ORIGINAL RESEARCH
RELIGIOUS COPING AND MENTAL HEALTH OUTCOMES: AN EXPLORATORY STUDY OF
SOCIOECONOMICALLY DISADVANTAGED PATIENTS
Michael M. Olson, PhD,1# Dorothy B. Trevino, PhD,1 Jenenne A. Geske, PhD,2 and
Harold Vanderpool, PhD, ThM3
Objective: This study was designed to investigate the association
between religious coping and mental health in a socioeconom-
ically disadvantaged population.
Methods: Participants were selected as they presented for men-
tal healthcare at a community health center for patients with
little, if any, financial resources or insurance. A total of 123
patients participated in this study. Multiple regression analysis
was used to identify religious coping predictors for mental health
outcomes.
Results: Positive religious coping (PRC) was significantly asso-
ciated with and predictive of better mental health (P ⬍ .01).
Conversely, negative religious coping (NRC) was found to be
INTRODUCTION
It is well documented that psychiatry and religion have, at least
during the past century, been at odds. Many influential writers
and philosophers, including the noted Renee Descartes and his
treatise on mind– body dualism, have contributed to the fractur-
ing of the mind⫺body and spirit in patient care. It is beyond the
scope of this document to review the relationship of psychiatry
and religion historically; importantly, however, there has been a
national shift in the culture of medicine, academic institutions,
and philanthropic organizations toward the recognition of the
importance of religious and spiritual life on health. The Interna-
tional Center for the Integration of Healthcare and Spirituality,
for example, was founded by the late Dr David Larson, a psychi-
atrist and epidemiologist who focused on potentially relevant
but understudied factors that might help in illness prevention,
coping, and recovery. There is a measurable movement toward
rerecognizing the patient as an integrated whole, with mind-
⫺body and spiritual factors affecting physical and mental
health.
Multiple reviews of the empirical literature support the con-
clusion that the relationship between religiosity and mental
1 Department of Family Medicine, University of Texas Medical Branch
at Galveston, Galveston, TX
2 Department of Family Medicine, University of Nebraska Medical
Center, Omaha, NE
3 Institute for the Medical Humanities, University of Texas Medical
Branch at Galveston, Galveston, TX
# Corresponding Author. Address: Department of Family Medicine, Uni-
versity of Texas Medical Branch at Galveston, Galveston, TX 77550
e-mail: mmolson@utmb.edu
172 © 2012 Elsevier Inc. All rights reserved
ISSN 1550-8307/$36.00
significantly associated with poorer mental health scores (P ⫽
.031) with gender, income, and ethnicity controlled for in the
model. The relationship between NRC and inferior mental
health outcomes was more robust than the relationship between
PRC and improved mental health scores.
Conclusions: This study illustrates the important association
between PRC and NRC and mental health outcomes among
economically disadvantaged patients. Interpretation of these
findings and clinical implications are offered.
Key words: Psychiatry, mental health, religious coping, religious
commitment, socioeconomically disadvantaged populations
(Explore 2012; 8:172-176. © 2012 Elsevier Inc. All rights reserved.)
health is a generally positive and salutary one.1-7 Despite the
preponderance of data on religious and spiritual factors on
health and mental health outcomes generally, there is a paucity
of data regarding religious coping and mental health generally
and among socioeconomically disadvantaged patients more par-
ticularly.
Religious coping involves religious behaviors or cognitions
that help a person cope with or adapt to difficult life situations or
stress. It may involve prayer to God to change a situation or to
give emotional strength, deciding to “turn a situation over” to
God, reading inspirational scriptures for comfort or relief for
anxiety, talking to a minister or chaplain to help work through a
problem, or using any other religious thoughts or behaviors to
relieve stress.8 Further, Pargament9 explains that religious coping
can include seeking religious support, forgiveness, seeking a spir-
itual connection, and benevolent religious reappraisal. In studies
in which patients are directly asked about how they cope with
health problems or other major life stressors, they frequently
mention religious beliefs and practices.4 This is true not just for
the acutely distressed (ie, “foxhole” religion) but for many deal-
ing with the day-to-day stresses of life.10 One of the inherent
challenges in conducting research in this area currently and his-
torically is the subjectivity of religious terms. On the surface,
“religious coping” relates to other common constructs like reli-
giousness and spirituality. Although precision in terminology is
complex, the term “religious coping,” in the context of this
study, was based on the instrument development and work of
Ken Pargament, a noted researcher in the field of religious cop-
ing.9,11
Existing data indicate that religious coping is a stronger pre-
dictor of mental health outcomes than general measures of reli-
giosity or religious commitment.9 Dr Pargament and his col-
EXPLORE May/June 2012, Vol. 8, No. 3
doi:10.1016/j.explore.2012.02.005
leagues have conducted several studies examining the role of
religious coping in dealing with life stressors. They argue that
individuals under stress frequently convert general religious be-
liefs and practices into specific coping or problem-solving be-
haviors.9 Through study of the factor structure of religious cop-
ing, both positive and negative religious coping constructs have
been identified as relevant to mental health outcomes.9,11
Positive religious coping (PRC)11 includes looking for a stron-
ger connection with God, seeking God’s love and care, seeking
help from God and letting go of anger, trying to put plans into
action together with God, trying to see how God might
strengthen a person facing a difficult situation, asking for for-
giveness, and focusing on religion to stop worrying about prob-
lems. Negative religious coping (NRC)11 includes wondering
about being abandoned by God, feeling punished by God for
lack of devotion, wondering whether one is being punished by
God, questioning God’s love, wondering whether one’s church
has abandoned them, deciding the devil made the difficulty
happen, and questioning the power of God. Both PRC and NRC
have been related to mental health outcomes, with PRC associ-
ated with better mental health and NRC with poorer mental
health outcomes.11,12 Pargament9 has further reported that pos-
itive religious coping patterns have been tied to benevolent out-
comes, including fewer symptoms of psychological distress, re-
ports of psychological and spiritual growth as a result of the
stressor. PRC has been shown to have an ameliorative effect on
psychological sequelae among patients with varied medical con-
ditions,12-14 with NRC being more strongly related to negative
mental health.15,16
Socioeconomic status, whether measured by income, occupa-
tion, or education, has been shown to be a strong, consistent,
and independent predictor of mental and physical health.17 Re-
ligiousness is often inversely related to education level and in-
come as economically disadvantaged residents, often lacking
other resources to fall back on, often turn to religion to cope.8
Considering the relationship between socioeconomic status and
mental health, and because of the paucity of research on reli-
gious coping among socioeconomically disadvantaged individ-
uals, our study set out to explore the relationship among these
variables. Our hypothesis was that among our study sample,
positive religious coping would have a significant association
with reduced mental health distress and that negative religious
coping would be alternatively associated with increased distress
and poorer mental health outcomes.
METHODS
Participants
The protocol for this study was approved by the Institutional
Review Board (#10-200) of the University of Texas Medical
Branch. The study was explained to patients as they presented
for outpatient psychotherapy at an ambulatory community
medical clinic for low-income and underserved patients. There
were no consequences nor incentives associated with partici-
pants participation in the study. Because the intent was to obtain
a convenience sample of patients presenting for mental health
services, patients were not excluded on the basis of any specific
criteria.
Religious Coping and Mental Health Outcomes
Procedures
The design of this study was cross-sectional. Patients completed
the religious coping measure brief Religious Coping Inventory
(brief-RCOPE),18 and the Short Form-36 (SF-36),19 a measure of
physical and mental health functioning.
Measures
Demographic questions. Several demographic questions were
asked of the respondents, including age, gender, ethnicity, mar-
ital status, religious affiliation and educational and income lev-
els.
The SF-36. The SF-36 is an eight-scale self-report measure de-
signed to assess health concepts representative of basic human
values that are relevant to everyone’s functional status and well-
being.19-21 The SF-36 mental component scale (MCS) is a sum-
mary scale comprising five individual subscale scores (general
health, vitality, social functioning, role– emotional, and mental
health) and has been shown to be a useful measure in the screen-
ing for psychiatric disorders.22 For example, using a cut-off score
of 42, the MCS had a sensitivity of 74% and a specificity of 81%
in detecting patients with depressive disorder.22 The MCS scores
were calculated with the use of an algorithm developed by Ware
et al23 with a linear t-score transformation and a mean score of 50
and standard deviation of 10. The Cronbach’s alpha of the MCS
is 0.90 with well-established validity.19
Brief-RCOPE. The brief-RCOPE18 is a measure developed to
assess an individual’s positive and/or negative religious coping
and consists of two seven-item subscales pertaining to positive
and negative religious coping, respectively. Scores range from
seven to 21 on each scale, with higher numbers indicating the
greater prevalence of that particular type of coping. Cronbach’s
coefficient alpha for the brief-RCOPE has been estimated at 0.87
and 0.69 for both the scales.18
Analysis
Multiple linear regression was used to examine the extent to
which positive and negative coping significantly predict SF-36
MCS scores after controlling for sociodemographic variables
such as gender, ethnicity, marital status, education and income.
RESULTS
The initial sample included 143 patients. Twenty of these pa-
tients reported annual incomes greater than $20,000 and were
removed from the analysis because their incomes were greater
than the federal poverty level at the time the data were collected.
Of the remaining 123 participants, 92 were female. Average age
of subjects was 40 years (SD 11.2). Seventy-eight percent of
subjects reported annual incomes less than $10,000, and the
remainder reported income between $10,000 and $19,000. Sev-
enteen percent of the subjects identified themselves as Hispanic
or Latino, 55% as white or Caucasian, and 26% as black or
African-American. Religious affiliation included 9% (fundamen-
talist Protestant), 34% (Baptist), 20% (Catholic), 6% (mainline
Protestant), and 13% (unaffiliated), with 17% reporting as “other
Christian.” The remaining 1% included Buddhists, agnostics, or
persons with no identified religious affiliation.
EXPLORE May/June 2012, Vol. 8, No. 3 173
Table 1. Descriptive Statistics
Mean SD
MCS 29.79 11.32
Positive religious coping 19.52 5.51
Negative religious coping 11.21 4.10
MCS, mental component scale.
From our study sample, the mean score on the SF-36 MCS
was 29.79 (Table 1). This mean score falls two standard devia-
tions below the normative mean, suggesting that our sample was
significantly distressed, ie, reporting a high number of negative
emotional and psychological symptoms. The values for the pos-
itive and negative RCOPE scales can also be found in Table 2.
The patients in our study reported, on average, more positive
religious coping behaviors than they did negative. However,
there is a substantial mix of both positive and negative religious
coping behaviors recorded.
Multiple linear regression showed demographic variables
(gender, ethnicity, marital status, education, and income) having
virtually no effect on explained variance on MCS scores (R2 ⫽
.01, P ⫽ .95). A full model, however, indicated that, after we
controlled for the demographic variables, positive and negative
religious coping as predictor variables explained a significant
amount of variance in MCS scores (dependent variable; R2 ⫽
13.8, P ⫽ .025). The negative relationship of negative religious
coping with mental health status was stronger (b ⫽ ⫺0.83, P ⬍
.001) than the positive relationship on mental health of positive
coping (b ⫽ 0.44, P ⫽ .03) (Table 2).
DISCUSSION
The relationship between negative religious coping and MCS
scores suggests that those with negative religious behaviors or
cognitions, such as feelings of being abandoned or punished by
God or their church, or questioning God’s love or devotion, may
have poorer mental health outcomes. Conversely, the relation-
ship between positive religious coping and MCS scores suggest
that those who look to God for strength and love may have
better mental health. These findings parallel those from other
published reports that have shown religious coping to be asso-
ciated with mental health outcomes in moderate- to high-in-
come populations.1,6,24,25
As with most cross-sectional studies, these results must be
interpreted with some caution. We are unable to shed light on
the duration of such effects, whether they are short-lived or
long-lasting. It is possible, for example, that feeling punished by
God or feeling anger towards God may manifest in an en-
trenched outlook or persistent psychological deterioration.9 For
example, in a recent longitudinal study of Orthodox Jews, neg-
ative religious coping appeared to precede and perhaps cause
future depression.26 On the other hand, negative religious cop-
ing, although related to negative mental health at one point in
time, may eventually lead to more positive mental health out-
comes. Theoretically, a patient may, in the acute phase of deal-
ing with a crisis or coping with a significant stressor, resort to
questioning self, one’s faith/beliefs, blaming God, etc., but such
critical examination and questioning of one’s values may ulti-
mately lead to a deepening of faith and reliance on more result in
positive religious coping in the future.
Pargament et al18 have argued that negative religious coping
may be “relatively harmful to some people, inconsequential to
others, and a source of growth to still others.” They further assert
that for some individuals, struggles with religious pain, conflict,
and the consequent distress may serve as a precursor or catalyst
for later personal growth. This concept relates to what Anton-
ovsky27 calls “salutogenesis,” meaning that negative coping in
this case may not be simply the other side of the coin but rather
a dynamic, multifactorial process.9 Just as health and disease are
not mutually exclusive or dichotomous concepts, but rather
overlap and fall along a continuum, negative and positive reli-
gious coping might similarly follow a continuous path.
Further research is needed to examine how the relationship
between religious coping and mental health plays out over time.
As noted previously, the predictive power of a cross-sectional
study is by nature limited. A future pre-post or longitudinal
study would better assess the relationship between distress and
religious coping.
Another interpretation of the possible consequences of nega-
tive religious coping could be that indigent patients’ religious
orientations serve to resonate with and validate their socioeco-
nomic circumstances, thus keeping them from searching to es-
cape from a cycle of relative poverty. Further studies of a cohort
of these persons over time would not only contribute to our

Table 2. Effects on Mental Component Scale

95% Confidence Interval
b Std Error t P Value Lower Upper
Gender 1.13 2.43 0.47 0.64 ⫺3.68 5.94
Ethnic background ⫺0.92 1.53 ⫺0.60 0.55 ⫺3.96 2.11
Marital status ⫺0.35 0.46 ⫺0.75 0.45 ⫺1.26 0.57
Educational level ⫺0.81 1.17 ⫺0.69 0.49 ⫺3.13 1.51
Annual income 0.07 2.16 0.03 0.97 ⫺4.22 4.36
Positive religious coping 0.44 0.20 2.22 0.03 0.05 0.83
Negative religious coping ⫺0.83 0.26 ⫺3.19 0.00 ⫺1.35 ⫺0.32

174 EXPLORE May/June 2012, Vol. 8, No. 3 Religious Coping and Mental Health Outcomes
understanding of religious coping and mental health but also to
our understanding of how various types of religious coping in-
fluence either an acceptance of one’s social status or a quest for
greater mental and socioeconomic well-being.
Individuals in underserved populations tend to use religious
counseling (and coping) in lieu of mental health treatment be-
cause it is available and usually without cost, whereas the stigma
of emotional illness often leads these individuals to avoid treat-
ment. The significantly distressed patients in this sample may be
self-selecting in that (1) they are more skeptical of the limits/
limitations of religious coping in assuaging acute distress, and/or
(2) more open to the potential synergistic benefits of both reli-
gious coping and psychological help. One interesting but unan-
swered question from this study is whether individuals with
NRC or PRC are more likely to seek mental health treatment.
IMPLICATIONS AND CONCLUSIONS
The findings from this study have important implications for
economically disadvantaged patients who use religious coping as
a primary strategy for dealing with and managing multiple stres-
sors, including those related to mental health issues. Several
notable psychologists have historically argued that religion can
be a source of meaning and stability in an uncertain world and
conducive to positive mental health.28,29 The “world” can truly
be “uncertain” for low-income patients, who often struggle to
find their way facing many challenges (eg, transportation,
healthcare, shelter, comorbid psychiatric/and physical health
diagnoses). Religious coping and the translation of internal be-
liefs and cognitions into practice may serve as an important
theological boat upon which patients navigate the waves of un-
certainty.
Since the clarion call and challenge to traditional biomedicine
in the 1970s by noted psychiatrist, George Engel, his integrative
model of biopsychosocial (BPS) medicine has become increas-
ingly relevant.30 Sulmasy,31 among others, has extended the BPS
to include spiritual dimensions to the integrative framework for
understanding and treating the “whole” person. In contempo-
rary medical training, medical schools and residencies across the
United States routinely include the BPS model in training stu-
dents. The spiritual aspect of the BPS model has lagged some-
what but is gaining momentum and credibility in the medical
training environment. For example, in 1994, only 17 of 126
accredited U.S. medical schools offered courses on spirituality
and medicine. By 2004, this number had increased to 84, well
over half of schools.32
The core concept here is that there is a reciprocal relationship
between an individual’s mental and spiritual health. A patient
who is actively using religious cognitions, beliefs, and practices is
very likely to negatively or positively affect his/her mental
health. If those who care for socioeconomically disadvantaged
patients become informed about the presence of negative and/or
positive religious coping behaviors and thought patterns among
their patients, they might facilitate discussion around these is-
sues as they relate to health.
Puchalski33 has written about the importance of healthcare
professionals recognizing and addressing the spiritual dimen-
sion in patient care. In fact, patients surveyed in this country
Religious Coping and Mental Health Outcomes
have indicated that their religion and spirituality are important
parts of their lives and that their spiritual faith can help them
recover from illness.33,34 Patients have also indicated that they
feel doctors should address spiritual issues as a part of their
medical care.35 Yet, ⬍10% of doctors ask about or discuss these
important aspects relevant to patient well-being, coping, and
ultimately mental health.35 Obviously, addressing religious
beliefs and practices is a delicate matter. Regardless of the
setting, providers must avoid being prescriptive, providing
interpretation regarding specific beliefs/practices, and trying
to give authoritative answers to existential questions. Com-
plex spiritual suffering and difficulties can appropriately be
referred to a religious/spiritual counselor, pastor, or other
faith leader as the patient deems appropriate. Providers can
and should recognize the religious/spiritual resources that are
already present in the patients they treat and support them in
examination/exploration of these as they relate to positive
health and mental health outcomes. This study indicates that
the use of religious coping as a component of overall mental
health is as valid and meaningful for low income and under-
served patients as it has been shown to be for individuals with
greater economic resources.
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