CHAPTER 2

LITERATURE REVIEW AND SYNTHESIS

Selection Procedures

            Four databases- PsychInfo, Medline, PsycLIT, and Sociofile- were searched for this systematic research synthesis. In these databases, the following keywords, alone and in combinations, were used: meditation, mantra, prayer, faith, spirituality, religion, health, stress, anxiety, depression, and social work.

            Klein and Bloom (1994) delineate five major types of articles in the social work literature- empiricism, technology, conceptualization, valuation and commentary. Of these, the empiricism, technology, and commentary categories are relevant to the classification system of this paper. Empiricism, according to Klein and Bloom (1994):

refers to activities of engaging the world and people in it by means of the five basic senses. The empirical component includes planned actions to observe and measure social events in laboratories, clinics, or community settings- what would be termed‘research’ or ‘evaluation’ in the current literature. (p. 422)

            The categorization scheme of Klein and Bloom (1994) will be further described in the categorization overview section of this chapter. For now, the categories are introduced to help the reader understand the discussion of selection procedures that follows.

            For the general relevance of spirituality and religiosity to the helping professions category (see Figure 1), commentary and empirical research articles that examined the importance of spirituality and religiosity to fields such as social work, mental health and medicine were sought. There are many such articles, and the 43 pieces chosen for inclusion in this section are by no means exhaustive. The main point of the general relevance section is to demonstrate that spirituality and religiosity are considered important factors for helping professionals. Therefore, variety in articles was stressed to illustrate the pervasive nature of these factors. If several articles covered the same topic, the most recent ones were chosen for inclusion. The main criterion for inclusion was diversity, with respect to population and professional area. For example, the studies selected examine the role of spiritual and religious factors in areas such as chronic illness, life satisfaction, attributes of caregivers in Alzheimer’s disease, death depression and anxiety, predictors of mortality, alcohol and drug use, management of HIV/AIDS, depression, delinquency, self-esteem, crime, hospice work, coping with war, general well-being, coping with a chronically ill child, resolving childhood abuse issues, suicide, and dealing with illnesses such as cancer and heart disease. Populations studied include adolescents, African Americans, elderly, long-term hospital inpatients, burn patients, mental health clients, suicidal persons, and hospice workers. 

            Not all articles in this section provide evidence for the potential importance of spirituality and religiosity, though the great majority of them do. Selection of empirical research articles in this category was based on title, to check for substantive area and population, and date, as described above. That is, results were not analyzed prior to selection. This methodology was incorporated to reduce selection bias. Commentary articles in this category were selected after the empirical research articles, in order to provide some theoretical framework that bridged a variety of fields, including social work, nursing, medicine, psychology, and psychiatry. Though more than the eight commentary articles included herein were found, none of these articles argued for the unimportance of spirituality and religiosity, and thus the tenor of the commentary articles can also be considered representative of the literature. 

            Articles in the measurement of spirituality section (see Figure 1) focus on quantitative empirical research on the measurement of spirituality. These studies focus on attempts to directly measure spirituality, rather than correlates of spirituality, such as general well-being. Three spirituality instruments are analyzed. The Spiritual Well-Being Scale (SWBS) is the most widely researched and utilized tool in the field,  and is based on Judeo-Christian psychological theory (Ellison & Smith, 1991). Based on Vedic guna theory, the Vedic Personality Inventory (VPI) is the guna scale that has been most extensively analyzed with psychometric methods (Wolf, 1998). Hatch, Hellmich, Naberhaus, and Berg (1995) have developed the Spiritual Involvement and Beliefs Scale (SIBS), which is an attempt, derived from dissatisfaction with the SWBS, to assess spirituality without Western bias.

            Articles in the spiritual interventions category (see Figure 1) constitute the main topic of this literature review. Included are articles that examine interventions that purport to be spiritual in nature, with regard to their effects on dependent variables such as depression, stress, and substance abuse recovery. This review focuses on the content of the interventions, as well as the methodological rigor of the studies. The prime selection criteria was diversity that reflects the heterogeneity of interventions and methodologies. Using this criteria, articles investigating the effects of Western-style prayer, Alcoholics-Anonymous non-sectarian spirituality, social work community interventions, and Eastern-style meditation were chosen. Only in the area of Eastern-style meditation were there many articles, necessitating further selection criteria. Delmonte (1983) and Delmonte and Kenny (1985) conducted literature reviews on Eastern-style spiritual interventions, and these reviews are included in this analysis as a summary of research in this area prior to 1985. For research on Eastern-style interventions since 1985, selections included studies with a variety of research techniques, especially with regards to qualitative and quantitative approaches, and studies that investigated a range of interventions, such as mantra-based, Buddhist, and physical yoga techniques.      

Categorization Overview

             Except for the commentary articles in the general relevance category, all literature classified in Figure 1 fits the definition for empiricism given by Klein and Bloom (1994), which is presented above in the section on selection procedures. For the specific purposes of this paper, general relevance, spiritual interventions, and measurement of spirituality categories have been differentiated. For the general relevance category, commentary and empirical research sub-categories have been created, and for the spiritual intervention category, empirical quantitative, empirical qualitative, and literature review sub-categories have been created. In the measurement category, all pieces are quantitative and meet the criteria for technology pieces, as defined by Klein and Bloom (1994). “Technologies may be mechanisms or procedures that extend empiricism in a research sense... or the tools that one may bring to bear in a given practice setting.” (p. 422). According to Klein and Bloom, quantitative empirical articles use standardized empirical methods such as descriptive research and bivariate and multivariate analysis, and qualitative empirical studies include case studies, ethnographic methods, and community case illustrations. The literature reviews in the Spiritual Interventions section examine empirical studies, and have been placed in a separate sub-category. Commentary articles refer to:

statements that describe, critique, or comment on empirical, technological, conceptual, or valuational activities....Commentary represents participation in public discussion of the issues of the day. These discussions provide the foundation on which to develop other components of the applied social science. (p. 423)

The articles in the commentary section of the general relevance category fit this description.

            In the general relevance of spirituality and religiosity to the helping professions category there are 8 commentary articles and 35 empirical research articles (see Figure 1). Each category is divided into sections according to field of practice, such as social work, medicine, and mental health. All these pieces address the influence of spirituality and religiosity on the helping professions in a wide variety of fields and populations, as described above. Social workers are active in all of the environments and with all the populations included in these articles. Therefore, social work researchers, administrators and practitioners will benefit by noting the contents of these articles. For example, several articles deal with health care, a field in which many social workers are employed. With an understanding of the spiritual and religious factors common to this setting, social workers will be better equipped to assist clients in coping with their situation. Similarly, studies on the correlation between spirituality and religiosity and delinquency can help social workers in case management, on individual, familial, and communal levels, with families and communities that struggle with juvenile delinquency.    

            In the measurement of spirituality category there are five articles (see Figure 1), all technology pieces, presenting various psychometric strategies for measurement of spirituality according to different orientations (e.g., Vedic, Western). These articles are included because it is sometimes suggested that spirituality is not the domain of science, since spirituality cannot be operationalized or measured. Here, however, are attempts at such operationalization and measurement, following accepted psychometric procedures.   

            There are 15 spiritual intervention pieces (see Figure 1). Among these, there are nine quantitative studies, four qualitative studies, and two literature reviews. The literature reviews deal with Eastern-style interventions, such as mantra chanting and meditation, as do five of the quantitative pieces and three of the qualitative articles. One quantitative study evaluates prayer to the Judeo-Christian God, and two quantitative articles examine effects of a 12-step program. There is one quantitative study that investigates a variety of spiritual and religious interventions, and one qualitative investigation presents a model for social work with religious and spiritual communities. These 15 pieces are the focus of this literature review, and will be analyzed in appendix A.

General Relevance of Spirituality and Religiosity to the Helping Professions (43 Articles)

Commentary (8 Articles)

            Social Work- Canda (1988), Keefe (1996)

                Medicine- Hudson (1996), Levin, Larson, & Puchalski (1997), McKee, & Chappel (1992), Peri (1995)

                Mental Health- Lukoff, Lu, & Turner, R. (1995), Templeton (1994)    

Empirical Research (35 Articles)

            Social Work- Joseph (1988)

                Medicine- King, & Bushwick (1994), Maugans, & Wadland (1991), Morgan, & Cohen (1994), Mickley, Soeken, & Belcher (1992), Ginsburg, Quirt, Ginsburg, & MacKillop (1995), Landis (1996), Rutledge, Levin, Larson, & Lyons (1995), Goldbourt, Yaari, & Medalie (1993), Harris, Dew, Lee, Amaya, Buches, Reetz, & Coleman (1995)

                Mental Health-  Bradley (1995), Levin, Chatters, & Taylor (1995), Ellison (1995), Krause (1995), Burgener (1994), Carson (1993), Carson, & Green, (1992), Pargament, Ishler, DuBow, Stanik, & Rouiller (1994), Pollner (1989), Valentine, & Feinauer (1993), Westgate (1996)

                Hospice and Emotions Surrounding Death- Millison (1995), Millison, & Dudley (1990), Alvarado, Templer, Bresler, & Thomas-Dobson (1995)

                Evaluation of Suicidal Potential- Kehoe, & Gutheil (1994)

                Mortality- Bryant, & Rakowski (1992), Janoff-Bulman, & Marshall (1982)

                Youth Substance Use- Burkett, & Warren (1987), Lorch, & Hughes (1985), Turner, Ramirez, Higginbotham, Markides, Wygant, & Black (1994), Cochran, Wood, & Arneklev (1994)

                Delinquency- Chadwick, & Top (1993), Evans, Cullen, Dunaway, & Burton (1995), Foshee, & Hollinger (1996)

                General- Witter, Stock, Okun, & Haring (1985)

 Measurement of Spirituality (5 Articles)

Technology

            Bufford, Paloutzian, & Ellison (1991), Butman (1990), Ellison, & Smith (1991), Hatch, Hellmich, Naberhaus, & Berg (1995), Wolf (1998).

Figure 1: Literature Classification for Spiritual Interventions

Spiritual Interventions (15 Articles)

Empirical Quantitative (9 Articles)

            Alford, Koehler, & Leonard (1991), Byrd (1988), Carroll (1991), Janowiak, & Hackman (1994), Kutz, Leserman, Dorrington, Morrison, Borysendo, & Benson (1985), Miller, Fletcher, & Kabat-Zinn (1995), Pearl, & Carlozzi (1994), Smith, Compton, & West (1995), Stern, Canda, & Doershuk (1992)

Empirical Qualitative (4 Articles)

            Kaye (1985), Nakhaima, & Dicks (1995), Sweet, & Johnson (1990), Urbanowski, & Miller (1996)

Literature Review (2 Articles)

                Delmonte, M. M. (1983), Delmonte, & Kenny (1985)

Figure 1. (Continued)

General Relevance of Spirituality and Religiosity to the Helping Professions

            These articles are presented as evidence for the importance of spirituality and religiosity, and as support for the pertinence of spiritually-based interventions to the helping professions. There are dozens of articles in this section, and as a whole they provide strong evidence that social workers, psychologists, counselors, psychiatrists, nurses, doctors, and other professionals will enhance their abilities to serve people by serious consideration of spiritual and religious factors. Detailed analysis of methodology is not provided, as it is for articles in the spiritual interventions category, because the mass of evidence is adequate to demonstrate the essential point of potential relevance of the topic to helping professionals, notwithstanding shortcomings in some of the studies. Before addressing the results of research articles, commentary articles will be presented to provide a framework for the empirical pieces.   

            Commentary Articles

Social Work

            Canda (1988) appeals to social workers to consider spiritual and religious issues in their dealings with clients. Claiming that spirituality is common to all people, he asserts that it is relevant to all areas of social work practice, and calls for a spiritually aware social work profession. Human dignity and potential, according to Canda, is intricately entwined with spiritual needs, and a helping professional must recognize this facet of human existence in order to wholly benefit individuals and society. He suggests that social work theory, research, education and practice need to more fully explore the spiritual dimension. Further, he advises that social workers should develop self-understanding regarding spiritual growth, examining their beliefs, motivations, values and activities in relation to spirituality, and should consider the impact of these factors on clients’ spirituality. He goes on to overview Christian, Jewish, Shamanist, and Zen perspectives on social work, and concludes that professional helping may be significantly enhanced by the introduction of prayer, meditation, contemplation, ritual, and study of scripture, as appropriate to client orientation. Additionally, he maintains that there are numerous meditative techniques, from Eastern and Western traditions, that have not yet been discussed and applied in social work.

            Keefe (1996) presents Eastern-style meditative techniques as potentially important in social work practice and treatment, describing specific applications in treating depression, substance abuse, excessive anxiety, and development of social work skills in professional training. Many social workers have adopted a bio-psycho-social model in their practice, and Keefe’s article provides a framework for progression to a bio-psycho-social-spiritual model, as is being developed in nursing and medicine (Mckee & Chappel, 1992). Keefe asserts that the potential of meditation in social work treatment and psychotherapy has already been recognized by some researchers and practitioners, and that meditative methods are natural adjuncts to social work interventions. He concludes that meditation “has the potential to be valuable in work with clients from diverse cultures. Yet meditation as a method continues to demand much from, and occasionally challenges, some theories underlying social work treatment for its full description and explanation. (p. 451)”

Medicine

            Levin, Larson, and Puchalski (1997) argue that more attention needs to be given by helping professionals to the religious and spiritual beliefs of the people whom they serve. They cite statistically significant associations between religious belief and health measures and measures pointing to differences in morbidity and mortality rates. Further, they state that systematic reviews and meta analyses quantitatively confirm that religious involvement is an epidemiologically protective factor. Additionally, they suggest that physicians should be more inquisitive about patients’s spiritual beliefs and practices, citing that 80% of Americans believe in the power of God or prayer to improve the course of illness, while only 10% of physicians ever inquire about spiritual and religious beliefs. Empirical research articles, which will be discussed in the next section, provide further evidence that clients and patients want professionals to inquire about spirituality more than they do at present.

            In medicine, a bio-psycho-social-spiritual model is being developed and practiced, as the spiritual dimension is gradually being recognized as essential (Mckee & Chappel, 1992). Mckee and Chappel claim that there is ample evidence to support the inclusion of spiritual issues in medical education and practice. They write:

There is growing evidence that spiritual practices can complement medical treatments in cases of both acute and chronic disease....It is evident that there is a growing body of medical literature suggesting that spirituality is of interest and beneficial to the practice of primary care medicine. (p. 204)

            Hudson (1996) stresses the importance of faith in a higher power as a fundamental  ingredient in guiding many patients to health. In relation to caring for AIDS patients, Peri (1995) claims that the spiritual dimension is routinely overlooked, and that development of spiritual well-being is crucial in helping persons with AIDS find meaning in life and death.

            Mental Health

            Lukoff, Lu, and Turner (1995) point to the importance of recognition and understanding of client spirituality and religiosity in the mental health professions. Generally, they assert, spiritual and religious issues that clients bring to treatment are ignored or pathologized. This unfavorable view is not warranted, however, as a meta-analysis of religiosity and mental health determined that they are significantly and positively related. In addition, church affiliation and perceived relationships with divine others, such as God, show a significant, positive correlation with several measures of well-being. For most people, religion and spirituality are viewed as sources of strength and well-being, rather than evidence of psychopathology. This article examines the roots of these attitudes, which, statistically, are not representative of the general population or persons who enter therapy, amongst mental health professionals. They conclude that this tendency towards a negative view of religion/spirituality can be traced to the roots of behaviorism, cognitive therapy and psychoanalysis. Freud regarded religion as a universal obsessional neurosis, Skinner largely ignored religious experience, and Ellis viewed religion as equivalent to irrational thinking and emotional disturbance. Similarly, spiritual experiences have been considered to be evidence of psychopathology. Surveys of therapists have revealed that distinct references to religion appear in about one-third of all psychoanalytic sessions. Carl Jung wrote (Templeton, 1994):

During the past thirty years...among all my patients in the second half of life- i.e. over thirty-five- there has not been one whose problem in the last resort was not that of finding a religious outlook on life. It is safe to say that every one of them fell ill because he had lost that which the living religions of every age has given their followers, and none of them has been really healed who did not regain his religious outlook. (pgs. 142-143)

To ignore or to adversely evaluate this dimension may be perceived as a sign of cultural insensitivity, a trait which social workers must strive to avoid. 

Empirical Research

Social Work

            Joseph (1988) explored whether social workers consider religious and spiritual issues to be a significant parameter of the client’s internal and external environment. In addition, he inquired whether social workers explore spiritual and religious issues and assess them in relation to other psychosocial factors. Also, he evaluated the extent to which social workers actively deal with spiritual and religious issues in the treatment process. This mail survey randomly selected 90 field instructors affiliated with a Master of Social Work program in Washington, D.C.. Sixty-one instructors responded to the survey, which included four sections. One section examined personal background, the second section addressed spiritual and religious issues in social work, the third section explored practitioner experience in using religious/church related resources in practice, and the fourth section dealt with religious issues that surfaced in practice. Joseph concluded “Data clearly show that practitioners consider religious issues important despite the lack of emphasis on them in graduate education” (p. 448). Further,  the data “clearly reflect the prominence of God and religion in times of illness and crises and suggest that such phenomena can hardly be overlooked in social work practice” (p. 450). He concludes that the religious dimension of the person, particularly as it interacts with life-cycle and ecological concerns, has been muted in social work practice, especially in dealing with populations such as the frail elderly.

Medicine

            King and Bushwick (1994), in a cross-sectional survey of hospital inpatients found that many patients believe that physicians should consider patients’ spiritual needs, and that 21% of patients believe it is the physician’s responsibility to inquire about religious issues. This research included a pre-survey power analysis to determine sample size. Maugans and Wadland (1991) cite many studies indicating the pervasiveness of religion and spirituality in the United States, and several studies pointing to the benefit of religious/spiritual association on various aspects of health. Their study, a cross-sectional survey of physicians and patients, found that patients tended to be more religious than physicians, though more doctors than patients reported that religion should affect the choice of a physician. Maugans and Wadland suggest, based on results of the survey, that doctors became more aware of spiritual and religious factors. Other notable findings were that physicians felt more strongly than patients that they had a right and responsibility to inquire about religion in their medical practice, though patients and doctors acknowledged that such inquiry occurs very infrequently. In this study, seven factors were found significant at the .01 level. These factors are that patients believe in the existence of God more than doctors, patients engage in prayer more often than doctors, patients feel closer to God than doctors, doctors believe more than patients that religion should be an important factor in choosing a physician, doctors believe more than patients that religion should be an important factor in the maintenance of the doctor-patient relationship,  doctors believe more than patients that doctors have the right to inquire about religious matters, and doctors believe more than patients that physicians have the responsibility to inquire about such matters. Morgan and Cohen (1994) obtained results indicating that psychiatrists are increasingly recognizing the importance of spirituality and religion to their clients.

            In an investigation of the relationship between spiritual well-being, religiousness, and hope amongst women with breast cancer, Mickley, Soeken, and Belcher (1992), using a cross-sectional survey design with a sample of 175 women with breast cancer, determined that intrinsic religiosity, defined as considering relationship with God more important to overall well-being than an existential sense of well-being, is positively associated with spiritual well-being. However, they did not assess whether spiritual well-being is correlated with survival rates among oncology patients. The authors did provide useful suggestions on how results from this study could be applied to hospital practice. For example, they outline a program for encouraging health-promoting spiritual expression among inpatients. Ginsburg, Quirt, Ginsburg, and MacKillop (1995), in a study of lung cancer patients, found that religion is commonly cited as an important means of symptom alleviation. Landis (1996) and Rutledge, Levin, Larson, and Lyons (1995), utilizing cross-sectional survey designs, found similar results in studies of chronic illness and coping of parents who have a chronically ill child, respectively. These assessments represent measurement at a single-point in time, and a longitudinal design with multiple points of data collection would be useful in future studies on these topics.   

            In research sponsored by the Israeli Ministry of Health, the Hadassah Medical Organization, and the United States National Institute of Health, Goldbourt, Yaari, and Medalie (1993) studied 10,059 Israeli adult males, using a prospective, longitudinal cohort with a stratified sample. They found that highly orthodox religious groups experienced significantly reduced coronary heart disease death rates and all-cause mortality rates, as compared with the other participants. These effects were maintained even after controlling for conventional risk factors of heart disease, such as smoking, diabetes, and high cholesterol. Also, controlling for area of birth did not eliminate the differences between groups. With such a large sample size, there is naturally concern about the magnitude of the effect of religious orthodoxy on the diagnoses. After multivariate analysis, performed with Cox’s life table proportional hazards model with estimations derived from Breslow’s modification for tied observations, the authors concluded that:

fatal coronary heart disease events according to religiosity indicated a small ‘independent’ advantage, in terms of the probability of dying from coronary heart disease and all causes, enjoyed by 20% of the sample who reported themselves as orthodox. In another study in Israel, albeit of a case-controlled nature, myocardial infarction odds ratios as high as 4.2 and 7.3 for men, after adjustment for ‘conventional’ risk factors, have been estimated for secular persons relative to religious ones among Jewish residents of Jerusalem... Since the results of our study suggest that differences in the distribution of blood pressure, serum cholesterol, cigarette smoking, prevalence of diabetes and prior coronary heart disease do not eliminate the advantage of the highly orthodox group, additional research is suggested to examine other associated life habits and other possible environmental sources of variability. (p. 119)

            Harris, Dew, Lee, Amaya, Buches, Reetz, and Coleman (1995) conducted a prospective cohort study and found that, among heart-transplant patients, religious beliefs and practices predict improved physical functioning, enhanced adherence to medical regimens, higher self-esteem, and diminished anxiety.

Mental Health

            Bradley (1995), in a prospective cohort study with a sample of 3,597 adults, found that religious attendance was strongly associated with support network size and perceived quality of relationships (p<.001), though he found no significant relationship between worship attendance and neuroticism or introversion. Levin, Chatters and Taylor (1995), in a cross-sectional survey of Black Americans using a national sample of 2,107 subjects, found, using maximum-likelihood structural modeling, that organizational religiosity is significantly associated (p<.01) with health and life satisfaction, non-organizational religiosity is inversely associated (p<.05) with health, and subjective religiosity and health are associated with life satisfaction (p<.05). Even controlling for health and several demographic factors, religiosity was shown to have a favorable effect on life satisfaction. This counters the assertion that religiosity serves as a proxy for functional health, which argues that those who are physically and emotionally healthier are more likely to attend church.

            Ellison (1995), in a cross-sectional survey study of 2,956 adults in North Carolina, found that public religious participation is inversely associated with depressive symptoms, particularly among African-Americans. Krause (1995), in a cross-sectional survey using a national sample of 1,103 elderly persons, found that use of religious coping mechanisms is associated with increased self-esteem. This survey used ordinary least squares multiple regression procedures, though the relationship between religious coping mechanisms and self-esteem appears to be U-shaped, casting doubt on the analytic procedure. Specifically, those who make most use of religious coping mechanisms, and those who make no use of them, appear to have the highest levels of self-esteem. The article did not attempt to explain why those not using religious coping had high self-esteem.  Burgener (1994) found that, for caregivers of Alzheimer’s patients, general well-being was positively associated with religious worship attendance. In this study, however, only 30% of the questionnaires sent to caregivers were returned, indicating the possibility that self-selection bias influenced the results.

            In studies of persons with AIDS, Carson (1993) and Carson and Green (1992), using cross-sectional survey designs, found that spiritual well-being is positively correlated with hardiness, as measured by a questionnaire consisting of 50 items divided into three subscales (challenge, commitment and control). Results of these studies indicated that spiritual well-being is an important factor in coping with HIV/AIDS, though the research did not investigate a relationship between spirituality and long-term survival. 

            Pargament, Ishler, Stanik, and Rouiller (1994), in a prospective cohort study of 215 undergraduate students, examined the effects of religious coping on levels of distress among college students, and determined that use of religious coping mechanisms makes a significant and positive contribution to individuals’ ability to cope with stressful events like the Gulf War. Pollner (1989) found that perceived relationships with divine others, such as God, has a significantly positive effect on several measures of well-being. Valentine and Feinauer (1993) concluded that religiosity and spirituality were positively correlated with successful coping in female survivors of childhood sexual abuse. In a review of counseling and medical literature, Westgate (1996) found a consistent inverse relationship between spiritual wellness and depression.

Hospice and Emotions Surrounding Death

            Millison (1995) and Millison and Dudley (1990) found that spirituality was an important component in the lives of hospice workers. More specifically, their research indicated that job satisfaction for hospice workers, 12.5% of whom were educated as social workers, was positively correlated with spirituality.   

            Alvarado, Templer, Bresler, and Thomas-Dobson (1995) found that belief in life after death was inversely correlated with death depression and death distress (p<.01). Strength of religious conviction was inversely proportional to death anxiety, death depression and death distress (p<.05). This study is especially significant because it indicates that, with regard to tempering death depression and death anxiety, religious beliefs are actually more important than religious practices, whereas many other studies in the field of religiosity/spirituality find that practices, such as church attendance, are more important than beliefs. This study, however, is limited by its heterogeneous and non-clinical sample. A study of death depression and death distress that samples persons who are seriously ill or who are actually dying would be interesting and productive.

Evaluation of Suicide Potential

            Kehoe and Gutheil (1994) examined measurement tools for suicidal patients with regard to spiritual and religious issues. This study is included here, rather than in the measurement of spirituality section, because it evaluates instruments for assessing suicidal characteristics, not spirituality. The measurement of spirituality section analyzes scales that directly attempt to measure spirituality, whereas this study simply adds to an understanding of the importance of spiritual factors, and therefore belongs in the general relevance section. Kehoe and Gutheil cited psychiatric literature that suggests that religion and spirituality are significant and meaningful forces in the lives of patients with mental disorders, particularly when these persons consider suicide. Yet scales assessing suicidal risk almost entirely fail to consider religion and spirituality. Durkheim, in 1897, found an inverse relationship between suicide and religious affiliation. Though Durkheim concluded that social integration was the active factor in this relationship, Kehoe and Gutheil cite other studies, that controlled for social factors, and determined that religious affiliation is directly connected to decreased suicides. Kehoe and Gutheil assess 12 scales commonly used for assessing suicidal risk. They write:

Designers of the scales appear to seek factors that may construct a profile of the suicidal person. Yet they seem to ignore the possible impact of what a person, on the brink of life itself,             believes about life and about life after death....Possibly clinicians simply ignore this aspect of a person’s life in their ordinary practice and therefore continue to do so in a suicidal crisis. If this             hypothesis is true, then the designers of suicide scales simply reflect clinicians at large. .. This result may point to neglect in training as well as a possible prohibition against such exploration created during clinicians’ role socialization....Comparison of the literature on religion and suicide and the literature on suicide assessment scales reveals a remarkable and paradoxical inconsistency. Although religion is noted as a highly relevant factor in the suicide literature, the number of religious items included on suicide scales approaches zero. (pgs. 367-368)

Mortality

              In a prospective cohort design, Bryant and Rakowski (1992), studying mortality rates among elderly (at least 70 years old) African-Americans in the United States, found that less frequent church attendance is related to higher mortality. This finding was maintained even after controlling for variables such as age, gender, health status, and extent of social networks. Conducting research on mortality rates amongst elderly nursing home residents, Janoff-Bulman and Marshall (1982), in a prospective cohort study with a sample size of 30, found that increased religious beliefs are predictive of increased mortality among elderly nursing home patients. The researchers suggest that patients who report enhanced well-being and greater religiosity are more accepting of the inevitability of death, and perhaps those who are already approaching death may turn to religion in old age. The findings of this study differ from other studies that have produced evidence that, among institutionalized patients, increased longevity correlates positively with religiosity. In this study, sample size is small, and 17% of the 30 persons sampled were lost to follow-up, two and a half years after the initial survey.

Youth Substance Use

            Examining the relationship between religion and adolescent marijuana use among high school youth, Burkett and Warren (1987), in a prospective cohort study of 264 high schoolers in a medium-sized city in the Pacific Northwest, found that religion has an indirect inhibitory effect on adolescent marijuana use by encouraging associations with peers who do not use drugs. Lorch and Hughes (1985), in a cross-sectional survey of 13,878 junior and senior high school students in a Colorado metropolitan area, determined that church members have a lower percentage of substance users than non-church members, and that the more important religion is to a young person, the less likely he/she is to use alcohol or drugs. Further, findings suggest that the controls operating in the youths’ choice not to use drugs exist as internalized values and norms rather than external pressures associated with church ideology or peer pressure. Turner, Ramirez, Higginbotham, Markides, Wygant, and Black (1994), using a convenience sample of 247 9th-graders in Austin, Texas, found similar results. Cochran, Wood, and Arneklev (1994), in a study of 1600 high school students, found that, even after controlling for the variables of arousal, parental control and institutional control, religious participation remained significantly and inversely correlated with substance use. 

Delinquency

            Studying juvenile delinquency, Chadwick and Top (1993), in a survey of 2,143 Latter-Day Saints adolescents, found that religious factors are inversely related to delinquent activities. This study focused on a highly religious group and may therefore be limited in its application to less religious youths. Cochran, Wood, and Arneklev (1994) concluded, in their survey of 1,600 high school students in Oklahoma, that the effects of religious participation and intensity of religious involvement upon interpersonal delinquency, property theft, and property damage were no longer statistically significant after controlling for arousal (e.g., impulsivity and thrill-seeking) and social control (e.g., parental control and institutional control) variables. Foshee and Hollinger (1996), in a prospective cohort study using a probability sample of 2,102 adolescents and their mothers, determined that maternal religiosity is predictive of lower rates of adolescent alcohol use (p=.003) when controlling for demographic variables, social control variables, and baseline adolescent alcohol use. Maternal religiosity was also positively associated with adolescent academic commitment (p=.001). Studying the relationship between religion and delinquency amongst adult males, Evans, Cullen, Dunaway, and Burton (1995) found that religious activity, though not necessarily religious beliefs, inhibits criminal activity among adult males. This study used a sample of 550 men from a midwestern urban area. 

            Summary

            In summary, commentators from many helping professions assert that spiritual and religious factors must be seriously considered by responsible practitioners in their professions, and that efforts to dovetail spiritual practices with current modes of treatment are necessary. Empirical findings demonstrate a clear and positive association between spirituality and religiosity and favorable outcomes in many helping fields. An understanding of spiritual and religious factors and their dynamics can be important for professionals to understand people and maximize service to clients. As a final empirical reference, Witter, Stock, Okun, and Haring (1985) conducted a meta-analysis on 556 empirical sources on subjective well-being and 17 correlates such as health, social activity, and religion. From the sources they extracted 56 religion/subjective well-being effect sizes. They found that, compared to the other 16 predictors of subjective well-being, religion was as strongly or more strongly associated with subjective well-being on half of the predictors. The authors made an appeal for researchers not to ignore religion when forming and testing causal models of subjective well-being.

Research on Related Interventions

            Since this dissertation describes a study on the effects of mantra chanting, it is appropriate to briefly delineate aspects of behavior therapy that relate to the chanting of mantras, as well as other yogic techniques.

            Behavior therapy is largely based on the principle of operant conditioning, which involves increasing or decreasing a person’s behavior by systematically changing its consequences each time the behavior is performed. According to the behavioral model, behaviors are caused by present events that surround the performance of behaviors. Antecedents are events that occur before the performance of the behavior, and they set the stage for the behavior to occur. Consequences are events that occur after the behavior has been performed and that influence future occurrences of the behavior. For example, feeling sleepy is an antecedent for going to sleep, and feeling refreshed is a consequence of that behavior (Spiegler & Guevremont, 1993).

            Chanting the Hare Krsna maha mantra, according to Vedic theory, provides the internal gratification of pleasure for the self, the non-material entity that sits within the gross and subtle material bodies. This purported pleasure serves as a consequence and maintaining condition for chanting the Hare Krsna maha mantra. Also, according to Vedic philosophy, because the happiness of chanting Hare Krsna applies directly to the self, rather than to any outer covering of the self, the pleasure is more satisfying than gratification directed at components of the gross or subtle material bodies, such as the senses or mind. Therefore, this more satisfying enjoyment can hypothetically serve as a replacement for behaviors that produce a less satisfying type of gratification, and that also produce undesirable side effects. As Sri Krsna explains in the Bhagavad-gita (Prabhupada, 1972), “The embodied soul may be restricted from sense enjoyment, though the taste for sense objects remains. But, ceasing such engagements by experiencing a higher taste, he is fixed in consciousness” (p. 78). Chanting the maha mantra may provide a “higher taste” for the non-material entity situated in the modes of material nature.

            In cognitive-behavioral therapy a common process is thought stopping, wherein a person interrupts disturbing thoughts by uttering the word “Stop!” After disrupting the distressing thought, the client is recommended to think about something that competes with the disturbing thought. However, it is often difficult for a person not to think about something (Spiegler and Guevremont, 1993). Chanting the Hare Krsna maha mantra can be an effective positive replacement thought in the thought stopping process, which is similar to aversion-relief therapy because it simultaneously reduces an undesirable target behavior and increases an alternative target behavior. For instance, persons who uncontrollably think depressing thoughts such as “I’m useless” may train themselves to replace such thoughts with thoughts of the syllables of the maha mantra. The undesirable target behavior, which leads to a depressive state of mind, is supplanted by an alternative target behavior that, according to Vedic guna theory, increases sattvic qualities such as contentment and peacefulness.

            In many areas of behavior therapy, such as medical applications, techniques such as emotive imagery and diversion of attention are included in treatment packages (Turk, Meichenbaum, & Genest, 1983). These techniques can utilize the maha mantra, hare krsna hare krsna krsna krsna hare hare hare rama hare rama rama rama hare hare, as a response to compete with anxiety and other unfavorable emotional responses. The maha mantra as a competing response might be used in treating conditions such as tic disorders and chronic pain, as well as in coping with painful medical procedures. Williams and Gentry (1977) describe the Shavasana yogic exercise, which was incorporated in the study of Janowiak and Hackman (1994), as a behavioral approach to medical treatment for conditions such as severe hypertension.

            When a mantra is chanted privately on beads it is called japa chanting, and the beads are called japa beads. Though chanting the Hare Krsna maha mantra does not require japa beads, the beads, as will be described in the next chapter, provide a means to quantify the number of times that the mantra is chanted. Additionally, usage of beads while chanting engages the sense of touch. According to the Bhagavad-gita (Prabhupada, 1972), the senses are centered around the mind, and therefore, the more senses that are engaged in an activity, the easier it is for the mind to focus on that activity. Chanting the maha mantra involves the tongue and the sense of sound, and with japa beads, the sense of touch is also engaged. This facilitates focusing the mind on the sattvic vibration, and enhances the effect of the mantra. A practical application of this idea could be helping clients to stop smoking. Smoking involves the mouth and the fingers, as does the activity of chanting Hare Krsna on japa beads. By engaging the same senses and organs in the process of chanting Hare Krsna, the person may experience a higher taste that allows one to abandon a type of pleasure that is less satisfying.

            Benson (1975) identified four common elements in relaxation techniques: 1) A mental device upon which to focus the mind; 2) A passive attitude regarding whether the relaxed response is achieved; 3) Decreased muscle tension- subjects should assume a comfortable position to reduce gross motor activity; 4) A quiet environment with minimal external distraction. Benson developed the “relaxation response” behavioral technique which utilizes a combination of body relaxation, attention to breathing, and repetition of the word “one” as a mental device to fix the concentration. One can note the similarity between “one” and the “Om” mantra used by Kaye (1985). This technique, as well as  several other behaviorally-based approaches, such as autogenic training and biofeedback, have been effective in facilitating relaxation and treating ailments such as severe headache and essential hypertension (Williams & Gentry, 1977).

            When chanting the maha mantra, a person focuses the mind on the syllables of the mantra. Although the chanter is not directed to think about relaxation, according to the Vedas relaxation is a natural effect of chanting the maha mantra. Further, the chanting is most efficacious when external distractions are minimized, which is achieved with a serene environment and comfortable body position. Thus, practice of maha mantra  chanting is consistent with all elements of behavioral relaxation techniques as described by Benson (1975). In fact, Benson’s relaxation response is a variant of meditation and yoga (Olton & Noonberg, 1980).

            Mantra chanting is a yoga technique, and there are many similarities between biofeedback training and yoga. Biofeedback is defined as any technique that increases a person’s ability to voluntarily control physiological activities by providing information about those activities. This technique, which utilizes machines to detect physiological states, has been effectively used to treat stress-related illnesses such as tension, ulcers, and asthma, as well as maladies such as incontinence and paralysis due to stroke.

            Biofeedback is a fundamental component of behavioral medicine, which emphasizes the importance of patient participation in the treatment program through processes of self-regulation (Olton & Noonberg, 1980). Yoga techniques are also systems of self-regulation. Such self-regulatory techniques are inherently different from methods depending on external regulation, such as hypnosis and pharmacological approaches. Green and Green (1977) have developed a psychotherapeutic technique called “theta training”, which is a combination of yoga practices and biofeedback that is designed to self-induce a state of integrative, relaxed introspection. Biofeedback evaluation of yoga practitioners has revealed that yogic meditative techniques are correlated with enhanced ability to control, recognize and regulate physiological conditions, such as metabolism rate and brain waves (Raskin, Johnson, & Roudestvedt, 1973; Green & Green, 1977). Just as mantra meditation engages several senses, biofeedback also regulates by engaging the senses of touch, sound, and sight.

            Thus, in many ways the process and effects of mantra yoga can be understood in terms of behavioral therapy. Though the theoretical orientation of this paper is Vedic theory, with its accompanying explanatory concepts of gross, subtle and spiritual bodies, behavior theory provides an alternative way to view mantra and yogic meditation.

Measurement of Spirituality

            During the 1960s and 1970s many tools for measuring social indicators, such as education, employment, health, and housing, were developed to assess quality of life. Many of these objective indicators reflected significant gains, though social unrest, substance abuse, family fragmentation, political alienation and several other negative indicators also increased during this period. This fostered the gradual recognition that quality of life was not solely dependent on objective factors, and thus efforts were increasingly directed toward measurement of subjective life experiences, such as life satisfaction and happiness (Bufford, Paloutzian, & Ellison, 1991).

            Though religion has often been included as a factor in quality-of-life assessments, and several scales measuring aspects of religiosity have been developed (Butman, 1990), spirituality has largely been neglected in these evaluations. As evidenced by the general relevance section, religion, spirituality, and life satisfaction have generally been found to be positively related. However, scales that assess religiosity tend to overlook the purely spiritual component, such as an inner sense of the immediacy of a higher power and the sense of one’s relationship with God, while focusing on aspects such as religious identification and lifestyle (Ellison & Smith, 1991).

            Three attempts at measuring spirituality will be reviewed in this section: The Spiritual Well-Being Scale (SWBS), the Spiritual Involvement and Beliefs Scale (SIBS), and the Vedic Personality Inventory (VPI). The SWBS is based on Judeo-Christian, or Biblical, theory, the VPI is based on Vedic guna theory, and the SIBS is an attempt at measuring spirituality that is specifically designed to avoid the perceived sectarianism of the SWBS. This is not to imply that the SIBS is the most universally applicable of the three instruments. From the Judeo-Christian perspective, a Biblical approach to psychology and spirituality is considered universal, encompassing all ethnic and cultural variations in the human experience. Similarly, from the Vedic perspective the philosophy of the three gunas applies to all entities in this world. A researcher or practitioner seeking to use a scale for spirituality will need to assess each instrument according to the particular purpose of the research. Herein, for the benefit of such researchers and practitioners, the fundamental orientation of these three measures has been presented.

            The following analyses are not intended to be detailed critiques of the instruments. Basic psychometric data are reported, though the essential reason for inclusion of this measurement of spirituality section is to illustrate that the construct of spirituality can be measured by empirical standards. Further, the existence of psychometric data for measures of spirituality strengthens the potential usefulness of the construct in clinical practice. For example, depression is a mental construct formulated in the minds of researchers. The development of reliable and valid self-report scales that measure the concept known as depression enhances the ability to utilize that construct when attempting to understand problems in human functioning and develop relevant interventions. Similarly, the development of spirituality scales with strong psychometric characteristics increases the practical utility of the concept of spirituality. Of course, nuanced questions about the nature and qualities of spirituality remain unresolved, but this is also true for most psychometric areas, such as self-esteem, anxiety, and depression. The instruments described below are technological pieces (Klein & Bloom, 1994) that facilitate the research of spirituality.

The Spiritual Well-Being Scale

            This instrument attempts to measure the Biblical concept of shalom, whose root meaning includes ideas of completeness, wholeness, harmony and well-being. Also implicit in this notion is the experience of unimpaired relationships with others and being fulfilled in one’s course of life. Additionally, shalom refers to physical health. According to Ellison and Smith (1991):

Shalom, or well-being, may be viewed as the integral experience of a person who is functioning as God intended, in consonant relationship with Him, with others, and within one’s self. Shalom describes the experience of being harmoniously at peace within and without. It presents a picture of the person functioning as an integrated system in proper equilibrium. (p. 36)

            The SWBS is the most extensively researched measure of spiritual well-being. It has been used in hundreds of practice settings, including a wide variety of medical, nursing, and mental health environments. Also, research has been conducted on this instrument in numerous contexts, including universities, seminaries, hospitals, and prisons, and with various populations, including teenagers, Christians, hospital inpatients, housewives, professional women, non-Christians, and the elderly (Bufford, Paloutzian, & Ellison, 1991).

            The scale consists of 20 items evenly divided to comprise two subscales. The Religious Well-Being (RWB) subscale contains 10 items that refer to God and assess the vertical dimension of spirituality. The Existential Well-Being (EWB) subscale contains 10 items that measure a horizontal dimension of well-being in relation to the world about us, including a sense of life purpose and life satisfaction. Each item is rated on a six-point modified Likert scale from Strongly Agree to Strongly Disagree, with no mid-point. Several items are worded in a reversed direction to minimize response sets (Ellison & Smith, 1991).

            In seven samples (total n=994), alpha, a measure of internal consistency, ranged from .89 to .94 for the SWBS, from .82 to .94 for the RWB subscale, and from .78 to .86 for the EWB subscale. Research has shown test-retest reliability for the SWBS, at intervals ranging from 1 to 10 weeks, to vary from .82 to .99, and from .73 to .99 for the subscales. Overall, these data suggest that the SWBS has adequate reliability (Bufford, Paloutzian, & Ellison, 1991).

            Factor analysis of the SWBS has revealed that it loads on two factors, corresponding to the two subscales, with the RWB subscale items loading stronger than the EWB items. Research has indicated that SWBS and its subscales correlate positively with several standard indicators of well-being, including a positive self-concept, strong meaning and purpose in life, high assertiveness, low aggressiveness, physical health, and emotional adjustment. Furthermore, SWBS is negatively correlated with ill health, dissatisfaction with life, and emotional maladjustment. In summary, this instrument appears to have strong factorial and construct validity (Bufford, Paloutzian, & Ellison, 1991).

            Among spirituality scales, the SWBS is the only one that has norms. SWBS data are available on many samples, including clergy, seminarians, college students, counseling clients, prison inmates, caregivers for hospice patients, medical outpatients, and several religious groups. These data indicate good predictive validity with regard to differentiating between populations. For instance, persons in training for or currently in religious leadership positions scored higher than any other group sampled. Also, religious groups scored higher than non-religious groups (Bufford, Paloutzian, & Ellison, 1991).

            A limitation of the SWBS is that many subjects among religious groups score at or near the ceiling score. For these groups, therefore, the scale is unable to differentiate. As a result, the scale’s practical uses seem limited to groups of mid-range and low scorers. For example, the SWBS would not appear to be useful in identifying leadership potential amongst seminary students. In addition, this ceiling problem suggests that the distribution for the scale is not normal, and this casts doubt on assumptions for various statistical procedures used in analyzing the SWBS, such as parametric correlational techniques. Though there are norms for the SWBS for many populations, such norms are conspicuously lacking for genders and ages. Further scale development and analysis should address this matter. Another area for consideration is that research on the SWBS, although fairly extensive, has been conducted almost entirely in the Pacific Northwest region of the United States, which raises questions about its generalizability (Bufford, Paloutzian, & Ellison, 1991).     

            The Spiritual Involvement and Beliefs Scale

            This instrument was specifically designed to create an assessment of spiritual status that is more comprehensive and widely applicable than the SWBS. It is meant to apply across religious traditions, and to assess actions as well as beliefs, whereas SWBS items focus on cognition. Formulation of items involved input from persons of varied spiritual and cultural traditions. Designers of the scale sought an instrument that could practically integrate spiritual assessment into client care and research (Hatch, Hellmich, Naberhaus, & Berg, 1995).

            The scale contains 26 items in a 5-point Likert format, and was administered to 83 participants, 50 of whom were patients from a rural medical family practice setting, and 33 were medical professionals affiliated with a medical school in Northern Florida. To evaluate validity, participants completed the SIBS and SWBS consecutively. Retest data was gathered seven to nine months after initial administration of the SIBS. With this sample, Cronbach’s alpha for the SIBS was .92, and test-retest reliability was .92. Correlation with SWBS scores was .80. Factor analysis revealed four factors- Faith/Ritual, Fluid/Reflective, Existential/Meditative, and Humility/Personal Hatch, Hellmich, Naberhaus, and Berg (1995).  

            Clearly, the SIBS has not been adequately tested to properly evaluate its psychometric strength. Still, initial reliability and validity data indicate a potentially useful instrument. Regarding factor structure, the sample size is too small to determine the validity of the current factor analysis.

            Compared to the SWBS, the SIBS utilizes more generic wording, and appears, based on examination of item content, to be broader in scope than the SWBS. Authors of the SIBS acknowledge that it is not possible to design an instrument free from bias. However, their effort makes a deliberate attempt to avoid the biases of Western spiritual traditions, and the SIBS may therefore be useful with diverse cultural populations.

The Vedic Personality Inventory

            The VPI is an attempt to measure the three gunas, or modes of material nature, as described in the Vedic literatures. According to the Vedas, all facets of material existence, including our mental processes, sound vibration, foods, disposition, and vocational choice, are permeated by the three gunas- sattva, rajas and tamas. Predominance of sattva indicates greater spirituality. In fact, according to Vedic philosophy, the state of complete spirituality is called suddha sattva, or pure sattva. In this way, the VPI serves as a spiritual assessment scale. Though there have been other attempts at guna inventories, such as Uma, Lakshmi, and Parameswaran (1971), Singh (1971), Rao and Harigopal (1979), and Das (1991), the VPI is the most extensively tested amongst the guna scales, incorporating larger sample sizes and more elaborate statistical analyses (Wolf, 1998). 

            This instrument contains 56 items, with the sattva subscale containing 15, the rajas subscale containing 19, and 22 items in the tamas subscale. There are seven Likert-type response choices for each item. The VPI has been tested on 494 subjects, most of whom were nurses or university students. For the sattva subscale internal consistency alpha is .93, for the rajas subscale alpha is .94, and for the tamas subscale alpha is .94. No test-retest reliability assessment has been conducted. Inter-subscale correlations are in the direction predicted by Vedic theory. That is, statistical analysis confirms that rajas is an intermediate mode between sattva and tamas. Research revealed evidence for construct validity in the form of correlations between verbal aggressiveness and rajas, hours of sleep per day and tamas, and life satisfaction and sattva. These correlations were substantially stronger than correlations of any mode with the discriminant validity variables of gender, height, and number of siblings. With regard to factor analysis, all items correlate positively and significantly with their intended subscale, though a few items have a higher correlation with another subscale, indicating that the subscales are not perfectly orthogonal.

            Initial research on this instrument provides encouraging evidence for the existence of the gunas. Potential for its use includes mental health counseling and vocational guidance. In the field of mental health, a counselor could assess client progress with reference to changes in predominance of modes of nature. For instance, a person with anxiety disorder would be predicted to have a high rajas score. After intervention, rajas would be expected to decrease, and sattva would be predicted to increase. With regard to vocational guidance, the Vedas match occupational tendency with modal predominance. With this theoretical guide, vocational counselors could administer the VPI as an assessment tool. Much work remains to be done in establishing norms for the VPI for various populations, and in evaluating the practical capacity of the instrument for differentiation amongst various groups.  

 Spiritual Intervention Articles: Methodological Critique

            Empirical Quantitative Studies

            Appendix A presents a framework for a systematic synthesis of the research literature on spiritual interventions. For the quantitative studies, seven categories are included in this schema: purpose, theory, design, measurement, analysis, results and generalizability.

            The purpose section is meant to clearly and succinctly present the aims of the researchers, as well as to state the tested hypotheses. In the theory section, the theoretical orientation underpinning the research is explained. Empirical research tends to assume a functionalist orientation to social science. This paradigm, typified by behaviorist theories, tends to focus on objectively verifiable results, often at the expense, sometimes deliberately, of theoretical formulations. As described previously, and as will be more substantially demonstrated later in this section, spirituality can lend itself to empirical verification and the scientific method, though such efforts are in their infancy. In this section on spiritual interventions the author considers it imperative to enunciate and examine the purpose and theory behind the research, as these components form the bridge and impetus for translating spiritual conceptualizations to the realm of empirical science.           

            In the design section, the intervention, sampling methods and type of design are described and critiqued. The measurement section includes description and critique of measurement instruments, focusing on psychometric characteristics. In the analysis section, statistical procedures used in the research are critiqued, and the results section presents the findings. Generalizability is the final section, and describes the applicability of the findings, based on the methodology of the sampling and design. Thyer (1991) delineates the importance of critiquing design, measurement, analysis, results, and generalizability for outcome studies.

            Among these quantitative studies, only the article of Kutz, Leserman, Dorrington, Morrison, Borsendo, and Benson (1985) is more than 10 years old. This research is included due to its unique combination of clinical sample, quantitative methodology, and an interventive technique derived from the Buddhist tradition. 

Empirical Qualitative Articles

            For these research pieces, the purpose, theory, and design sections serve the same function as for the empirical quantitative studies. For the qualitative articles, the analysis and results sections are combined, as these reports did not contain numerical analysis, and analyses and results were presented in text form in the same paragraphs. Also, the generalizability section for the qualitative articles makes special note of the replicability of the study, as replicability is a key feature in assessing the reliability of qualitative research endeavors. The Sweet and Johnson (1990) article contains a measurement section, as the researchers utilized a tool for coding dyadic interpersonal behavior, though quantitative data is not provided. Otherwise, the articles in this section do not use psychometric instruments, and therefore they do not contain a measurement section. The Kaye (1985) article is included, although it is more than 10 years old, because of its innovative use of yoga techniques with an elderly population, as well as the interesting style in which the report is presented.

            Literature Reviews

            Among the spiritual intervention articles that are analyzed in Appendix A, there are two literature reviews (Delmonte, 1983; Delmonte & Kenny, 1985) (see Figure 1). The format for the analysis of the two literature reviews is the same as the basic format for the qualitative studies, including sections for purpose, theory, design, analysis/results, and generalizability. These literature reviews provide an overview of the research prior to 1985 on silent and mantra meditation techniques, with special attention given to the therapeutic effects of these interventions. These reviews describe results in a qualitative fashion, preferring narration to numerical analysis. Consequently, there is no measurement section for these articles, and the analysis and results sections are combined. 

Methodological Considerations   

Purpose

            This research attempted to isolate the effects of an intervention that was postulated to be spiritual in nature and origin. This collection of studies dealing with spiritual interventions contains eight pieces focusing on Eastern-style meditation techniques, plus two literature reviews covering these meditative interventions. There is one study examining the effect of prayer to the Judeo-Christian God, two articles investigating 12-step interventions, one general study on non-medical interventions, and one qualitative study delineating a spiritual approach to social work practice. Regarding dependent variables, common targets in the meditation studies included stress, anxiety and empathy, and some studies also evaluated effects on self-actualization, happiness, compassion, self-esteem, friendliness, and trauma resolution. Coronary disease was the dependent variable in the prayer study, while substance abuse, with adolescents and adults, constituted the main dependent measure in the 12-step studies. 

Theory

            These articles contain a wide range of theoretical expositions. Some, such as Kaye (1985), do not address theoretical concerns, while others (e.g., Sweet & Johnson, 1990; Delmonte & Kenny, 1985) relate in some depth the theory behind the spiritual intervention. These more extensive attempts are sometimes integrated, relevant and informative, and occasionally disjointed (e.g., Janowiak, & Hackman, 1994).

            Though ideas regarding effects are abundant (e.g., the effect of meditation on anxiety), there is a paucity of conceptualization related to mechanism. That is, rarely do authors attempt to explain how an intervention produces an effect. Interestingly, Byrd’s (1988) article, though the theoretical section is surprisingly short, succinctly describes a mechanism for the improvement of coronary conditions. The process is prayer to the Judeo-Christian God, and this is effected by this personal God, who is omnipresent and omnipotent, taking personal action. When the Absolute is postulated to be personal, the implication is that this entity is sentient, meaning that the Absolute possesses desires, likes and dislikes. With such a personal philosophy, causal explanations are simplified. Such an explanation is of little empirical value, though it stands as a provocation for other theorists to explain the results of this experiment on intercessory prayer. 

            In the theoretical passages of the meditation and mantra articles, the question of how these interventions produce effects was not addressed. Of course, a research article is not the place for elaborate philosophical exposition. Still, with a basic  understanding of the epistemology and ontology underpinning a practice, researchers will be enabled to formulate designs to isolate effects, and practitioners will increasingly be prepared to effectively apply techniques according to time and circumstance.

            For example, mantra science, according to the Vedas, is based on sound vibration that is completely in the mode of material nature called sattva. Literally, a mantra is a sound vibration that can extricate the mind from the modes of material nature. Consciousness, from the Vedic viewpoint, is affected by all sounds that we encounter. If we associate with sounds in rajas guna, we develop rajasic qualities, and sound in tamas will cause us to cultivate tamasic attributes, such as depression and indolence. Attentive concentration on a mantra that is in the mode of sattva will, according to Vedic philosophy, help us to attain sattvic qualities, such as satisfaction, peacefulness, and compassion. A mantra can be tested by measuring effects, such as depression and life satisfaction, with respect to guna theory. Without an understanding of these gunas, it will be very difficult to effectively implement mantra therapy. In summary, these articles (e.g., Janowiak & Hackman, 1994; Kutz et. al., 1985; Miller, Fletcher, & Kabat-Zinn, 1995; Pearl & Carlozzi; Smith, Compton, & West, 1995; Kaye, 1985; and Sweet & Johnson, 1990) provide evidence indicating positive effects of mantras and meditation. Due to lack of understanding of the processes responsible for these effects, however, intervention techniques and research methodology, especially with regard to outcome variables, are often less than maximally efficient. For instance, with insight into guna theory, meditation techniques can be extensively tested with regard to the many qualities associated with each guna as described in the Vedas.

Design

            Eleven of the studies are primarily quantitative, and 4 are mainly qualitative. Convenience sampling is the most common sampling strategy in spiritual intervention research, with the quantitative studies preferring random assignment to matching. Power analysis was not performed to determine sample size. College students were the most common subjects. Meditation and mantra research utilized group and qualitative designs, and a cross sectional survey design was used in 12-step research as well as in the general non-medical intervention investigation. Most of the group designs suffered from lack of follow-up assessment, and many did not contain adequate description of the interventive method. Duration of intervention ranged from 6 weeks to 2 years, with 8 weeks being the mode for meditation and mantra studies. Many studies lacked a control group as well as a true placebo group to adequately isolate the effects of the experimental intervention. In research on spiritual intervention it is common to mix group sessions, or sessions with a therapist, and private home practice of meditation or mantra chanting. Byrd’s (1988) study on prayer involves a rigorous design and large sample size, with all parties blinded to group assignment of subjects.

            Concerning outcome variables, they were generally appropriately selected with regards to theory and purpose of the research endeavor. For example, the study of Miller, Fletcher, and Kabat-Zinn (1995), using a clinical sample of persons with anxiety disorder or panic disorder, included measures of frequency and severity of panic attacks at pretest, posttest, and follow-up. Many studies could have included additional dependent measures, and presumably this was not done due to resource limitations and to minimize complexity of design. For instance, the study of Janowiak and Hackman (1994), which investigated the influence of meditation on stress and personality, could have included relationship competency as an outcome variable, as personality is intimately connected with relationships.

            With regard to Keefe’s (1996) theoretical conceptualization of the link between social work and meditative interventions, the outcome variables of these studies are productive and useful. According to Keefe, social work and meditation intersect at the common human experience of stress. He theorizes that meditation has immense potential as a clinical adjunct technique in reduction of stress and anxiety. Moreover, he postulates that these techniques can facilitate other social work skills, and can be an antecedent to sober and productive action. Specifically, Keefe asserts that meditation can be an important component in the development of empathic skill, as well as in the development of the overall personality of therapists. He states that these endeavors “have generated interest among clinical social workers and social work educators. (p. 440)” Further, he cites the diverse origins of meditation as being compatible with social work’s emphasis on oneness containing variety. To summarize this theory of social work intervention and meditative techniques, Keefe contends that meditation has the capacity to be relevant for the profession as a whole, and concludes that “The reciprocal influences between meditation and social work should be exciting” (p. 440). With this theoretical orientation in mind, the focus of the outcome studies included in this paper on dependent variables such as stress, anxiety, and development of empathy is commensurate with social work treatment.

            The most glaring lacuna in outcome variables is spirituality. This may be due to the fact that measurement of spirituality is not a very developed field. Still, future studies of spiritual interventions can utilize the scales described in the measurement section, and researchers interested in this area can develop increasingly refined instruments, especially with regard to operationally defined indicators of spirituality. 

            Though a few studies discuss experience and training of intervention providers, many articles neglect this important point, which isn’t to say that the practitioners were necessarily unskilled in the particular technique. Considering that empirical application of spiritual science is a new field, this issue is particularly poignant. In academe, spirituality is generally considered to be unscientific, primarily based on belief and faith. Therefore, those attempting to advance this field must be especially assiduous in assuring high standards in conducting scientific experiments on spiritual topics. As mentioned in the Introduction, Levin, Larson, and Puchalski (1997), referring to the field of medicine, concluded that research on spiritual and religious factors has been subject to greater scrutiny than most research. Thus, practitioners in this area must be well-trained in the interventions they utilize, just as a practitioner using behavioral, cognitive or psychodynamic techniques is expected to be expert in their theory and implementation. Otherwise, spiritual interventions will be considered to be a whimsical practice.  

Measurement

            Research on spiritual interventions utilizes self- and therapist-rated standardized tests as well as compliance logs, daily self-report inventories, and open- and closed-ended questionnaires developed by the researcher. Many articles failed to report psychometric data, though references were provided to locate this information. The 12-step studies did not use standardized instruments, instead relying on tools developed by the authors. In the study on adolescents and substance abuse, parents and subjects were interviewed for validity. A few meditation studies also sought validity by administering surveys to therapists and subjects. Interestingly, all of the research on Eastern-style interventions used instruments based in Western theory. Of course, this is largely due to lack of development of measuring devices that are rooted in Buddhist or Vedic conceptualizations. Moreover, as described above, direct measurement of spirituality is lacking in these studies, though this is approximated with measurement of constructs such as self-actualization and capacity for empathy.

Analysis

            Quantitative studies consistently and appropriately utilize t tests and analysis of variance, reporting p levels. The most common alpha level, when it was set prior to analysis, was .05. Power analysis was conspicuously lacking in these analyses, both before and after design implementation. Prior to experimentation, such analysis could have helped to determine efficient sample size, and following intervention power analysis would have added to the understanding of effect magnitude of various factors, especially the element of spiritual intervention. Additionally, researchers regularly neglected to analyze gender differences. This may be significant, considering that there tends to be a difference between genders regarding spiritual and religious participation and issues. The two literature reviews included in this paper could have benefited by some form of numerical analysis, to assist understanding of effect sizes across research endeavors. Additionally, many of the reports would have been enhanced by multivariate analysis. This would assist in identifying interactive effects between predictor variables and isolating effects on outcome variables. For example, in the study of Janowiak and Hackman (1994), a multivariate analysis including age and gender, with respect to the three groups included in the experiment, would have been interesting and informative.

Results

            Research has consistently found that meditation and mantra chanting are related to decreased stress and anxiety levels and improved capacity for restful sleep. Compliance with these interventions is positively correlated with psychological health, though there appears to be a ceiling effect. These practices also improve physiological outcomes, such as blood pressure and heart rate. However, due to design limitations and varying outcomes, it is not clear from the research whether these psychological and physiological effects are due to the intervention or some other factor, such as contact with therapist or a placebo effect. Moreover, it is not certain that mantra and meditation techniques are more effective than other methods, such as established relaxation procedures. Response to Eastern-style interventions does not appear to be related to gender. Also, research indicates that benefits of these practices are limited to those who are reasonably well-adjusted. Severely disturbed persons may incur harm from these practices. Further, the literature suggests that meditation can be a useful adjunct to psychotherapy, with the caveat that the therapist should be experienced in the meditative technique and expert in applying a combination of the Eastern and Western approaches to each client.

            Regarding mantras, research indicates that any device upon which the mind can concentrate is as effective as mantras which are routinely prescribed by schools of meditation, with regards to stress, anxiety and physiological symptoms. These results should be considered in light of the fact that the research does not adequately differentiate, at least in the reports, between various techniques. Especially with regard to mantras, the mantra itself is almost never included in the article. This is significant, considering that many of the mantras popular in the West are not found in original sources, such as the Vedas. Thus, the possibility that the mantras being investigated are actually placebo interventions must be considered. At least, the mantra should be included in the research report, and the source of that mantra should be provided.

            Eastern-style intervention studies that contained follow-up assessment found that benefits maintained over time. Also, a few researchers examined cost effectiveness and concluded that meditation and mantra interventions have potential value in this regard. Other results reported from these interventions include resolution of childhood trauma, decreases in anger, confusion and tension, and an increase in friendliness, sensitivity, and ability to work productively and socialize.

            In the 12-step studies, the most significant result, with regard to spirituality, is that prayer and meditation positively correlate with alcohol use for recovering alcoholics. These activities also correlate positively and strongly with a sense of purpose in life.

            In the study with cystic fibrosis patients, it was clear that prayer was used as a treatment method by many persons, and that most (92%) who used prayer believed it to be effective. Authors of that study conclude that physicians should at least be understanding of alternative, and especially religiously-based, treatment methods (Stern, Canda, & Doershuk, 1992). Byrd (1988) conducted a more rigorous study on the effects of prayer, and found that prayer to the Judeo-Christian God improves the health of coronary patients.

Generalizability  

            Since most of the Eastern-style intervention studies do not use random sampling, external validity of the designs are weak. However, most of the quantitative research incorporates random assignment, and therefore the results can be applied to the sample. Examining the studies together, a general impression of results and applicability can be gleaned. For example, though the results of Miller, Fletcher, and Kabat-Zinn (1995) can only be generalized to a clinical population of persons diagnosed with anxiety or panic disorder, combined with studies such as Delmonte and Kenny (1985) and Kutz, Dorrington, Morrison, Borysendo, and Benson (1985), we can understand that meditative and mantra techniques have good potential for effectiveness as an adjunct to psychotherapy, provided the client’s disturbance is not too severe and the therapist is sufficiently competent and experienced with the intervention practices. In the qualitative studies (Sweet & Johnson, 1990; Kaye, 1985; Urbanowski & Miller, 1996; Nakhaima & Dicks, 1995), procedures are adequately described for replicability, and practitioners in the particular fields can judiciously apply the techniques. For instance, social workers in all fields can probably find some aspects of the model presented by Nakhaima and Dicks applicable in their work, since a large percentage of social work service recipients value spirituality and religiosity. Therapists who have experience with meditation and who work with persons who have suffered childhood trauma can probably benefit from the report of Urbanowski and Miller. Similarly, professionals working with a geriatric population should consider the results obtained by Kaye in relieving depression in elderly persons.

            Byrd’s (1988) study contains a large sample and rigorous design, providing an impressive combination of internal and external validity. Considering the import of the results, replications should be performed to confirm or negate the conclusions.

            The 12-step studies are limited by somewhat homogeneous samples. Still, results can be cautiously generalized in the adult study (Carroll, 1991) to rural, White, Christian alcoholics.

            Equivalent effects of mock mantras and experimental mantras, as reviewed by Delmonte (1983), can be generalized, though only to the mantras actually examined in the studies included in the literature review.

Conclusions

            Byrd’s (1988) study on the effects of prayer to the Judeo-Christian God provides the most startling results in the spiritual intervention literature. In this investigation, where all parties were blinded to the group identity of patients, prayer was found to have a significantly beneficial effect on many factors involved in the course of coronary disease. Perhaps more astounding than the results is the fact that this study has not been replicated. To illustrate, if a study, possessing the rigor, sophistication and sample size of this one, revealed that a new drug produced the same results as prayer apparently generated in this research endeavor, it is likely that millions would be spent to confirm the findings and then to publicize the results, and the treatment would then be advertised and made available on the market. That this process did not succeed Byrd’s findings indicates that there may be bias at work. That is, there may be factors other than maximizing treatment outcomes that drive decisions concerning research projects. In any case, considering the outcomes of this study, replication studies with various samples should be conducted.

            Several research endeavors have examined Eastern-style interventions, including Buddhist and Vedic techniques for silent meditation, mantra chanting, social interaction and relaxation. There is sufficient evidence that these practices have potential for enhancing several aspects of mental and physical health. Still, there is a gap in the research concerning differential effects of these processes. For example, analyses that control for variables such as gender and socio-economic class would be a valuable addition to the literature, and would assist practitioners in applying these interventions. Also, there is a need for more studies that compare Eastern-style interventions with each other, and with conventional counseling treatments, as well as with placebo groups. 

            Concerning mantra interventions, only in Kaye’s (1985) article was the mantra itself printed (OM). This may be due to the fact that mantra meditation has become popularized in the West by a group that offers “secret mantras”, though the author of this specialization paper is not aware of any justification, based on Vedic authority, for those mantras to be kept confidential. Delmonte’s (1983) literature review indicates that the purported mantra-person fit suggested by many teachers and practitioners of mantra meditation is not validated.

Summary and Integration

            According to the Vedas, we are currently in the Kali-yuga, an age that will continue for hundreds of years. In this particular age, the most recommended spiritual intervention for countering mental disturbances such as depression and anxiety is chanting of the maha mantra. Fortunately, this mantra is not secret, as the Vedas widely broadcast the maha mantra. The Kali-santarana Upanisada states (Prabhupada, 1975):

hare krsna hare krsna

krsna krsna hare hare

hare rama hare rama

rama rama hare hare

iti sodasakam namnam

kali-kalmasa-nasanam

nata parataropayah

sarva-vedesu drsyate

            “Hare Krsna, Hare Krsna, Krsna Krsna, Hare Hare/ Hare Rama, Hare Rama, Rama Rama, Hare Hare. These sixteen names composed of thirty-two syllables comprise the only mantra that can completely eradicate the pernicious influences that afflict the mind in this Kali-yuga” (p. 274).

            Similarly, the Brhad-naradiya Purana (Prabhupada, 1976) declares:

harer nama harer nama

harer namaiva kevalam

kalau nasty eva nasty eva

nasty eva gatir anyatha

            “In the Kali-yuga, the mantra containing the name of hari  is the most effective process to enhance one’s spirituality” (p. 1463).

            In this verse, the name of hari, and the word “only”, are repeated three times for emphasis.Many similar references can be found in Vedic literatures, such as the Srimad-Bhagavatam (Prabhupada, 1976), Bhakti-rasamrta-sindhu (1971), and Sri-Caitanya-Caritamrta (Prabhupada, 1975).

            Therefore, research on the maha mantra needs to be done. The maha mantra is customarily chanted congregationally (kirtana) or privately (japa). Both of these methods should be investigated, though a japa study may be more conducive for control of variables. Many studies lacked follow-up testing, which the japa study described in this dissertation included. Another helpful device, included in a few of the above investigations, is a compliance log, to assess the effects of chanting frequency.

            As mentioned above, the studies on Eastern-style interventions did not utilize scales derived from Vedic knowledge. The study on the maha mantra described in this dissertation, in addition to using standardized Western-style measures of factors such as stress and depression, also incorporated a Vedic-based measure that assesses guna propensities. This study utilized a control group and a placebo treatment group that chanted a pseudo-mantra. There are many potentially effective meditative practices that have not been applied in social work (Canda, 1988).  Japa chanting of the maha mantra may be one of these techniques.   

Pilot Research

            The author conducted a single-system design pilot study on the maha mantra. In this study, five subjects chanted the maha mantra for about 25 minutes per day for four weeks. These subjects were measured on well-being, sattva, rajas, tamas, spirituality, depression, stress, verbal aggressiveness, and life satisfaction. Measuring instruments for all of these variables are found in Appendix D. The hypotheses of this study were that chanting the Hare Krsna maha mantra, which was the independent variable, would reduce the dependent variables of stress, depression, verbal aggressiveness, tamas guna, and rajas guna, and would increase the dependent variables of sattva guna, spirituality, satisfaction with life, and a sense of well-being.

            Although the design of this pilot study had many limitations related to external and internal validity, such as lack of random sampling, small sample size, and lack of a control group, the results were encouraging and suggested that further research on the maha mantra would be valuable. More specifically, examining baseline phase to intervention phase scores for each subject, 80% of the dependent measures responded according to the research hypothesis. A detailed analysis of this pilot study is provided in Appendix B. Overall, the results warranted that a more rigorous examination of the maha mantra be conducted.

            The next chapter of this dissertation, entitled methodology of the japa experiment, will describe in detail the methodology of a group experimental study on the effects of the maha mantra chanted privately with japa beads. This study incorporated many of the features described above, such as a compliance log, follow-up testing, a placebo treatment group, and use of a Vedic-based scale to measure the three gunas.