Other research has focused ‘God’ [8] and 66% reported being a member of a on the efficacy of specific religious beliefs and church or synagogue [9]. In another national survey practices in promoting health, including traditional McCaffrey et al. [10] 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 [28]. that people who prayed reported high levels of A review of the literature by Koenig and colleagues perceived helpfulness. Newsweek [2] further indi- [29] 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 [30], fessionals to appropriately use religion to promote increased social support associated with religious positive health outcomes. congregations [31], and a positive worldview which promotes well-being [32]. 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 [33] 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 [20], heart disease [21],
  3. 3. Religion and disability 1155 lung disease [22], HIV/AIDS [23], kidney disease indicated that spirituality is positively correlated with [19], cystic fibrosis [24], diabetes [25], sickle cell psychosocial adjustment. disease [26], and ALS [27]. Persons facing impen- Powell et al. [33] 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. [33] did find that years, even decades, after the onset of their injury or studies by Haley, Koenig, and Bruchett [39] and disease and may use religion to help them cope with Idler and Kasl [40] 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 [34], 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 [4], although five of the six how individuals search for meaning in their disability articles were non-empirical narrative articles, and the [41] and how they integrate their disabilities into only empirical study reported the validation of a their self-concept [42]. 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 [43], while other [35] 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 [44]. For example, some individuals may cope small sample. McColl et al. [12] 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. [36] 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
  4. 4. 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 [45], while coping mechanism which is necessary to address simultaneously decreasing their emphasis on physical when evaluating and treating patients with health attributes or characteristics [46]. 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 [50] 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. [53] 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 [54] 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 [6] 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.
  5. 5. 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- [68]. The findings indicated that the death rates of ing [57]. 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 [54]. 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 [64]. 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 [28]. 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 [69]). 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 [70] have stressed that Ray [54] 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 [67] 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 [71], 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
  6. 6. 1158 B. Johnstone et al. high stress [75]. 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 [76]. (i.e., acceptance that God will work with them in their difficult time for a specific reason), Practical suggestions 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 [2]). 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 [70] 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
  7. 7. 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 [6] 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
  8. 8. 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 [82]. Many Sikhs [79]. 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. after discharge. Research issues 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 [2] 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 [80] 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 [81]) 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 [57] 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 [54], 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
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