Crisis of faith can lead to increased risk of death

Although religion, prayer, and church attendance have long been shown to reduce the risk of death, a new study suggests that elderly Christian men and women who experience a religious struggle in connection with their illnesses may be an at increased risk of death.

Patients who felt "alienated from or unloved by God" or attributed their illness to "the devil" had a 28% increased risk of dying during the two-year period, according to results of the study from Bowling Green (OH) State University.1

Researchers, led by Kenneth Pargament, PhD, a psychology professor at Bowling Green, conducted the study to evaluate religious coping strategies, including potentially helpful and harmful religious expressions. They found that those who experienced a religious struggle, such as spiritual discontent and questioning God’s powers, were at increased risk of death, even after controlling for baseline health, mental health status, and demographic factors.

Why does spiritual doubt bring about an increased risk of death? "That’s the $64,000 question," Pargament says. "It’s our best guess that religious struggle somehow compromises the immune system." He also suggests that religious struggle in itself may cause poorer health or that it could be associated with emotional or personality differences that relate directly or indirectly to mortality.

Pargament suggests that religious struggle may result in social alienation, depriving the patient of the support of a congregation, clergy, perhaps even friends and family and in turn, a loss of social and emotional support. He looked at 595 patients ages 55 and older who were medical inpatients at Duke University Medical Center in Durham, NC, and at the Durham Veterans Affairs Medical Center. Participants were predominantly Christian — the majority representing conservative (e.g. Baptist) or mainline Protestant (e.g. Methodist) denominations. Patients were suffering from serious heart disease, cancer, and gastrointestinal disorders. Religious coping and religious struggle were measured by RCOPE, a 14-item questionnaire that assesses the extent to which the patient uses specific methods of religious coping.

Positive religious coping consists of seven items that measure seeking spiritual support, seeking a spiritual connection, collaboration with God in problem solving, religious forgiveness, and benevolent religious appraisals of the illness. Religious struggle was measured by the negative religious coping subscale made up of seven items that assess feelings of being punished by God, interpersonal religious discontent, demonic appraisals, spiritual discontent, and questioning God’s powers. Participants also were asked how often they attend church or other religious meetings; how much time they spend in private religious activities, such as prayer, meditation, or Bible study; and how important religion is in their lives.

After two years, researchers found survivors at baseline were significantly younger, more educated, and more likely to be white; and have fewer active medical diagnoses, less severe ratings of illness, better subjective health, more independent functional status, and better cognitive functioning. Both survivors and patients who subsequently died reported some degree of religious struggle, but survivors attended church more frequently than those who died during the study. Mortality was not predicted by gender, race, diagnosis, cognitive functioning, independence in daily activities, depressed mood, or quality of life.

Furthermore, Pargament’s group analyzed the depth and duration of religious struggle by comparing those who had no religious struggle at all, those who had a short crisis, and those who engaged in a chronic struggle.

"Mortality was directly linked to the length and intensity of the struggle," he says. "People who got stuck in the struggle and seemed unable to work out their crisis definitely did not do as well as those who worked their way through the struggle, whether by their own steam or with the help of clergy or other religious supporters."

His colleague, Richard Penson, MD, director of clinical research in medical gynecological oncology at Massachusetts General Hospital in Boston, agrees.

"There is no doubt that patients who don’t have much spiritual faith are disadvantaged." Penson has observed that when his patients experience religious crisis, they frequently give up. "They simply lose hope."

Penson and Pargament also agree that it is incumbent on health care professionals to address the spiritual needs of their patients.

"A spiritual history is just as important as a medical history. It should become routine," says Pargament. By spiritual history, Pargament says, he means that practitioners should ask about religious and church affiliations and ask questions that would determine how important religion is in the patient’s life.

Doctors, nurses, and other practitioners often may feel uncomfortable or unqualified to raise spiritual issues with their patients, but Penson asserts that patients often raise these issues themselves. "I think it is definitely part of our jobs to encourage people to make realistic positive adjustments to their illnesses and particularly to help them cope with feelings of guilt if the illness goes badly."

Penson also says health care professionals shouldn’t open the subject of religious struggle, but they should not be fearful if the subject is raised.

Be ready to listen

Nurses often become confidantes of hospitalized patients undergoing religious struggle, and an awareness of the increased risk associated with religious struggle may give nurses a signal to suggest a chaplain visit. "Sometimes it’s enough to just talk about it," he says.

Pargament suggests that health care professionals should be more vigilant in observing their patients (particularly elderly patients with serious illnesses), treat them for depression if it’s appropriate, and consider referrals to a chaplain.

"Acknowledging and addressing anger or guilt, common sources of suffering, are essential to adjustment," says Penson. "Simply being there for the patients and being open to their hurt can help resolve their spiritual crises, a responsibility that is shared by the whole health care team."

Pargament, who says his research has, over the years, "brought me closer and closer to my religious life," warns that the results of his study "shouldn’t in any way undermine religion as an unusually potent personal resource for so many people with serious illnesses. Most people don’t report religious struggles. They’re not that common, but a religious struggle should be a red flag for every health care professional that the patient’s health may be at increased risk," he says.


1. Pargament KI, et al. Religious struggle as a predictor of mortality among medically ill elderly patients. Arch Intern Med 2001; 161:1,881-1,885.

Key points

  • Elderly Christian patients who undergo religious crises associated with their illnesses are 28% more likely to die than those who do not experience such struggles.
  • Researchers suggest crises may suppress immunological function.
  • Health care professionals who are cognizant of the increased risks associated with religious struggle can help their patients by turning a sympathetic ear and recommending chaplain care, if it seems appropriate.