Abstract
This article is part of an international study on meaning-making coping aimed at understanding the role of culture in coping in different cultural settings. The international study was conducted among cancer patients in 10 countries. This article contains the results obtained in the study in Portugal. The main aim is to investigate the impact of culture on the meaning-making coping methods used by cancer patients. In this article, only religious/spiritual coping methods are in focus. Thirty-one participants with various kinds of cancer (e.g., breast, testicular, lymphoma) were interviewed. Nine different kinds of coping methods related to religion and spirituality emerged from analysis of the interviews. These methods, which are categorized on the basis of religious coping’s five basic religious functions, are as follows: seeking spiritual support, spiritual connection, spiritual discontent, benevolent religious reappraisal, punishing god reappraisal, God’s trust in personal strength, support from clergy or members, self-directing religious coping, and active religious surrender. The study confirms the notion that the strategies people employ when they are stricken by disease, accidents, misfortune, and so on are cultural and temporal constructions. As such, they are valid in concrete contexts and time periods. It is, thus, important that cultural context be taken into consideration when exploring the use of meaning-making coping strategies in different countries.
Introduction
According to World Health Organization, millions of people will die of cancer by 2030. In Portugal, the number of deaths due to cancer has been increasing since the 1960s (PORDATA, 2016). In 2016, 24.7% of deaths were caused by malignant tumors (Instituto Nacional de Estatística [INE], 2018). Fortunately, improvements in cancer treatments and increased screening have improved the survival rate among cancer patients in Portugal (Direção-Geral da Saúde, 2017).
Cancer may cause serious psychological problems such as feelings of despair, powerlessness, anxiety, and fear. There are significant differences in the ways patients react to the disease, and these differences are due to sociodemographic, disease-related, and psychosocial factors (F. Ahmadi & Ahmadi, 2018). Less attention has been paid to the cultural contexts that individuals are socialized in and that probably influence how people choose or adhere to different coping methods.
The lack of a cultural approach to the study of meaning-making coping methods has paved the way for an increased tendency toward generalization of results obtained from research conducted among religious people, especially in the United States, to other people. It is for this reason we are trying, within the framework of an international project, to turn our focus to studying the religious, spiritual, and existential meaning-making coping methods used by people facing a crisis from a cultural perspective. In doing this, we have conducted studies in 10 countries (Sweden, South Korea, China, Japan, Malaysia, Philippines, Turkey, Iran, Brazil, and Portugal) to investigate the role culture plays in meaning-making coping. In this article, however, we have confined ourselves to religious/spiritual coping (mainly religious coping [RCOPE]) in Portugal. 1
Cancer patients use a multitude of meaning-making coping methods. The strategies people employ when they are stricken by disruptive challenging events—such as disease, accidents, and misfortune—are the result of their psychological developmental histories and are culturally and historically embedded. Culture can affect the coping process in at least four ways: First, the cultural context shapes the type of stress individuals are likely to experience. Second, culture may affect assessment of the stressfulness of a given event. Third, culture affects selection of the strategies an individual uses in a given situation. Fourth, and finally, culture provides the institutional mechanisms individuals may use when trying to cope with stressful situations.
The findings of our studies, among others in Portugal, verify the third way, that is, ‘culture affects selection of the strategies an individual uses in any given situation.'
The specific goal of our study in Portugal was to investigate which meaning-making methods cancer patients in Portugal use and to determine whether divergent meaning-making methods could be identified. The results presented here are restricted to RCOPE methods. Finding on methods other than those categorized as religious/spiritual will be presented in another article.
Conceptual Framework
Meaning-Making Coping
We define coping as a process through which individuals try to understand and manage important demands in their lives (Ganzevoort, 1998) or as the search for meaning during periods of stress (Pargament, 1997). Coping can be seen as a multilayered contextual phenomenon involving several basic skills (Lazarus & Folkman, 1984; Pargament, 1997). During coping, the individual and the situation meet; coping is multidimensional, multilayered, and contextual in nature. It is diverse and involves opportunities and choices. Another aspect of coping is that it is a process and thus develops and changes over time (Pargament, 1997).
In many studies in the field of coping, the terms ‘religious' and ‘spiritual' have been used to address coping methods that are essentially based on existential issues (see the review done by Hall, Shannonhouse, Aten, McMartin, & Silverman, 2018, on several studies on meaning making, religion, and cancer). Nevertheless, the results of several studies (F. Ahmadi, 2006; F. Ahmadi & Ahmadi, 2013, 2018; La Cour & Hvidt, 2010; Park, 2010) reveal the occurrence of other coping strategies that can hardly be regarded as religious or spiritual, for instance, some strategies connected to nature.
It should be mentioned that not all ways of using nature are secular existential. As F. Ahmadi (2006) shows, the use of nature as a coping method can also occur in a religious context.
These kinds of coping methods can be defined as existential in nature, referring to a search for meaning that has no connection whatsoever to religion and religious symbols, or no obvious connection to a sacred religious/spiritual source. The term existential coping is used because these methods concern individuals’ endeavors to find an inwardly source—in nature, in themselves or in others—that can help them cope with their problems. Their problems have caused an existential vacuum that requires elaboration of the old order into a new order—a new order that could help them fill this vacuum. Figure 1, presented by F. Ahmadi and Ahmadi (2018), shows the relation between religious, spiritual, and secular existential coping used in our project.
Relation of existential meaning-making domains (F. Ahmadi & Ahmadi, 2018).
According to this model (see Figure 1), the concepts and topics belonging to the religious and spiritual domains are somewhat overlapping. The concepts and topics of spiritual and secular meaning-making coping overlap as well, but note that there is no overlap between secular and religious concepts and topics (F. Ahmadi & Ahmadi, 2018). This is the case because we define religion as a search for significance that unfolds within a traditional sacred context (F. Ahmadi, 2006). Moreover, we define spirituality as a search for connectedness with a sacred source that is related or not related to God or any religious holy sources (F. Ahmadi, 2006). Thus, secular meaning-making coping has almost no point of connection with a traditional sacred context but can intersect with a search for connectedness with a sacred source without any reference to God or traditional religious contexts. As mentioned before, here we do not define the sacred as being related to a religious context but instead to an inwardly context of sanctification.
Starting from the results of the studies in the international project on meaning-making coping, F. Ahmadi and Ahmadi (2018) make a distinction between theistic sacred objects and nontheistic sacred objects. In doing this, they present a different set of “sacred rings” (see Figure 2), one where the inwardly transcendent is the sacred core (nontheistic sanctification); this is in contrast to the set of rings presented by Pargament, Omanb, Pomerleaua, and Mahoney (2017), which has the outwardly transcendent as its sacred core (theistic sanctification; for more information, see F. Ahmadi, 2006; F. Ahmadi & Ahmadi, 2018).
Alternative sacred core and ring.
In our international project, we have used the term meaning-making coping to refer to the entire range of religious, spiritual, and existential coping methods.
Culture, Religion, and Coping
In this article, we present the results of the study in Portugal, which looks at religious/spiritual coping methods from a cultural perspective. It should be mentioned that we refer to culture as a system of norms and values that is shared by the members of a society, a community or a group and the explicit expression of these norms and values. These norms and values are necessary for construction of individuals’ identities and of their ethical and moral world, which in its turn functions as an orienting system in social relationships. Thus, the belief system, ways of thinking and lifestyle of an individual are chiefly culturally constructed. (F. Ahmadi, 2006).
In the following, we explain our view of the relation between culture, religion, and coping.
When discussing RCOPE, it is important that we consider situations in which religion and coping are interwoven. It would seem reasonable to suppose religion is more accessible to individuals who have religion as a major part of their orientation system. The notion of orientation system refers to the ways in which culture affects individuals’ lives. Given this, it is appropriate to argue that the reason people turn to religion in times of crisis is that, compared with other possible resources, religion is more accessible in their sociocultural context. Religion is not necessarily the only available resource in the individual’s orientation system, and other resources may be easier to access. If this holds, then for those with limited options, religion may play an even greater role as a coping resource. In cultures where nonreligious resources are many and where religion is less important in everyday life, religion may play only a minor role in the coping process. Thus, “turning to religion in coping” is principally a question of religion’s prominence in the individual’s culture of socialization. Once religion becomes a greater and more integral part of the orientation system, it plays a more important role in coping. When it is less crucial to the orientation system, and less applicable to life experiences, it loses its importance as regards coping (F. Ahmadi, 2006; Ellison, 1991; Ferraro & Koch, 1994; Wicks, 1990).
Religion in Portugal
In Portugal, Church and State were formally separated during the Portuguese First Republic (1910–1926), and this separation was reiterated in the constitution of 1976, after the April Revolution and 40 years of dictatorship.
Although there is no official religion, the Catholic culture is predominant (81% according to the Censos, 2011). There is growing religious pluralization, mainly in the country’s urban centers (Dix, 2010), as a result of immigration (Coutinho, 2015; Vilaça, 2013). During the past three decades, new churches and new branches of Christianity, along with older religious minorities with public and social expression, have painted the Portuguese religious landscape 2 (Vilaça, 2013).
There are differences in geographic distribution. Despite some heterogeneity, Catholics are more represented in the northern and the central region, and the southern region is less religious in orientation (INE, 2018). Based on data from the European Values Survey, Coutinho (2015) presented five different clusters of religiosity in the Portuguese Population (three internally consistent clusters of Catholics, 60%, and two not internally consistent clusters of heterodox believers, 40%) showing the heterogeneity of the Catholic religious field. Still, results revealed that the Catholic culture is widespread and influences the beliefs of Portuguese people as well as that deinstitutionalization is not a clear process (Coutinho, 2015).
This being the case, it is convenient to maintain that the reason people turn to religion in times of crisis is that religion is more accessible in their sociocultural context than other resources are.
Method
Data-Gathering method
In this study, we used semistructured interviews. Interview questions were mainly constructed on the basis of the Swedish study interview (F. Ahmadi, 2015), but order of the questions was changed and new open-ended questions were added (see Appendix). Some questions and phrases were modified to make them more suitable to the Portuguese culture. At the end of the interview, all participants completed a brief questionnaire covering sociodemographic (e.g., age, education, marital status) and clinical (e.g., diagnosis date, type of cancer) data.
Participants
For the present qualitative study, we used a convenience sample. A total of 31 participants were recruited in the district of Porto (North), Aveiro (Center), and Faro (South) using the snowball method. In the study, the inclusion criteria were female and male adults who had confronted a cancer diagnosis in the past or patients who were still undergoing oncology treatments (e.g., chemotherapy, hormone therapy). Religious orientation was not a criterion for participation.
The participants included 20 women and 6 men, between 20 and 80 years of age. Regarding their religious affiliation, 14 were Catholic, 4 were Christian, 1 was a Jehovah’s witness, 3 described themselves as a spiritual person, 1 was agnostic, another 1 believed in God but do not affiliate with any religion, and finally, 2 were atheists. The participants had various types of cancer (e.g., thyroid, lung, prostate, lymphoma), but most of them had breast cancer (N = 12). Participants’ stage of cancer varied from earliest to metastatic disease, and their social status was diverse, including housewives, retirees, and the currently employed. Most participants were married or living with their partner (19 married, 4 singles, and 3 widows). Only four participants had no children. Regarding the age of participants, 3 were 20 to 39 years of age, 20 were 40 to 59 years, and 8 were older than 60 years. Concerning their education level, 1 participant was illiterate, 5 had completed elementary school, 1 middle school, 9 high school, and 10 had a college degree (one a PhD; two a master’s degree). The employment status of participants was also diverse, including 12 currently employed, 6 retirees, 3 housewives, 1 student, and 4 on sick leave.
Procedure
At the beginning of the interview, the participants read and signed an informed consent form explaining the purpose of the study, ensuring confidentiality and obtaining permission for audiotaping. Two female interviewers conducted face-to-face, individual interviews with the participants. All data were audiorecorded, and the interviews took place in a setting chosen by the participant, such as the facilities of the Faculty of Psychology and Education Sciences at the University of Porto, the participant’s home, or the medical clinic.
The average duration of the interviews was 55 minutes (ranging from 15 to 162 minutes). The interviews were conducted from October 2017 through June 2018, and the transcriptions were completed by mid-July 2018. After all the interviews were completed and analyzed, the main citations for each category were translated into English by two of the participating Portuguese researchers.
Method of Analysis
The interviews were transcribed verbatim with the support of QRS NVivo10. After the transcription process, the material was coded in accordance with the themes found in the study using a thematic analysis method (Braun & Clarke, 2006) as well as using QRS NVivo 10. The subsequent discussion concerning categorization of the themes was based on a modified version of Pargament’s RCOPE (Meaning, Control, Comfort/Spirituality, Intimacy/Spirituality, and Life Transformation) 3 used by F. Ahmadi in the qualitative Swedish study (2006, pp. 45–47) as well as on the results of both the qualitative and quantitative Swedish studies (2006, 2015). Two main themes (Religious and spiritual coping, and Secular existential coping) were divided into several categories. The categories and subcategories were then linked to relevant codes in the material. To accomplish this, the researchers read the transcribed interview protocols independently. The researchers then met to compare the meaning units that emerged, and in cases of different coding, the authors discussed each individual case until consensus was reached.
To achieve conformability, the authors discussed their own previous knowledge in the field to minimize their influence on the coding process and maintain their objectivity. After the first coding scheme, the researchers analyzed and discussed the categories to determine which had the same meaning as the main dimensions and subdimensions of RCOPE. When there was no initial agreement, all researchers discussed the data, and the final category or subcategory was arrived at through a consensus. In some cases, it was necessary to return to the original interview transcripts to ensure that the identified meaning units corresponded to the participants’ discourse. After the coding process, the essential characteristics of the different methods of coping with cancer found among the participants were established. The point of departure was the aim of the project and the results of the previous studies obtained in the project (F. Ahmadi, 2015; F. Ahmadi & Ahmadi 2018; F. Ahmadi, Certez, Erbil, Ortak, & Ahmadi, 2017; N. Ahmadi, Ahmadi, Erbil, & Certez, 2016; F. Ahmadi, Erbil, Ahmadi, & Cetrez, 2018; F. Ahmadi, Park, Kim, & Ahmadi, 2016, 2017; N. Ahmadi & Ahmadi, 2017). Concerning RCOPE, we took into consideration the five key religious functions that constitute the basis of RCOPE (Pargament, Koenig, & Perez, 2000). 4 In this article, we present findings from the first theme regarding religious and spiritual coping.
Ethical Considerations
This study was approved by the ethical committee of Faculty of Psychology and Education Sciences at the University of Porto (ref. no. 2017/10-1). In the study, we gathered data on the meaning-making coping strategies used by people belonging to a vulnerable group, namely, people who had been diagnosed with a life-threatening disease. It is obvious that the act of bringing these issues to the fore is of ethical relevance, as it is related to very fundamental layers of an individual’s ego. Before the participants signed the informed consent form, the interviewer made it clear that participation was voluntary, the data would be treated with confidentiality and would not be made available to anyone outside the research team, participation could cease at any time without any consequences for the participant, and the results obtained would be published in such a way that identification of individual respondents would be impossible. When participants demonstrated great difficulties in talking about the disease period, the interviewer asked whether they wished to interrupt the interview. None of the interviews was interrupted.
Results and Discussion on RCOPE Methods
In the following, we present the results related to RCOPE methods (Pargament et al., 2000). The results on secular existential coping will be presented in another article. To categorize these methods, we used the five key religious functions that constitute the basis of RCOPE (Table 1).
Themes and Patterns—Religious Coping.
Religious Methods of Coping to Gain Comfort and Closeness to God
Seeking spiritual support
We observed some informants using a coping method that can be categorized as seeking spiritual support (searching for comfort and reassurance through God’s love and care; Pargament et al., 2000).
Two patterns are found in this study. In the first pattern, praying is an active religious act for getting support from God; in the second, the act of praying is a deep-rooted habit, which functions as a coping method that makes the individual feel safe and calm. The following citations are answers to our question to informants about the coping method they have used.
Concerning the first pattern, one interviewee, a 73-year-old man, expressed his search as follows: I am a believer and I have my prayers. I always asked God that everything goes well. (…) If possible, in the morning, I begin with a prayer for those who have been [who died] and then for those who are here. For my family, for humanity
However, not all the interviewees who reported using these coping methods can be categorized as traditional religious persons; some would better be defined as spiritual. Here, we have the second pattern:
A 42-year-old woman emphasized the following: If I needed to pray, I prayed, because that’s how I was raised, but I don’t believe in all those stories they tell us.
Proceeding from Pargament’s (1997) discussion on the availability of religion in coping—that religion ‘is more likely to be accessed in coping when it is available to the individual, that is, when it is a larger part of the individual’s orienting system for relating to the world' (p. 149), we can understand not only the first pattern but also the second one. Regarding the second pattern—that is, prayer as a deep-rooted habit functioning as a way to achieve a sense of safety and calm—we are dealing with the availability of religion in the orienting system. As the 42-year-old woman mentioned, she was raised to pray, and though as an adult she may no longer believe in conventional religious ideas, she has used praying as a means of feeling comfort and tranquil when dealing with the challenges of the disease.
In Portugal, the religious education of children has been (and still is) a prevalent feature in their socialization that facilitates the emergence of this resource in times of difficulty, even if it has been dormant for part of people’s lives. The informants represented in the second pattern seem to turn to prayer for relaxation because praying is an accessible tool in facing difficult situations in their orientation system. Notwithstanding, they can be quite skeptical regarding the more ritualistic practices, like service attendance, and may not identify themselves with the moral attitudes and beliefs (of Catholicism).
A point that distinguishes the second pattern from the first one is that praying is less ritualistic, more individualized, more conscious, and lacking in any outwardly power. In fact, it is the result of individualization, where religion is no longer controlled by the religious institution but by the individual (Heelas & Woodhead, 2005; Hervieu-Leger, 2005).
Spiritual connection
In our study, we found some informants who use spiritual connection as their coping method. Spiritual connection can be defined as ‘Experiencing a sense of connectedness with forces that transcend the individual' (Pargament et al., 2000, p. 523).
In this respect, one 54-year-old woman made the following statement: I have always thought that “God” helps me. I don’t relate myself with religion,… I need to believe in something. My faith helps a lot. More faith than religion. (…) I can’t say the word, [but] I consider that there is something that we have, I don’t know if it’s a form of intelligence, a soul; it’s not important what it is; it’s not palpable, but it is very strong and accompanies us. It’s something that’s not objective. I meditate in my own way, I talk with my brother [he died more than 20 years ago], this may seem strange, but it’s true. If it has to do with believing, I don’t know. I already went to Fátima.
5
Not because of religious pledges or to pray in a fundamentalist way. I like to go to the sanctuary of Fátima because it brings peace to the spirit I had a terrible fear of being alone at home. (…) I said ‘Jesus, I’m so afraid to be [alone] at home. (…) Oh my God, get rid of this fear, this anguish, free me for life because I can’t continue like this. I’m afraid of life. I’m afraid of death. (…) Please, help me.' (…) [After that] I was never afraid (…) I have faith in God, [and sometimes], I wake up at night, thinking of God: ‘Oh God, I feel your presence. You are with me.' I didn’t go through this (cancer) alone, I always did it with the feeling that I was with God. So, I went through this process in my moments of prayer, and especially in my moments of conversation, with God. When I did the second treatment, I went to Fatima with my friend, and I felt so good there, it seemed like I had nothing. I felt lighter and thought that I had one more reason to keep fighting, because she was taking care of me.
Spiritual discontent
Spiritual discontent is one of the RCOPE methods in the coping group, religious methods of coping to gain comfort and closeness to god. Our analyses showed that the informants in the Portugal study used this method. Spiritual discontent refers to ‘Expressing confusion and dissatisfaction with God’s relationship to the individual in the stressful situation' (Pargament et al., 2000, p. 523). The use of this method is reflected in the following citations: I went so many times to Fatima [walk/pilgrim] and I was sad, because Our Lady of Fatima would certainly think: ‘This girl is a good girl, so she does not deserve to get sick.' (…) And I was very angry. And I said I will never go again [to Fatima], but now, I’m better and I’d like to go again to Fatima. I was still very sad with Our Lady because I got cancer. (46-year-old woman) There is a very strong inner rebellion [toward God]: ‘Why me? I didn’t harm anyone. I’m such a good person. I follow you [God]. I was even a Catechist. I know that everything I do, you [God] analyze and view, and you [God] do not criticize [me], because I’m not a bad person. I take care of my mother. I’m present in the family. Considering the problems I have, I am a happy person. I know, I’m a good person. Why did you pick me?’ There are times of interior rebellion and silence that are not easy to deal with. (52-year-old woman)
People who face difficult events in life, such as life-threatening illness, may feel as though God has abandoned them and begin to challenge their own trust in God or to believe in supernatural powers, for instance, black magic. Earlier studies have portrayed some religious and spiritual (R/S) struggles as negative RCOPE responses; these include blaming God, the Devil, or one’s own sins for serious problems or viewing problems as a form of divine retribution. According to some researchers (Stauner, Exline, & Pargament, 2016; Wilt, Pargament, & Exline, 2017), R/S struggles that result in negative coping strategies can have a variety of health outcomes, such as additional medical diagnoses, functional disabilities, depression, diminished cognitive functioning and subjective health, and negative effects on quality of life.
Stauner et al. (2016) suggest that R/S struggles consist of tensions, conflicts, or worries regarding sacred matters (Exline, Pargament, Grubbs, & Yali, 2014; Pargament, 2007). Sometimes these struggles focus on the supernatural (God, the Devil), on other people, or on the self (doubts, moral conflicts, no meaning in life). Key points related to R/S struggles are: conflict, tension, and turmoil concerning sacred matters within oneself, with others, and with the supernatural; over the life course, people may be traumatized spiritually as well as physically, socially, and emotionally; people struggle with challenges so as to attain meaning (Exline et al., 2013; Stauner et al., 2016).
However, an R/S struggle is not only a personal matter; it is influenced by the cultural setting the individual was socialized in. Inozu, Clark, and Karanci (2012) suggest that obsessive belief characteristics may lead to subjectively recognizable R/S struggles, such as the fear of God and sin, that vary across individuals and cultures. Research has shown that religious struggles are common in theist countries (Balboni et al., 2013).
Religious Methods of Coping to Find Meaning
Benevolent religious reappraisal
We observed some informants using a coping method that can be categorized as benevolent religious reappraisal, that is, using religion to redefine the stressor as benevolent and potentially beneficial (Pargament et al., 2000)
In this respect, one 58-year-old woman provided the following explanation: I got cancer in order to change my life, to understand that there are more important things [in life], and for not having doubts anymore [doubts about the existence of a God]. Some thoughts used to come to mind sometimes: ‘There are so many kids who die, so many wars.' Sometimes I asked: ‘My God, are you nonexistent?' No, I got cancer to understand things differently. (…). It was a message from God. I never let the disease lead me into a state of depression. I’ve always tried to fight this with faith, because it was the only thing that made sense to me. I didn’t revolt ‘why me?' I’ve always tried to understand ‘for what,' what I have to learn from this? Without a doubt I am a much better person after having gone through the illness.
Punishing god reappraisal
When using punishing god reappraisal, the individual redefines the stressor as a punishment from God (sins I have committed in my life; Pargament et al., 2000):
One 46-year-old woman who had used this method explained it: I asked God what I had done. I didn’t do anything wrong (…). But when I got pregnant?? I wanted the child, and at the same time I didn’t want the child, and lots of things came to mind (…) I thought that God had punished me [she eventually aborted following medical advice, but felt guilty].
God’s trust in personal strength
In our study, we identified an RCOPE method used by the participants that we could not find among the RCOPE methods. In this method, the informants redefined the stressor as a privilege, that is, a sign of God’s trust in their ability to cope with the stressor.
One 56-year-old woman explained the application of this method as follows: If God gave me this [cancer], it is because [God realized] I had the strength to deal with it. I think that God gave me this (cancer) for me to be able to overcome it and to become a stronger person.
Religious Methods of Coping to Gain Control
Because stressful situations generally lead to perceptions of loss of mastery over important areas of everyday life, religion provides their faithful with a number of ways to gain control through coping, namely, through perceptions of God’s power and his involvement with the world, which is often referred to in the literature as God’s locus of control (Nelson, 2009).
Active religious surrender
In this type of cooperative RCOPE, which emphasizes the individual’s partnership with God, there is an active surrender of control of the situation to God following the efforts of the individual (Pargament et al., 2000). This can be illustrated using the statement of this 36-year-old respondent: (When I talked to God) I felt comfort and somehow security and I put the situation in him. I told him, ‘You know what you’re going to do, of course, but I trust you and I know we’ll be able to overcome this situation together.'
Religious Methods of Coping to Gain Intimacy With Others and Closeness to God
Support from clergy or members
Support from clergy or members, which refers to “Searching for comfort and reassurance through the love and care of congregation members and clergy” (Pargament et al., 2000), is identified as a RCOPE method used by our informants. One 66-year-old woman explains her coping method as follows: My husband is a Jehovah’s Witness, and he goes to church. (…) I’m not a Jehovah’s Witness, but I went with him to the meeting room and they [members of the community] also came to my house. They helped me a lot too. (…) They kept calling me on the phone. They were exemplary, everybody was great. (…) Everyone came to me. They gave me a friendly word. It’s the love…It helped me a lot. My mother said to me: ‘You know, your grandmother has already spoken to that lady who is the sister of priest C, and they usually do group prayers at night and vigils…and they have prayed for you. Everyone asks about you and I tell them how you’re doing. You know, people care about you.' This was very important to me, because I felt my importance, and that I was present in the lives of others, and that gave me the strength to know that it made sense to continue living. All this gave me a lot of strength to overcome this situation, and I was comforted in some way.
Final Discussion
In sum, across societies, people have always used certain methods, objects, and belief systems—including faith in God or another supreme being, religious sacraments, fate, or comparable figments of their own or others’ imagination—to seek relief from the anxiety and stress caused by adversity. Certain strategies used can be conceived of as passive acceptance and others as active resistance.
Regardless of the strategies used or their secular or religious characteristics, coping is a matter of consoling. The coping methods individuals choose depend on where they live and the period in which they are living—as well as on the trends prevailing in their life context.
Thus, to better understand the present results, we need to take into consideration the prevalence of the Catholic culture in the ways of thinking of Portuguese people. To be sure, we are not implying that all Catholics understand health as it is described later. We only present an ideal type in the Weberian sense. 6 In discussing views on health found in Catholicism, we draw on ideas presented by the well-renowned health and medicine researcher Nancy Clare Kehoe, from Harvard Medical School. As Kehoe (1998) points out, the Catholic Church has specific teachings and educational programs, although there is not single ‘Catholic perspective.' The Roman Catholic Church is worldwide. Both its structure and its protagonist, the Pope, are highly visible. Papal statements are usually public, and they are sometimes aimed at the citizens of the world. Thus, in this respect, familiarity with Catholicism is greater than familiarity with other religions around the world. Moreover, there may be more negative transference given the authoritarian structures of the Church and the public nature of some official statements. Nevertheless, the Catholic collective or subculture is not identical to the Catholic Church as an institution. Several factors may be important to the Catholic psychology and may affect coping in Catholic patients.
According to Kehoe (1998), one of these factors is the dominance of authorities and the diminished importance of individual responsibility. In our study, we find that support from clergy or members is one of the meaning-making coping methods used by our interviewees.
In Pargament’s (1997) view, certain RCOPE methods, such as God’s punishment and pleading for divine intercession, are associated with negative outcomes. These methods are directly or indirectly tied to feelings of guilt. Consider, for instance, the RCOPE method punishing god reappraisal, which involves redefining the stressor as a punishment brought down by a God/Spiritual Being on an individual for his or her sins. Here, the patient wonders whether he or she is being punished by a God/Spiritual Being for lack of faith or sinful behavior. Another example is the RCOPE method demonic reappraisal. Here, the individual redefines the stressor as an act of the ‘Devil'/an evil power, who makes horrible things (such as deadly illness) happen when people are sinful.
Naturally, the notions above do not apply to all Catholics. People have a wide variety of approaches to Christian messages. One well-known approach to Christianity and health is found in Christian Science. This religious teaching deals with the value of spiritual healing and is based on Mary Baker Eddy’s interpretation of the Bible, which is presented in her book entitled Science and Health with Key to the Scriptures (published in 1875). Students of Christian Science are typically, but not always, members of the Church of Christ, Scientist. Science and Health is founded on a wholly metaphysical view of Christianity, according to which sin, sickness, and death do not emanate from God and are, thus, not real. Following this doctrine, these ‘false convictions' can be expunged from our experience if we strive for spiritual understanding of the world as the perfect creation of God (Kehoe, 1998).
Such a view can encourage conceiving of a life-threatening disease like cancer as a lesson from God as well as attempting to discover how the situation could be spiritually beneficial. In this connection, the RCOPE method, benevolent religious reappraisal or spiritual connection, may be a relevant strategy.
It is clear that, within Christianity, there are different ways of viewing disease and health. We find, for example, the authoritarian view, which reduces the importance of individual responsibility and strengthens the role of physicians and other authorities. One common factor across the various Christian treatment methods is the stress put on the role of particular religious practices, such as prayer, attending church, and so on, in healing. This has led to the emergence of the various RCOPE methods we discussed earlier in relation to RCOPE.
Appendix
Project: Meaning-Making Coping With Cancer
Interview guide
Background factors
Age: Sex: [Database] Education: Job (before retirement): Family: Environment informant grew up: Functional status: Religious orientation: Situational factors: Disease stage: Age of diagnosis: Type/location of cancer:
Interview questions
Religiosity
Are you from a religious family? Do you believe that God exists?
If yes
How often do you pray? Do you go to church now? How often?
If no?
a. Do you believe that some kind of spiritual being or vital power exits? 3. Have your spiritual beliefs and religious practices changed after being struck by cancer? 4. Do you believe in life after death?
Meaning-making coping
5. In period of crisis, how do/did you cope? Who helps/helped you? What helps/helped you? 6. Have religion or spirituality played any role in this respect? 7. Has your illness caused you to ask God/a spiritual being to help you find a new purpose in life or a total spiritual reawaking? 8. Has nature been an important resource for you in dealing with your illness? 9. Has being alone and pondering about your life and its meaning been a way to deal with your illness? 10. Have you used any form of Holistic Health in relation to your cancer problem? If Yes, was it as an alternative to conventional treatment? 11. Do you regularly meditated in order to deal with your illness? 12. Have you used visualization in order to deal with your illness? 13. Do you think/have you ever thought that God/a spiritual being allowed this to happen to you because of your sins or because of your lack of faith? 14. Do you think that your illness is caused by an evil power? 15. Do you work with God/a spiritual being to relieve your worries? 16. Do you think that you have done your best and now it is only to give up control to God/a spiritual being? 17. Do you expect that God/a spiritual being will take your worries away because you know that you cannot handle the situation, or do you think that that God can help you take care of your illness? 18. Do you pray or negotiate with God/a spiritual being to make things better? 19. Do you try to deal with the situation on your own without God’s/a spiritual being’s or any supreme being’s help? 20. Have you ever experienced a sense of strong connection with God/a spiritual being? 21. Have you ever experienced a sense of spiritual connection with other people? 22. Have you ever thought that your life is part of a larger higher power? 23. Have you ever experienced a stronger feeling of spirituality? 24. Have you ever wondered why God has abandoned you or felt angry that God/a spiritual being was not there for you? 25. Do you look for spiritual support from clergy? 26. Do you give spiritual strength to others? 27. Are there other methods you have used to deal with your situation?
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Högskolan i Gävle.