spiritual correlates of functional well-being in women with breast cancer

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2002 1: 166Integr Cancer TherEllen G. Levine and Elisabeth Targ

Spiritual Correlates of Functional Well-Being in Women With Breast Cancer

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Levine, TargSpiritual Correlates of Functional Well-Being

Spiritual Correlates of Functional Well-BeinginWomenWith Breast Cancer

Ellen G. Levine, PhD, MPH, and Elisabeth Targ, MD

Breast cancer is the most common cancer in women in theUnited States and constitutes a major source of medical andpsychological morbidity. The psychosocial sequelae, whilenot always severe, can last up to a year after diagnosis. Thismay be a time when spiritual and social resources becomeimportant. It is known that practical and emotional supportduring treatment for breast cancer benefits the patient’smood and quality of life, but it is unclear as to how spiritual-ity and spiritual well-being may benefit the patient. Thisstudy examined this question by exploring the relationshipsbetween spirituality, spiritual well-being, physical well-being,functional well-being, mood, and adjustment style in a sam-ple of 191 women recently diagnosed with breast cancer orwho had metastatic cancer. The women were asked to com-plete questionnaires pertaining to the above topics at enroll-ment to a group intervention study. Measures of spirituality,spiritual well-being, physical well-being, functional well-being, mood, and adjustment style taken at the same point intime were then correlated with each other. There were moresignificant correlations of spirituality and spiritual well-being with functional well-being than physical well-being,but items pertaining to meaning and peace tended to corre-late significantly with physical well-being. Spirituality alsocorrelated significantly with several coping styles, but notavoidance as has been previously suggested. Regressionanalyses were also performed to find the best combinationof variables to predict physical and functional well-being. Acombination of social well-being and several questions per-taining to peacefulness accounted for 18% of the variance inphysical well-being. However, a combination of social well-being and the spiritual scales accounted for 46% of the vari-ance in functional well-being. When the spiritual scales wereexamined alone, they accounted for 40% of the variance infunctional well-being. The results of this study confirm theimportance of spirituality and spiritual well-being in bothphysical and functional well-being. Asking patients about therole of spirituality in their lives may be a useful marker topredict patient’s ability to cope with stress in their lives andof their quality of life.

Breast cancer is the most common cancer in women inthe United States, with an estimate of 175,000 newcases a year,1 and constitutes a major source of medicaland psychological morbidity. In addition to the impactof medical treatment, poor psychological adjustmentto breast cancer can influence compliance with treat-

ment, sexual functioning, social relationships, andquality of life.2-8 While for many patients, the distress ofcancer surgery and treatment declines over time, ithas been estimated that up to 30% of women continueto have some disruption in quality of life one year aftertreatment for breast cancer.9,10 One landmark study of215 cancer patients found that 47% of the sample hadsevere enough psychiatric disorders to be classifiedwithin DSM-III diagnostic criteria.11,12 Most of thepsychosocial issues that come up revolve around qual-ity of life and attributions of why the patient got cancer(eg, self-blame9). Recent research has shown that alarge number of women are incorporating spiritualityas part of their breast cancer treatment.13,14 However,little work has been done to assess the impact of thespiritual framework on women’s response to breastcancer.

While over the past 2 centuries, spirituality hasbeen viewed as separate and not necessary to medicalcare, in fact, the first hospitals were built in religiousinstitutions, and the first physicians were generallypriests, monks, rabbis, or shamans. The first nursescame from the convents. It has only been since the18th century that medicine and health were partedfrom religion and spirituality, separating out into hos-pitals that were not part of religious institutions. Therehas been a recent resurgence of interest in the possi-ble relevance of spiritual experience and belief sys-tems to coping with illness. Proponents point to corre-lations between religious practice and longevity, whilecritics express concern that physicians may prosely-tize, or that measures of religion or spirituality are sim-ply duplicating other measures of social support.15

Spirituality has been defined as a felt connectionwith a nonmental, non-emotional, and nonphysicalaspect of being.16 It can be seen as comprising ele-ments of meaning, purpose, and connection to ahigher power or something greater than the self.17

Levine, Targ

166 INTEGRATIVE CANCER THERAPIES 1(2); 2002 pp. 166-174

EGL and ET are at the California Pacific Medical Center, San Fran-cisco.

Correspondence: Ellen G. Levine, California Pacific Medical Cen-ter, 2300 California St, Suite 207, San Francisco, CA 94115.E-mail:[email protected].

at GEORGIAN COURT UNIV on December 7, 2014ict.sagepub.comDownloaded from


Many studies have found positive relationshipsbetween spiritual or religious practice and physicalhealth.18 There are even several studies that show adecrease in cancer rates and mortality among mem-bers of various religions.19-21 Other studies have foundthat religious attendance and prayer are related tobetter health and longevity.22,23 On review, the majorityof surveys in this area have been positive, although afew have not shown a relationship between spiritualityand illness, or the relationship has been negative.22

Significant associations have also been foundbetween spirituality and factors related to quality oflife. For example, one survey study of 400 family prac-tice patients found that low scores on measures of spir-ituality were associated with the greatest level of pain.7

In addition, a study involving 80 patients at Harvard’sbehavioral medicine clinic found similarly that spiritu-ality was correlated with having fewer physical symp-toms.8 A multiple study review by Levin22 suggests thateven after controlling for health status, spiritualitystrongly relates to quality of life and psychologicalwell-being. Measures of spirituality usually incorpo-rate both the existential and religious dimensions,24-26

and have been associated with better health habits,19

less anxiety,27 and less depression.28 Measures of spiri-tuality or “spiritual well-being” have also been foundto predict specifically active and optimistic copingstyles, and improved overall quality of life.29

The reasons for these associations are clearlymultifactorial. Some religions, for example, requirehealthy behaviors, such as strict vegetarian diets, dailyconscious exercise, or prohibit alcohol consumption,all of which certainly affect health outcomes in thesepopulations. Overall, people who engage in religiouspractices such as regular church services, daily prayer,or daily scripture reading, have a lower incidence bothof smoking and of drinking alcohol.22 Of significance,however, in a study by Larson,30 even when smokingand drinking are controlled for, smokers whoattended religious services still had lower blood pres-sure than non-attenders. These people also tend tohave fewer days in the hospital than people who do notparticipate in a religious practice. Another potentialcontributing factor of spiritual involvement is the roleof social and community support. This point was evi-denced in a religious community in a study that docu-mented very extended social networks among church-goers.24 Clearly, the factor of community may provideresources and support in the context of illness. Peoplewith larger social networks and quality support havebeen shown to recover from illness faster and arebetter able to cope with illness than people who do nothave social support.10

The act of prayer itself has been associated withgood health, quality of life, and lower levels of

psychological distress in healthy people.22 This hasusually been assumed to be the result of stressreduction31 or cognitive reframing.32 There are alsosome well-controlled studies that demonstrate theeffectiveness of intercessory prayer in reducing dis-ease progression and severity even in a double-blindsetting, which eliminates psychosocial determinantssuch as hope and expectation.33-35 In a review of the 135distant healing and prayer studies published before1992, Benor36 found two thirds had significant positiveresults. This leaves open the question of the potentialrole of personal prayer in coping with illness. Whilespirituality is known to be a significant coping strategyin cancer patients overall,28,37 breast cancer patients, inparticular, make significant and explicit use of prayerand spiritual healing approaches as part of theirresponse to their illness. In a large Canadian study (n =300), 81% of women with breast cancer chose to useprayer as a way to help them cope with their illness andtreatment.13 Another study of 112 breast cancerpatients found that 76% specifically used prayer as ahealing modality.14 A larger survey of women withbreast cancer in American Cancer Society supportgroups found that 88% felt that spiritual or religiouspractice was important in coping with their illness.37

Although the studies mentioned above demon-strate the popularity of spiritual and religious practicein healing from illness, and the fact that spiritualityand religious practice are related to health promotionand behavior, studies have not examined their poten-tial role in predicting or supporting a patient’s abilityto maintain role functioning and community partici-pation in the context of illness. Functional well-beingis an important and perhaps under-examined aspectof quality of life. The aim of reducing physical symp-toms is to improve the patient’s ability to function inlife to the same level as before he/she had an illness.

The purpose of this study was to examine the role ofspirituality and spiritual well-being in increasing func-tional abilities and functional quality of life. We wereinterested in examining which aspects of spiritualitymight be most relevant to coping with cancer, and inidentifying a simple and straightforward way in whicha clinician could assess risk of maladaptive coping andpoorer functional quality of life.

Methods

SubjectsParticipants were 191 women ages 26 to 78 within 18months of initial diagnosis of primary breast cancer, orwho had been diagnosed with metastatic breast cancerat any time. Patients were recruited from the greaterSan Francisco Bay Area through hospitals, flyers, and

Spiritual Correlates of Functional Well-Being

INTEGRATIVE CANCER THERAPIES 1(2); 2002 167



public service announcements. Interested womencalled the study office, and if they met eligibility crite-ria, they were invited to come to the clinic for an initialinterview.

ProcedureAt the time of the initial interview, women filled outthe psychometric measures described below and com-pleted consent procedures and a brief initial inter-view. After completion of questionnaires, they wererandomized to participate either in a 12-week Inte-grated Program or the 12-week Life-Issues Program.The groups are detailed fully elsewhere.17

MeasuresSociodemographic information was obtained fromeach participant, as well as information on comple-mentary and alternative practices, and spiritual prac-tices. Spiritual practices were enumerated, andpatients indicated frequency of practice.

Quality of life was assessed using the FunctionalAssessment of Chronic Illness Therapy–Breast, Ver-sion 4 (FACIT-B).25 The FACIT-B is a self-report mea-sure of quality of life designed for breast cancerpatients. The scale is made up of 28 items designed toassess 7 domains common to all cancer patients: physi-cal well-being, social/family well-being, emotionalwell-being, and functional well-being, with a separateadditional subscale for items that pertain to specificsymptoms of breast cancer. The scale has good concur-rent reliability and validity.25

Mood was measured using the Profile of MoodStates.38 It is made up of 65 items that are divided into 6subscales: tension-anxiety, depression-dejection, anger-hostility, fatigue-inertia, confusion-bewilderment, andvigor, with a combined total mood score. The scale hasbeen used in studies of psychological distress andadjustment in cancer patients, including breast cancerpatients.39-42

Spiritual well-being was measured using the Spiri-tual Scale of the FACIT, the FACIT-Sp and the Princi-ples of Living Survey (PLS).43 The FACIT-Sp consists of12 items measuring meaning and purpose, harmonyand peace, and closeness to God or a Higher Power. Itis divided into 2 subscales: Faith and Assurance, andMeaning and Peace. The internal consistency was0.87. A new version has come out with 24 questionsand reliability and validity testing is under way.42,43

Because the added questions were related to variousaspects of spirituality, they were included in the analy-ses, even though less than half of the sample com-pleted these items. The Principles of Living Survey is a19-item measure of spiritual integration. It is dividedinto 3 subscales: Spiritual Practices (reliability = 0.93),

Spiritual Growth (reliability = 0.80), and EmbracingLife’s Fullness (reliability = 0.76). Further validity dataare being collected.43

We found that 2 of the questions in the FACIT-Sp,#9 (I find comfort in my faith) and #10 (I find strengthin my faith), when combined were highly correlatedwith the overall FACIT-Sp (r = 0.71, P = .0000), and hadhigh internal consistency (Chronbach α = 0.97). Wetherefore hypothesized that these 2 questionstogether could be used as a brief measure ofspirituality.

Adjustment to cancer was assessed using the shortversion of the Mental Adjustment to Cancer Scale,44

the Mini-MAC.45 The MAC is a 38-item scale specifi-cally developed to measure cancer patients’ adjust-ment to illness. The scale measures 5 coping styles:fighting spirit, helpless/hopeless, anxious preoccupa-tion, fatalism, and avoidance. The MAC scale wasdesigned from studies that found that these adjust-ment styles were used by breast cancer patients. TheMini-MAC was designed as a refinement to the origi-nal MAC. The Mini-MAC has 29 items which result inthe 5 subscales mentioned above. Factor loadings foreach subscale range from 0.62 (Fatalism) to 0.88.46

In addition, participants in both groups were askedabout their use of yoga, meditation, imagery, andprayer. Specifically they were asked to rate the numberof times they meditated, prayed, or used imagery inthe last 2 weeks. Lastly, a series of questions designedby the authors were used to measure certain aspects ofspirituality and attributions of illness (see Appen-dix A).

Results

A. Population CharacteristicsThe women ranged in age from 26 to 78 years, with amean age of 40 years (see Table 1). Mean time since di-agnosis was 13.8 months with a range of 0 to 211months. Fifty percent of the women had been diag-nosed within 3 months before entering the program;75% of the women had been diagnosed within 11months. Ten of the women had metastatic cancer.Eighty-three women (47%) were on chemotherapy atentry to the study, and 46 women (52%) were on hor-monal therapy. The majority of the women (84%)were Caucasian, and 82% of the total had finished col-lege or postgraduate study. Almost half (49%) of thewomen had children, and almost half (48%) had in-comes over $60,000 per year. Almost half of thewomen (49%) were married or living with someone;26% were divorced or separated; and 24% had nevermarried.

Levine, Targ

168 INTEGRATIVE CANCER THERAPIES 1(2); 2002



Women were asked about adjuvant medical, psy-chological, spiritual, and complementary/alternativetherapies. One hundred and thirty-one women (70%)were receiving some sort of medical adjuvant treat-ment (chemotherapy, hormonal therapy, or radia-tion) when they entered the study. Seventy-three per-cent had used alternative therapy. Half of the womenhad practiced meditation or imagery at some time,with an average of 2 times per week. Only 10% of thewomen stated that they had practiced yoga at sometime. Half of the women stated that they prayed in thelast 2 weeks, with an average of 6 times during thattime period. However, only 34% of the women statedthat they had a “religious practice.”

B. Relationship of SpiritualWell-Being and Spirituality toPhysical and Functional Well-BeingFor the first set of analyses, Pearson r correlationswere performed with the physical well-being (PWB)and functional well-being (FWB) subscales of theFACIT-B25 and the spiritual scales. In a second analysis,individual items from the scales were also examined.In the third set of analyses, relationships between spiri-tual well-being, adjustment style, and psychologicaldistress were examined. And finally a fourth set ofanalyses looked for predictors of PWB and FWB. Tocorrect for the multiple correlations performed, aBonferroni correction was used for each set of analy-ses to determine significance. A Bonferroni correc-tion is used when numerous analyses are being made.The more analyses that are conducted, the higher isthe probability of declaring that a finding is significantwhen indeed it is not (Type 1 error). To correct for thehigher probability, the standard level of .05, which isused to determine significance, is divided by the num-ber of tests being made. This will provide a level of sig-nificance that should be used. For example in the firstset of analyses, the Bonferonni correction was P = .006(.05/9).

As seen in Table 2, none of the spiritual variablescorrelated significantly with physical well-being, butall except one (spiritual practice) correlated signifi-cantly with functional well-being. Although thesubscale of meaning and peace did not meet theBonferroni criteria for significance, it does show atrend towards significance. The use of prayer andmeditation did not correlate significantly with eitherPWB or FWB.

The next set of analyses looked at the correlationsof PWB and FWB with specific items from the spiritualscales, the combination of 2 questions from theFACIT-Sp and the additional questions designed bythe authors and listed in Appendix A. To correct formultiple correlations in this set, the Bonferroni cor-rection was P = .002. As seen in Table 3, physical well-being was significantly correlated only with questionsrelating to peace of mind and hopefulness, while func-tional well-being correlated significantly with almostall of the questions, except the item: “My illness hasstrengthened my faith or spiritual beliefs” and ques-tions examining love, forgiveness, and connectionwith nature. When the additional questions wereexamined, physical well-being was not related signifi-cantly with any of the questions, while functional well-being was only related to question 1 (I believe that anillness can have a positive effect on my life) and ques-tion 3 (I do not believe that illness can be a form ofpunishment).



Table 1. Demographics of Study Population

Variable Mean (SD) Number (Percent)

Age 49 (8.6)Time since diagnosis

(months) 13.8 (28.9)Number with metastases 10 (5)Marital status

Married 76 (40)Living together 17 (9)Widowed 1 (0)Divorced/separated 49 (26)Never Married 46 (24)

Income<$15,000 4 (8)$15,000-29,000 26 (14)$30,000-44,000 24 (13)$45,000-59,000 32 (17)>$60,000 89 (48)

EthnicityAsian 14 (8)Hispanic 3 (2)African American 11 (6)Caucasian 152 (84)

Use of adjuvant therapyYes 131 (70)No 57 (30)

Use of alternative therapyYes 135 (73)No 51 (27)On chemotherapy 83 (47)On hormonal therapy 46 (52)

Religious practiceYes 63 (33)No 121 (63)No answer 7 (4)

Guided imagery/meditationYes 93 (50)No 93 (50)

YogaYes 19 (10)No 172 (90)

SchoolLess than 8th grade 1 (1)Some high school 1 (1)High school graduate 2 (1)Some college 29 (15)College graduate 46 (24)Postgraduate study 110 (58)



The third set of analyses looked at the relationshipbetween spiritual well-being, adjustment style, andpsychological distress. Table 4 shows the correlationsfor the spiritual well-being subscales and the Profile ofMood States. Table 5 shows the correlations for spiri-tual well-being and the Mini-MAC subscales. TheBonferroni correction here was P = .007. As seen in thetable, spiritual well-being correlated significantly andnegatively (lower numbers mean less distress with theexception of vigor) with all of the distress variables.The exception was that there was not a significant cor-relation with the anger and fatigue, and the subscaleof meaning and peace. Avoidance did not correlatesignificantly with any of the spiritual well-being scales,whereas all of the other adjustment styles were signifi-cantly correlated with spiritual well-being (SpWB) andits subscales.

A fourth set of analyses tried to identify significantpredictors of PWB and FWB. First it was assumed fromthe literature that social well-being (SocWB) might bea significant predictor of PWB and FWB and may be apotential confounder. Social well-being is in fact corre-lated significantly with PWB (r = 0.20, P = .004) andFWB (r = 0.54, P = .0000). Therefore a series of regres-sion analyses were formed, with SocWB entered first inthe model. When the spiritual well-being subscales ofFaith and Assurance and Meaning and Peace, alongwith the subscales from the Principles of Living Survey(Spiritual Practice, Spiritual Growth, Embracing Life)were added after SocWB, the combination of variablesexplained 46% of the variance in FWB (F = 25.36, P <.0001). When SocWB was left out of the model, thespiritual variables alone accounted for 40% of the vari-ance in FWB (F = 23.8, P < .0001). Therefore althoughSocWB correlated highly with FWB, adding SocWB tothe spiritual model accounted for only 6% more of thevariance than by using the spiritual scales alone.

Levine, Targ


Table 2. Correlations Between Physical Well-Being,Functional Well-Being, and Spirituality Scales

Physical FunctionalWell-Being Well-Being

r P r P

Spiritual well-being* .15 .05 .59 .0000†Faith and assurance* .06 ns .34 .0000†Meaning and peace* .2 .007 .64 .0000†Spirituality Total‡ –.05 ns –.32 .0000†Spiritual practice‡ –.02 ns –.19 .08Spiritual growth‡ –.03 ns –.27 .0002†Embracing life‡ –.04 ns –.38 .0000†Use of meditation/guided

imagery –.17 .02 –.12 nsPrayer –.5 ns –.08 ns

*From the FACIT-Sp.†Significant using Bonferroni correction of P = .006.‡From the Principles of Living Scale.

Table 3. Correlations Between Physical Well-Being,Functional Well-Being, and Individual Questions*

Physical FunctionalWell-Being Well-Being

r P r P

I feel peaceful.* .23 .002† .55 .0000†I have a reason for living. .08 ns .44 .0000†My life has been productive. .16 .03 .52 .0000†I have trouble feeling peace

of mind. –.24 .001† –.47 .0000†I feel a sense of purpose

in my life. .11 ns .48 .0000†I am able to reach down

deep into myself for comfort. .23 .002† .50 .0000†I feel sense of harmony within

myself. .20 .007 .55 .0000†My life lacks meaning and

purpose. –.06 ns –.37 .0000†I find comfort in faith or

spiritual beliefs. .03 ns .24 .0008†I find strength in faith or

spiritual beliefs. .06 ns .31 .0000†My illness has strengthened

my faith or spiritual beliefs. .04 ns .20 .006I know that whatever

happens with my illness,things will be OK. .05 ns .38 .0000†

I feel connected to a higherpower (or God).‡ .22 .07 .32 .007

I feel connected to other people. .28 .02 .38 .0009†I feel loved. .11 ns .44 .0001†I feel love for others. .12 ns .24 .04I am able to forgive others for

any harm they have evercaused me. .10 ns .24 .04

I feel forgiven for any harm Imay have ever caused. .14 ns .32 .007

Throughout the course of myday, I feel a sense ofthankfulness for my life. .34 .003 .42 .0003†

Throughout the course of myday, I feel a sense ofthankfulness for whatothers bring to my life. .22 .06 .34 .004

I feel hopeful. .38 .001† .61 .0000†I feel a sense of appreciation

for the beauty of nature. .24 .06 .24 .04I feel compassion for others

in the difficulties they arefacing. .21 .08 .44 .0001†

I feel a sense of meaning inmy life. .26 .03 .48 .0000†

Combination questions (9&10) .05 ns .29 .0001†I believe that an illness can

have a positive effect onmy life.§ –.1 ns –.26 .0003†

I believe that my thoughtsor emotions can cause meto have a serious illness. .17 .02 .17 .02

I do not believe that illness canbe a form of punishment. –.11 ns –.21 .004

I believe that being ill is meantto teach me something. .02 ns .02 ns

I believe that I am responsiblefor how healthy or sick I am. 0 ns –.07 ns

*From FACIT-Sp.†Significant using a Bonferroni correction of P = .002.‡From here on n = 69-71.§n = 191.



Similar analyses were performed to predict physicalwell-being. Social well-being and physical well-beingsignificantly correlated with each other (r = 0.20, P =.004). Therefore, SocWB was also forced first into themodel as a possible confounder. A combination ofSocWB and several single questions (“I feel peaceful,”“I have trouble feeling peace of mind,” “I am able toreach down deep into myself for comfort,” “I feel asense of harmony within myself,” and “Throughoutthe course of my day, I feel a sense of thankfulness formy life”) accounted for 18% of the variance in PWB(F = 3.47, P = .005). Without SocWB in the model, thequestions accounted for 13% of the variance in PWB(F = 3.05, P = .02).

DiscussionThe purpose of this study was to determine whetherspiritual well-being is an important predictor ofpsychosocial outcomes in women with breast cancer.While many epidemiological survey studies havefound that individuals espousing spiritual beliefs orpractices tend to experience less psychological dis-tress,46no studies to date have examined spiritual well-being as a marker for functional or physical well-beingin a breast cancer population. Functional well-being is

a pivotal quality of life indicator in the lives of cancerpatients. It describes the extent to which patients cancontinue activities of daily living, including basic mo-bility, self-care, cooking, and cleaning, as well as workor school outside the home. Physical well-being de-scribes a patient’s self perception of the extent of herillness, and subjective experience of pain, nausea, andfatigue. This study used baseline data from 191 womenwith breast cancer entering support groups.

As expected, results in this study did confirm thework of others finding that spiritual well-being doescorrelate with less psychological distress. This patternincluded the finding of less anxiety, less depression,less anger, and less hopelessness. Spiritual well-beingwas also significantly correlated with greater func-tional and physical well-being. An initial hypothesiswas that because spirituality is often associated withparticipation in communities of faith and spiritualpractice, it might really be a measure of social support.Social support, in the form of community networks,practical assistance, and availability of family andfriends, has historically been strongly associated withboth functional and physical well-being. The impor-tance of social support in promoting functional well-being was confirmed in our study as well, with a find-ing of a strong correlation between social well-beingand functional well-being. Perhaps people who havehigh “spiritual well-being” are simply benefiting fromthe communities affiliated with spiritual institutions.To test this hypothesis several regression formulaswere used. Interestingly, social support accounted foronly 24% of the variance in functional well-being,while spiritual well-being (as measured by the two spir-itual scales together) accounted for fully 40% of thevariance. Thus we conclude that spiritual well-being ismeasuring something other than practical or socialsupport.

Spiritual well-being, as measured by the FunctionalAssessment of Chronic Illness Therapy is made up oftwo subscales: Faith and Assurance and Meaning andPeace. This study found that each of these subscalesindependently and significantly correlated with func-tional well-being, while only the subscale Meaning andPeace showed a significant correlation with physicalwell-being. This raised the question as to what was themental process within spirituality that might relate toeach of these outcomes. A question by question analy-sis of each of the two spirituality subscales was done.While nearly every question on the Faith and Assur-ance subscale correlated independently with func-tional well-being, in contrast it was the questions con-cerning peace rather than meaning that correlatedwith physical well-being. Patients who felt a sense of“harmony” or felt they could “reach inside themselves



Table 4. Correlations Between Spiritual Well-Being andPsychological Distress

Spiritual Meaning/ Faith/Well-Being Peace Assurance

r P r P r P

Total mooddisturbance –.58 .0000* –.31 .0000* –.65 .0000*

Anxiety –.43 .0000* –.23 .002* –.70 .0000*Depression –.62 .0000* –.35 .0000* –.70 .0000*Anger –.36 .0000* –.18 .02 –.43 .0000*Vigor .53 .0000* .34 .0000* .53 .0000*Fatigue –.34 .0000* –.17 .02 –.42 .0000*Confusion –.42 .0000* –.21 .005* –.49 .0000*

*Significant using a Bonferroni correction of P = .005.

Table 5. Correlations Between Spiritual Well-Being andAdjustment Style

Spiritual Meaning/ Faith/Well-Being Peace Assurance

r P r P r P

Fighting spirit .47 .0000* .30 .0000* .46 .0000*Helpless/hopeless –.58 .0000* –.38 .0000* –.61 .0000*Anxious

preoccupation –.51 .0000* –.41 .0000* –.48 .0000*Avoidance –.17 .02 –.12 ns –.18 .02Fatalism .61 .0000* .60 .0000* .49 .0000*

*Significant using a Bonferroni correction of P = .006.



for comfort” were less likely to report physical symp-toms. Meaning alone was more strongly correlatedwith functional well-being.

Because of interest in developing interventionsthat might incorporate useful aspects of spirituality,spiritual practice was examined both from the per-spective of spiritual “activities,” in this case meditationor prayer, and from the perspective of spiritual atti-tudes or cognitive approaches as measured by the spir-itual well-being subscales described above, as well asthe scales Embracing Life and Spiritual Growth fromthe Principles of Living Scale. Although meditationand prayer did correlate with overall spiritual well-being, they did not correlate significantly with physicalor functional well-being. Spirituality of the cognitivetype, however, did show a significant correlation withfunctional well-being. This finding supports the ideathat spirituality is not equivalent to a form of stressreduction. Rather it is a cognitive set or an attitudetoward life, that may be supported or driven by experi-ences encountered in the setting of prayer ormeditation.

Further analysis found that the spiritual well-beingscale also correlated with cognitive styles known to beadvantageous in coping with chronic illness. Theseincluded a positive association with fighting spirit,fatalism (acceptance), and a negative association withhelplessness and avoidance. Of interest is that whilethere is a popular concern that spirituality may be a“defense” or way of avoiding the truth, in this study itwas correlated with actively confronting the illnessexperience.

An additional aim of this work was to identify 1 or 2simple questions that could be used by clinicians thatwould serve as adequate markers of spiritual well-being. While many of the questions on the spiritualwell-being scale were strongly intercorrelated, the sin-gle question “do you derive comfort and strength fromyour spirituality and religion” has a correlation (r =0.71, P < .00001) with the overall spiritual well-beingscale and (r = 0.29, P < .0001) correlation with func-tional well-being. This single question therefore maybe of value to clinicians in assessing functional copingresources.

We conclude that individuals who describe them-selves as having spiritual faith show beliefs, attitudes,and possibly coping strategies that confer an advan-tage both in quality of life and physical symptomreports in breast cancer. Findings from this study sug-gest that spirituality is not a type of avoidance. Individ-uals endorsing spiritual values and experiencesshowed neither the cognitive coping style, nor the typ-ical outcomes of avoidant personality. Data from thisstudy suggest that asking patients about the role

spirituality plays in their lives may serve as a usefulmarker for the likelihood of successful managementof stressors associated with breast cancer, and the abil-ity to participate actively in life despite catastrophic ill-ness. A potential limitation on interpretation of resultsfrom this study is the question of cause and effect. Dothe patients have faith because they are doing well—orare they doing well because they have faith? Althoughsignificant findings from the multiple regression anal-yses suggest that the directionality came from spiritualwell-being, future studies will examine whether spiri-tuality also conveys a long-term coping or physicaladvantage.

Given the large number of studies indicating theimportance of spirituality and religious practice inpromoting and maintaining health and recovery fromillness, it is surprising that the use of prayer, religiousfaith, and enhancement of a sense of spirituality arenot more deliberately supported to aid patients. Thislack of use of spirituality by physicians and otherhealth practitioners may stem from the reluctance ofphysicians and health practitioners to discuss theseconcerns, often from lack of training or knowledge. Aproblem can arise when the health care provider isuncomfortable with spirituality in a medical setting orfeels ill-equipped to discuss this aspect of life with his/her patient. Professional health providers may feel asif addressing spiritual or religious concepts would bean intrusion, while others who do not having a strongreligious belief themselves refrain from such topics, orstill others might fear the risk of imposing their beliefsystem on their patients. But given the strong data thatsupport the importance of spirituality and religiouspractice to health, training in this area may provehelpful.

AcknowledgmentsSponsored by Grant No. DAMD17-96-1-6260, US Department ofDefense.

We would like to acknowledge and thank the following peoplefor their involvement in this project: Rosalind Benedet, RN, NP,Alison Brady, BA, Jnani Chapman, RN, Janelle Eckhardt, PhD, RN,Deborah Hamolsky, RN, Adina Klien, MA, Cory Fitzpatrick, PhD,Sian Cotton, PhD., Kristie Dold, BA, Michelle Baumgardner, MSW,Sylvine Jerome, MD, Carol Kronenwetter, PhD, Diane Neighbor,DTR, Cindy Perlis, MA, Megan Rundel, MA, Brooke Stone, LCSW,and Laura Esserman, MD, MBA. We would also like to thank theanonymous editors who helped to refine this paper.

Appendix AAdditional Questions

1. I believe that an illness can have a positive effect onmy life.

2. I believe that my thoughts or emotions can cause meto have a serious illness.

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3. I do not believe that illness can be a form ofpunishment.

4. I believe that being ill is meant to teach mesomething.

5. I believe that I am responsible for how healthy or sickI am.

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spiritual correlates of functional well-being in women with breast cancer

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