A developmental Approach to Spiritual Experience at Life’s End



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Do Religious People Live Longer?

Active religious involvement increases the chance of living longer by 29% according to a new study in the May issue of Health Psychology, the journal of the American Psychology Association. Lead author Dr. Michael E. McCullough notes that "religious involvement is associated with higher odds of survival (or, conversely, lower odds of death) during any specified follow-up period." The study, entitled "Religious Involvement and Mortality: A Meta-Analytic Review" and co-authored by McCullough, William T. Hoyt, David B. Larson, Harold G. Koenig, and Carl Thoresen was conducted under the auspices of the National Institute for Healthcare Research in Rockville, Maryland and supported in part by the John Templeton Foundation.


McCullough and his research team summarized the findings of 42 individual studies that had examined the relationship between religious involvement and longevity using the statistical method of meta-analysis. Since not all of these studies yield numerically identical estimates of the strength of the association, meta-analysis is a way of taking the individual study results, converting them to a common numerical measure, estimating a sort of "average" of all 42 studies, performing additional analyses to determine what factors might account for the variability in the studies’ results, and estimating how robust the results are.
And the results are quite robust. Based on this meta-analytic sample representing nearly 126,000 participants, the researchers concluded that "religious involvement has a nontrivial, favorable association with all-cause mortality." They found that the link between religious involvement and mortality was so strong that it would take 1,400 new studies showing no association between religious involvement and living longer to overturn them. According to Dr. David B. Larson, NIHR president and co-author, "a lack of religious belief or practices stood out as a health risk for early death to nearly the same degree as heavy alcohol consumption, exposure to organic solvents in the workplace, and hostility."
The study found a stronger link with living longer among those who engaged in public religious activity like attending religious worship services than those whose religious activity was essentially private. According to McCullough, who is leaving NIHR to take a position in the Psychology Department at Southern Methodist University, "private religiousness appears to be a much less useful indicator of whether one is at reduced risk of early death;" rather, "it is public religious involvement in particular that appears to be such a good indicator of longevity."
Not everyone welcomes such studies. Scientific analysis of religious activity tends to draw fire from several quarters. Some theologians and clinicians object to an approach to religion that smacks of instrumentalism. Those holding this view do not believe that religion should be used as a means to another end, such as health. Religious activity should not be used like pharmaceuticals or surgical intervention as one of several weapons in a physician’s arsenal.
Others worry about the implications of seeking scientific validation for religious truths. According to this line of thinking, religions are based primarily on sacred stories and beliefs; thus science should not be given the power either to establish or dispel the effects of religion. Columbia University psychologist Richard Sloan has been critical of several of the studies which the meta-analysis sampled and evaluated. He raises both methodological questions about the empirical basis of religion, spirituality, and health studies, and ethical questions about the involvement of medicine in the religious life of patients. The study’s co-authors draw somewhat different conclusions and tend to view these criticisms as understandable–if not relevant–concerns raised by colleagues from the scientific and theological communities.
While McCullough states that "the religious involvement-mortality association is a real association that is not just popping up by chance in a few isolated studies," the researchers admit that the nature of the association is "poorly understood" and requires significant further research at the interface of psychology and health. The researchers want to know what it is that religion or spirituality does to prolong life even in the short range? Larson indicates that more research is needed to better assess the influence of factors like social support, enhanced coping skills, or even the possession of a worldview that might lessen the impact of stress on the individual. According to co-author and Duke University professor of psychiatry and medicine Dr. Harold Koenig, the study raises many questions. "Could you design clinical interventions to take advantage of this? What do we have to do to better understand this effect? Why is it that religiously involved people live longer? Is it because they are genetically healthier individuals and that is connected to their personalities, which are more likely to be religious?"
Larson also is encouraged by some of the work in "positive psychology" which is beginning to look at the relationship that lifestyle factors like love, gratitude, hope, humility, or optimism might play in overall health. These factors may help to better explain the link to mortality. In December 1998, the NIHR hosted a three-day conference, entitled "Classical Sources of Human Strengths," funded by the John Templeton Foundation. It focused on the possible interplay between many of these "human strengths," spirituality, and health. The conference papers appeared this Spring in a special issue of the Journal of Social and Clinical Psychology (Vol. 19, No. 1).
The findings of the meta-analysis provide considerable incentive for researchers to continue investigations into the relationships between spirituality, religion, and health. Clearly, the favorable link between religious involvement and living longer "is a health phenomenon with some relevance for a substantial proportion of the American population."

 

Vol 1.1 September, 00

Religion and Health to the End of Life

Ellen Idler on the relevance of religion to health at every age

There has been much in the news lately about religion and health. Major news magazines and nightly news broadcasts have covered stories on spirituality and health, prayer for healing, religion in the doctor-patient relationship, spirituality in end-of-life care, and so on. Despite the recent positive publicity, however, this has not been an easy area in which to do health research. Since I began work on my dissertation in 1982, I have encountered much disinterest and worse in the reactions of my colleagues. In a recent interview, I was asked, "But we’ve spent years getting the mumbo-jumbo out of our medicine, why would you want to put it back?"

While I would agree that there are many poor studies, in this field as in any other, there are also many excellent ones that show the relevance of religion to health at all stages of life. This is not mumbo-jumbo. There is a strong scientific basis for concluding that religion is beneficial for human health.

Religion and health are weighty matters to be talking about. In C. S. Lewis’ little book The Problem of Pain, he writes: ". . . when pain is to be borne, a little courage helps more than much knowledge, a little human sympathy more than much courage, and the least tincture of the love of God more than all."

I quote this because, with his masterful use of the English language, Lewis makes God’s love sound like potent medicine. But he also puts knowledge in its place, as somewhat less useful than courage, or human sympathy.

We can trace the origins of research on religion and health to France at the beginning of the 20th century. A sociologist named Emile studied the population statistics of the countries and regions of Europe and discovered that Protestants were much more likely to commit suicide than Roman Catholics or Jews. His theories about why this was true have been very influential, but first let us look at an up-to-the-minute example of research on this topic. The May 1999 issue of the journal Demography reports a study by Robert Hummer and his colleagues at the University of Texas at Austin. They analyzed data from the National Health Interview Survey, a nationally representative sample of more than 20,000 adults who were followed for eight years, beginning in 1987. During that time, just under 10 percent of the participants in the study died. Respondents to the 1987 survey who never attended religious services had a 72 percent higher risk of death when compared with respondents who attended one or more times per week. This figure is "adjusted" for the age, sex, race, region, and health status of the respondents, and it translates into an additional seven or more years of life expectancy for those who were frequent attenders.

This is just one study, but there are quite a few others that consistently show beneficial effects of religious involvement on physical health, mental health, and especially mortality rates. This association of religiousness with better health and longer life is not mysterious, not miraculous, but, in fact, makes perfect sense. It is complex, because both religion and human health are multifaceted, subtle, and complicated phenomena. But they are phenomena that can be studied scientifically.

Consider adolescence. One of the things about religion that makes it relevant to health, and especially to adolescence, is that religion provides rules for living. Some religions have very particular rules about diet and alcohol use, and most faiths have beliefs about maintaining the purity of the body as the vessel of the soul. In general, religions discourage self-indulgent behaviors and promote "moderation in all things," if not actual asceticism.

A University of Michigan study analyzed data from an annual survey of high school seniors from 135 schools in 48 states. Researchers found that religious involvement had an enormous impact on the lifestyles of these late adolescents. The more important religion was in their lives, and the more frequently they attended religious services, the lower were their rates of cigarette smoking, alcohol use, and marijuana use; the higher their rate of seat belt use, and eating fruits, vegetables, and breakfast; and the lower their rate of carrying weapons, getting into fights, and driving while drinking. These findings demonstrate that the origins of a healthy adult lifestyle may be strongly influenced by the influence of religion during adolescence.     

Another population study in Alameda County, Calif., also showed that people who attended religious services were less likely to smoke; but those who attended, and who  did smoke at the start of the study  were more likely than the non-attenders to quit smoking during the course of the follow-up. This brings us back to our theme. There is nothing mysterious about the effect of religiousness on health. If people who are members of religious groups are less likely to smoke, drink heavily, have sex with multiple partners, or get into fist fights, then should we be surprised that they have a longer life expectancy?

Other important aspects of religion are the many ways in which religious groups provide support and reduce stress in people’s lives. In 1979, a landmark study in California revolutionized our understanding of the impact of the social environment on health. In a nine year study of nearly 7,000 adults, researchers found that the most socially isolated people, those with the fewest social ties to others, were at the highest risk of mortality. This finding persisted even when adjusted for the health status of the respondents at the beginning of the study, their risk factors such as smoking and obesity, their physical activity, and their use of health services. Along with family relationships, friendships, and community groups, membership in a church or temple was considered an important social tie. This gets us back to Durkheim, who wrote that social groups benefit people not only because they provide them with rules for living, but also because social groups nurture, care for, and support their members. "Support" can mean helping out with tasks around the home when someone is sick, or assisting someone in finding a new job, a dentist, or day care for their children; or it could mean having someone to confide in, to share feelings with. Religious congregations often excel at providing social support to their members. A University of Michigan survey found that regular attenders at religious services report larger social networks overall, more frequent telephone and in-person contact, and a stronger feeling of support from all of the members of their social circles.

Religious congregations are unique social institutions. The people one meets at church or temple are different from those one knows at work, or school, or the neighborhood. Attending religious services gives us opportunity to meet people we wouldn’t otherwise have met, the chance to broaden our social worlds, and to do it within a context that emphasizes the ethical aspects of relationships. 

Religious congregations as social groups cut across the entire life course. No other social institution regularly brings the very old and the very young, and everyone in between, into contact with each other. The importance of a healthy lifestyle, and the social networks and support of a congregation, hardly diminish as we grow older, but there are also new challenges in the later years.

A large survey of elderly people done at Yale University took a representative sample of nearly 3,000 New Haven, Conn., residents and interviewed them every year in their homes or on the telephone, about their health, their functioning in daily life, their use of health services, their contacts with friends and family, and their participation in religious and community groups. They also had their blood pressure measured and their prescription medications reviewed. It was a very important study of "successful aging," or the ways in which healthy elderly people live in the community.

The Yale respondents in New Haven who attended services regularly were less likely to smoke cigarettes, less likely to drink heavily, and more likely to get regular physical exercise. They reported having more social contacts—with friends as we expected, but also with family.

One of the reasons old age is different from earlier stages of the life course is that the prevalence of chronic illness is much higher, frequently leading to disabilities. Moreover, disability frequently leads to feelings of depression. The Yale project assessed disability and depression in this population, so these phenomena were measured very well. Respondents who attended religious services, as a group, were significantly less likely to be depressed, but there was an especially strong effect for those in the sample who had some disabilities. This heightened effect was correlated with the number of friends respondents saw, the number of holiday celebrations they attended, and their feelings of optimism. For the disabled respondents, these factors were crucial. Overall, religious involvement was tied to a broad array of other health and social resources in the lives of the elderly respondents. None of the other characteristics of these individuals, such as their level of education, marital status, income, or housing type, were as broadly beneficial as their religious involvement. For the one–third of the sample with substantial disabilities, this tie made a very substantial difference in their quality of life, reducing their risk of loneliness and isolation.

This study also had a second phase and that was to look at the effect of religious involvement over time on the health of these respondents as they aged. It was found that those who attended services regularly were both less likely to become disabled and more likely to improve their functioning during the period of the study. These findings were very strong, and it didn’t matter whether the respondent was male or female; Protestant, Catholic, or Jewish; or even already somewhat disabled.

Religious individuals can draw on the stories and beliefs of their faith tradition to put their own lives into a much larger context, to learn lessons from others who have faced similar troubles, to allay fear, or to gain hope for the future. This is particularly true for the crises of old age. When researchers ask respondents how they have coped with different types of crisis situations, they find that people most often turn to religion in situations of loss over which they tend to have little direct control. Studies of heart surgery patients, recent widowers, parents who had lost a child, and women with hip fractures, all found significantly lower levels of depression among respondents who had religious resources to help them cope. So religion appears to prevent depression among people in crisis, but researchers at Duke University have taken it a step further and examined patients who had already become depressed. They studied 94 elderly patients admitted to the hospital for medical illness and diagnosed by a hospital psychiatrist with major depression. These patients were followed up by telephone at 12, 24, 36, and 48 weeks after their discharge from the hospital. Patients who felt that religion was more important in their daily lives recovered significantly faster than those who did not.

In 1991 and 1992, I had the privilege of interviewing 146 disabled persons at a rehabilitation clinic in New York City. The project was officially about perceptions of health and reports of pain, but, as I had an interest in religion, I included some questions on this topic. Some identified their illnesses as turning points in their religious lives. They saw a growth in their spiritual lives that came about as a direct result of their shrinking physical capacity. A loss in one area of life became a gain in another.

Other respondents spoke about religious awakening in a different way, not as a feeling of spirituality, but as a conviction that God had a purpose for them. A number of these people’s illnesses or injuries had brought them close to death, and the very fact of their survival took on a religious meaning, causing them to see their lives in a new way. One man, a 42–year old Russian Orthodox immigrant, had fallen down five flights of stairs, had injured his head and pelvis, and had nerve damage.

"When I had my accident, I had spent time in a coma for three weeks. And finally I survived and was on my way to recover, and I think that if God saved my life, he had a purpose. So I believe him, and I’m not going marching down."

Respondents’ attempts to find religious meaning in their crises also often included stories about healing. They spoke of prayers for strength and healing, and often they were stories of gratitude for the progress they had made, however small.

What is really important about patients’ responses to their disabilities is that the struggle to find meaning is carried out with the vocabulary of religious beliefs. In these voices, we hear themes of new insight, of the relevance of religious beliefs to some of the most challenging and threatening of human experiences, and of the growth and development of the self. People turn to religion in times of need, and one of the ways religion helps them is by letting them "rise above" their problems, so to speak, by putting them in a context in which the physical body does not matter that much.

A 54-year old Roman Catholic woman who had a stroke explained her experience:

"Well, I know that some people if they believe in God and if they believe in prayer would pray to be relieved of their pain," she said. "But I always could see others that were worse off than me so when I went to pray, I couldn’t pray for myself when the guy next door was so much worse. So, I wound up praying for him, and it helps to take my mind off my own problems."

Now we come to the final stage of the life course, the period at the very end of life. In gerontology, or the study of aging, there is a lot of emphasis on healthy aging, and the compression of morbidity and disability. The goal should be a disability-free old age, with only a short final period of incapacity, if any at all. So what we really want to do is study populations of elderly people who are at the end of their life but who may not be thinking of themselves as in the famous phrase: "In the world according to Garp, we’re all terminal cases."

The study of New Haven elderly provided a perfect opportunity to study the quality of life of people in their last year of life. The respondents were contacted every year for 14 years, and when any of them died (and more than half had died by the end of the study), their death certificates were obtained and their date of death recorded. Four hundred and ninety-nine respondents were interviewed some time during their last year of life, a very rare kind of sample to work with.

The real interest lay in determining whether religiously-involved individuals would have a better quality of life than those without access to religious resources. First, what about social ties to friends and relatives? A previous study had shown that the more religious respondents had more social contacts, but would this be true for those respondents who were near to death? Indeed it was true. Our more religious respondents in their last year of life were seeing five or six friends regularly, compared with only two or three for the less religious. It was especially interesting that the respondents not in their last year of life were in between these two figures; in other words, we found the most socially isolated and most socially connected respondents among those in their last year of life, and the factor that differentiated them was their religiousness. These were large and statistically significant differences, and the data were quite similar for the number of family members seen.

Levels of depression in these groups and the findings were quite striking. The respondents in their last year of life who attended religious services regularly were significantly less depressed, and it was attendance at religious services that had the beneficial effect on health. However, when we look specifically at the respondents in their last year of life, we find that they maintained their overall high level of feelings of religiousness and that it was these subjective feelings, rather than the behavior of attendance at services, that was associated with several indicators of a higher quality of life.

In his later book, Elementary Forms of the Religious Life, Durkheim writes about the crucial importance of celebrations and rituals for bringing the members of religious groups together, to remember their past, and to renew their sense of social solidarity. The study at Yale asked if the respondents would show a delay in deaths around the time of annual religious holidays. With the Jewish and Christian sample, and a complete record of their death dates, it was possible to compare the number of deaths that took place in the 30 days before and the 30 days after the Jewish holidays of Rosh Hashanah, Yom Kippur, and Passover, and the Christian holidays of Christmas and Easter. The studies hypothesized fewer deaths for Christians but not Jews in the period before Christian holidays, and fewer deaths for Jews only before the Jewish holidays. Findings strongly supported the hypotheses. For both Christian holidays, there were significantly fewer deaths in the month before compared with the month after. For Jews, the pattern held for men but not for women. There were, of course, no differences for Christians around the Jewish holidays, nor for Jews around the Christian holidays. There was no overall impact on mortality in this study, only a short-term delay in the timing of a death that was going to occur anyway. The opportunity to celebrate one last holiday with family and friends in the congregation, and with the symbols and rituals of their faith may provide a last measure of continuity and meaning, contributing to the high level of emotional stability seen in the religious respondents in their last year of life.

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