See related article, pages 993–997.
Stroke affects many dimensions of human behavior and performance, often with profound and long-lasting consequences. Recent years have seen dramatic progress in the measurement and alleviation of the neurological, physical, cognitive and psychological consequences of stroke. In contrast, the adjustments that many patients have to make to a restricted life and their determinants remain poorly understood, despite their importance in the long-term well-being and quality of life of stroke survivors.
This unique and well-designed study investigates the role of religious beliefs in enhancing the ability to cope and reducing emotional distress in stroke survivors.1 The strength of this study is that it includes acute stroke patients in whom stroke characteristics, level of impairments, disability and emotional state were clearly defined. Religious beliefs and spirituality were measured using a validated instrument. Outcome measures were predefined and data were subjected to rigorous statistical evaluation in models with construct and criterion validity, lending further objectivity and credence to the results. The central message of the study is that people with religious beliefs experience the same amount of stress as those people who do not have these beliefs but are able to deal better with negative life events and the attendant stress. Although this association may sound intuitive, the positive role of religion in life adjustments after stroke has not been systematically examined previously, especially in a well-characterized sample of acute stroke patients and using objective measures of outcome.
The study makes an important contribution to rehabilitation literature but many questions remain unanswered. The terms faith, spirituality and religious beliefs have been used interchangeably in this study but have significant conceptual differences which may be relevant in trying to understand their influence on coping ability. Religious beliefs represent a specific doctrine system shared by a group of people and defined by prescribed rules, value systems and practices of social participation that may mimic formal but secular counseling, support and psychotherapeutic activities, many of which have been shown to be of benefit in improving psychosocial outcomes in stroke patients. It is well known that religious attributes can have both a positive and negative effect on life adjustments and emotional health in chronic disease. Fitchett et al2 have shown opposing emotional consequences with positive beliefs that provide a sense of self-efficacy in the face of stress or a way to positively reframe negative events and negative attitudes that interpret illness or disability as a sign of abandonment or punishment by God. The predominantly positive associations with religious beliefs seen in this study may reflect an inadvertent bias in selection possibly because of the nature of the rehabilitation facility or its setting.
Spirituality represents a broader concept embracing not only religious well-being but also the belief of some higher objective to life which transcends the corporeal world. Changes in spiritual beliefs up to 2 years after sudden onset of disability have been shown in patients undergoing rehabilitation in whom the ability to realign personal and extrapersonal issues in a spiritual context was an important aspect of positive adjustments.3 Other aspects of spirituality rather than religious beliefs alone may be more important for coping ability, adjustments to life changes and emotional health. Laubmeier et al4 have shown that existential and not religious beliefs were associated with reduced symptoms of distress in cancer patients and both these were more important than the perceived threat to life. The concept of faith has never been defined fully and encompasses elements of both spirituality and religious beliefs, which may be further modified by culture and personal value systems. Clearly, this is a very complex areaand the present study is confined only to examining the association between 1 independent predictor ie, religious beliefs as measured by the Royal Free Index with only 1 dependent variable ie, emotional distress as measured by the HAD subscales.
The demonstration of an association between religious belief and better coping abilities in stroke patients does not imply causality. The study does not establish that religious beliefs will definitely reduce emotional distress but shows that people who are religious have better coping abilities. Hence, both these variables may define personal attributes of the patient; in other words, religious beliefs do not make a person cope better but identify patients who have better abilities to cope with chronic illness.
Stroke rehabilitation includes not only restitution of physical or functional limitations but also the management of psychological and social sequelae that affect long-term adjustment. Although coping strategies are the key psychological resources required to rebuild lives in the aftermath of stroke, very little is known about coping mechanisms in stroke patients. In a recent review, Donnellan et al5 concluded that although active problem-oriented coping strategies were reported more often than emotion-focused coping strategies, the effectiveness of either strategy remained unproven. Higher levels of psychological distress were present in those using less active, problem-oriented coping strategies and more avoidance strategies. These observations imply that religious perceptions and spirituality may well be a double-edged sword. On one hand, positive beliefs can bring out the best in individuals, reinforcing active problem-solving behavior, but on the other hand can equally encourage negative avoidance strategies based on the beliefs of abandonment and punishment. An intriguing possibility that arises is whether religious and spirituality aspects can be modulated by pastoral interventions to improve coping ability and recovery in stroke patients. In other words, is the time to expand the philosophy of rehabilitation and investigate interventions beyond healing the body to healing the spirit?
The opinions in this editorial are not necessarily those of the editors or of the American Heart Association.