Specific religious beliefs and practices should be distinguished from the idea of a universal capacity for spiritual and religious experiences. Although this distinction may not be salient or important on a personal basis, it is important conceptually for understanding various aspects of evaluation and the role of different beliefs, practices, and experiences in coping with cancer.

The most useful general distinction to make in this context is between religion and spirituality. There is no general agreement on definitions of either term, but there is general agreement on the usefulness of this distinction. A number of reviews address matters of definition.[1-3] Religion can be viewed as a specific set of beliefs and practices associated with a recognized religion or denomination. Spirituality is generally recognized as encompassing experiential aspects, whether related to engaging in religious practices or to acknowledging a general sense of peace and connectedness. The concept of spirituality is found in all cultures and is often considered to encompass a search for ultimate meaning through religion or other paths.[4] Within health care, concerns about spiritual or religious well-being have sometimes been viewed as an aspect of complementary and alternative medicine (CAM), but this perception may be more characteristic of providers than of patients. In one study,[5] virtually no patients but about 20% of providers said that CAM services were sought to assist with spiritual or religious issues. Religion is highly culturally determined; spirituality is considered a universal human capacity, usually—but not necessarily—associated with and expressed in religious practice. Most individuals consider themselves both spiritual and religious; some may consider themselves religious but not spiritual. Others, including some atheists (people who do not believe in the existence of God) or agnostics (people who believe that God cannot be shown to exist), may consider themselves spiritual but not religious. In a sample of 369 representative cancer outpatients in New York City (33% minority), while only 6% identified themselves as agnostic or atheist, only 29% attended religious services weekly; 66% represented themselves as spiritual but not religious.[6]

One effort to characterize individuals by types of spiritual and religious experience [7] identified the following three groups, using cluster analytic techniques:

1. Religious individuals who highly value religious faith, spiritual well-being, and the meaning of life.



2. Existential individuals who highly value spiritual well-being but not religious faith.



3. Nonspiritual individuals who have little value for religiousness, spirituality, or a sense of the meaning of life.

Individuals in the third group were far more distressed about their illness and were experiencing worse adjustment. There is as yet no consensus on the number or types of underlying dimensions of spirituality or religious engagement.

From the prospective of both the research and clinical literature on the relationships between religion, spirituality, and health, it is important to consider how these concepts are defined and used by investigators and authors. Much of the epidemiological literature that has indicated a relationship between religion and health has been based on definitions of religious involvement such as membership in a religious group or frequency of church attendance. Somewhat more complex is assessing specific beliefs or religious practices such as belief in God, frequency of prayer, or reading religious material. Individuals may engage in such practices or believe in God without necessarily attending church services. Terminology also carries certain connotations; the term religiosity, for example, has a history of implying fervor and perhaps undue investment in particular religious practices or beliefs. Religiousness may be a more neutral way to refer to the dimension of religious practice.

Spirituality and spiritual well-being are more challenging to define. Some definitions limit spirituality to mean profound mystical experiences; however, in considerations of effects on health and psychological well-being, the more helpful definitions focus on accessible feelings, such as a sense of inner peace, existential meaning, and purpose in life, or awe when walking in nature. For the purposes of this discussion, it is assumed that there is a continuum of meaningful spiritual experiences, from the common and accessible to the extraordinary and transformative. Both type and intensity of experience may vary. Other aspects of spirituality that have been identified by those working with medical patients include a sense of meaning and peace, a sense of faith, and a sense of connectedness to others or to God. Low levels of these experiences may be associated with poorer coping (refer to the Relation of Religion and Spirituality to Adjustment, Quality of Life, and Health Indices section).[3]

The definition of acute spiritual distress must be considered separately. Spiritual distress may result from the belief that cancer reflects punishment by God or may accompany a preoccupation with the question “Why me?” A cancer patient may also suffer a loss of faith.[8] Although many individuals may have such thoughts at some time following diagnosis, only a few individuals become obsessed with these thoughts or score high on a general measure of religious and spiritual distress (such as the Negative subscale of the Religious Coping Scale [the R-Cope–Negative]).[8] High levels of spiritual distress may contribute to poorer health and psychosocial outcomes.[9,10] The tools for measuring these dimensions are described in the Screening and Assessment of Spiritual Concerns section.

References

1. Halstead MT, Mickley JR: Attempting to fathom the unfathomable: descriptive views of spirituality. Semin Oncol Nurs 13 (4): 225-30, 1997.  [PUBMED Abstract]
   
   
2. Zinnbauer BJ, Pargament KL: Spiritual conversion: a study of religious change among college students. J Sci Study Relig 37(1): 161-180, 1998. 
   
   
3. Breitbart W, Gibson C, Poppito SR, et al.: Psychotherapeutic interventions at the end of life: a focus on meaning and spirituality. Can J Psychiatry 49 (6): 366-72, 2004.  [PUBMED Abstract]
   
   
4. Task force report: spirituality, cultural issues, and end of life care. In: Association of American Medical Colleges.: Report III. Contemporary Issues in Medicine: Communication in Medicine. Washington, DC: Association of American Medical Colleges, 1999, pp 24-9. 
   
   
5. Ben-Arye E, Bar-Sela G, Frenkel M, et al.: Is a biopsychosocial-spiritual approach relevant to cancer treatment? A study of patients and oncology staff members on issues of complementary medicine and spirituality. Support Care Cancer 14 (2): 147-52, 2006.  [PUBMED Abstract]
   
   
6. Astrow AB, Wexler A, Texeira K, et al.: Is failure to meet spiritual needs associated with cancer patients' perceptions of quality of care and their satisfaction with care? J Clin Oncol 25 (36): 5753-7, 2007.  [PUBMED Abstract]
   
   
7. Riley BB, Perna R, Tate DG, et al.: Types of spiritual well-being among persons with chronic illness: their relation to various forms of quality of life. Arch Phys Med Rehabil 79 (3): 258-64, 1998.  [PUBMED Abstract]
   
   
8. Pargament KI: The Psychology of Religion and Coping: Theory, Research, Practice. New York, NY: Guilford Press, 1997. 
   
   
9. Pargament KI, Koenig HG, Tarakeshwar N, et al.: Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study. Arch Intern Med 161 (15): 1881-5, 2001 Aug 13-27.  [PUBMED Abstract]
   
   
10. Hills J, Paice JA, Cameron JR, et al.: Spirituality and distress in palliative care consultation. J Palliat Med 8 (4): 782-8, 2005.  [PUBMED Abstract]
    
    

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