1. Taking both secular, spiritual and religious meaning making seriously RESEARCH IN FAITH AND HEALTH IN SECULAR SOCIETY May 18 th 2010 University of Southern Denmark Peter la Cour Multidisciplinary Pain Center, National Hospital, Copenhagen Niels Christian Hvidt Health, Man, and Society University of Southern Denmark

2. Trends in medical care, where more focus is laid on patient centered care and on prevention, lifestyle and chronic conditions - issues all linked to an overall attitude toward life. Contemporary medical research focuses on the need for taking existential, spiritual and religious issues much more serious, even in Denmark – the “least religious nation” in the world (Zuckerman)

3. How to make research? Theory and research in this field have been divided in two major traditions The existential psychology (theology/philosophy) tradition This is mainly rooted in European tradition. Although the tradition is very broad (and has many American thinkers) it is mainly centered on meaning making strategies that do not include belief in any transcendent reality. There are both theistic and atheistic versions of the existential psychology, but usually the tradition is founded on concepts of secular nature (meaning, worth of life, values, freedom, responsibility, loneliness etc). These concepts are seen to potentially include the spiritual and religious, but they are neither elaborative nor concise in these domains. Often linked to qualitative methods (phenomenology) “Who needs the concept of ‘spirituality?’” - provocative title of a Letter to the Editor of Psycho-Onchology, published by professor Pär Salander (2006) from Lund University, Sweden.

4. How to make research? Theory and research in this field have been divided in two major traditions Religious/spiritual coping tradition The (almost exclusive) American theories and research on religious coping and the development and debates about useful concepts in this research. For some years a debate about the concepts of “religiosity” versus “spirituality” has been going on. These concepts and this debate are only relevant in ery religious societies, where it can be supposed that the vast majority of medical patients can relate to either spirituality or religiosity. This is not that case in modern secular countries like in Northern Europe (especially Scandinavia) where only minorities can be called spiritual or religious in a traditional meaning of the words. Often linked to quantitative methods (social science) “Who needs the concept of spirituality? Human beings seem to” William Breitbart, published in Palliative and Supportive Care, (2007)

5. Religion and health research Examples: Religious problem solving (Pargament). Three first questions in the main religious coping questionnaire: 1. When I have a problem, I talk to God about it and together we decide what it means. 2. Rather than trying to come up with the right solution to a problem myself, I let God decide how to deal with it. 3. When faced with trouble, I deal with my feelings without God's help. We can not ask this way, when people have no thought of God in the first place…

6. Reality is multilayered The split between the academic traditions is artificial and counterproductive Coping with medical conditions is about coping with meaning making. Real patients think both in secular, spiritual and religious existential terms. Their understandings maybe melted together, maybe situated at different places, maybe separated at different times of their lives. Reality is multilayered, and investigation, theory and research should basically reflect this multilayered reality, or at least try not to exclude other tangled dimensions, when focusing on one. The need for more consensus in concepts are obvious

7. Simplistic understanding of coping Coping (while under current stress) Bad result Good result This model is not working…

8. The general problem: When are life events good? a) Immediately he feels relief, but do not see the children very often b) Half year later he feels rather lonely c) One year after he gets a depression and can not work for a year d) Five years later he marries a new woman and feels very happy for many years, but has no kids with her e) Twenty years later he has grand-children from first marriage, but no contact with them f) When old, he bitterly regrets that he had nor been present for his children and grandchildren g) The day he dies he thinks about the missing contact to children and grandchildren Was it good or bad coping with the divorce? A man is divorced (after long time quarrels with wife about children) …and he copes with it

9. Meaning making and illness - general theory of coping with personal crisis 1.World view as a personal ressource 2.World views as a current coping strategy 3.World view as outcome / (posttraumatic growth) The person before crisis The person during crisis The person after crisis

10. Conceptual work is troublesome It includes at least two un-answareable questions: 1. What is the meaning of the words: Religion, spirituality, and existential orientation? 2. How can the endless numbers of expressions and dimensions of meaning making be captured in research? - Well, we have made a try……

11. Materials at work 1.For the domains of meaning making: - systematic reviews of definitions of the three conceptual domains or layers 2. For the dimensions of meaning making: - analysis of previous systematic suggestions for categorizing dimensions We do not propose either clear-cut borders or specific definitions connected to the model, but merely want to draw a possible frame for theory and research with the purpose to be more aware of own status and limitations.

12. Premisis: All three existential domains are valid and cannot be reduced to one another. There are great areas of overlay Phenomena placed in the middle might be pure experience Phenomena placed at the sides might be pure contextual (cultural)

13. Example 1. The enchanting feeling of “being alive when looking up on the stars in a clear night” - can be placed in the middle - every elaboration in words or deeds are drawing to a side (cultural elaborated as existential, spiritual, religious)

14. Example 2. “What happens after personal death” -is usually elaborated in all three domains. -It is not one question, it is three Secular – sorrow, history Spiritual – consciousness Religious - justification

15. Example 3. There is no “non-belief” without a specific notion of, what is not believed in The opposite of any meaning making belief would be “meaning making ignorance” – because there is never “meaning making knowledge” This is the premises for taken the domains serious

16. What are the meaning of the Meaning Making conceptual domains? Systematic reviews of definitions of the three conceptual domains 1. Selecting and grouping definitions 2. Organize definitions into nodes and themes 3. Ranking definitions, finding endpoints of definition continua

17. Definitions of secular existential orientations Dimension: From subjective constructivist viewpoints over reflections over collective conditions to inherent meaning Interest in the abstract sense of identity, meaning, value, and purpose … a trend toward consideration of existential themes… Pyszcynski, et al. 2004 There is not one space and time only, but as many spaces and times as there are subjects.Binswanger 1956 (p196) A philosophy that confronts the human situation in its totality to ask what the basic conditions of human existence are and how man can establish his own meaning out of these conditions. Barrett, 1959 A conflict that flows from the individual’s confrontation with the givens of existence.Yalom, 1980 (p 8) Death, freedom, existential isolation, and meaninglessness. These are deep, potential terrifying issues, and consequently, people typically avoid direct confrontation with them. Yalom in: Pyszcynski, T. et al, 2004 How do people cope with their understanding of their place in the universe? Often, this amounts to the study of how people shield themselves from their knowledge of their mortality, their uncertainty, their isolation, and their deficits of meaning. Pyszcynski, T. et al 2004 QUEST “These persons view religion as an endless process of probing and questioning generated by the tensions, contradictions, and tragedies in their own lives and in society. Not necessarily aligned with any formal religious institution or creed, they are continually raising ultimate “whys”’ about the existing social structure and about the structure of life itself. Batson, 1976, (p 32) Ultimately, man should not ask what the meaning of his life is, but rather must recognize that it is he who is asked. In a word, each man is questioned by life; and he can only answer to life by answering for his own life; to life he can only respond by being responsible. Frankl, Viktor, 1963. (p 172) The meaning of our existence is not invented by ourselves, but rather detected. Frankl, Viktor 1963, (p157)

18. Definitions of spirituality Dimension: From evolved humanistic values over striving for an inner truth to contact with the transcendent..gives expression to the being that is in us; it has to do with feelings, with the power that comes from within, with knowing our deepest selves and what is sacred to us. Roof, 1993 The search for existential meaning. Doyle 1992 ( p. 302) Conspicuously in today’s spirituality is the frequent absence of an explicit transcendent object outside of the self Wulff, 1997 ( p 5) The way one lives out one's faith in daily life, the way a person relates to the ultimate conditions of existence. Hart, 1994 (p. 23) Process of inner change and development, metaphorical described as: Awakening, de-hypnosis, enlightenment, freedom, metamorphosis, and wholeness Walsh, 1999 Spirituality – the domain of life beyond the body and mind Levin, 2001 Striving to experience the spiritual source of one’s own existence Fontana, 2003 Belief in a superhuman reality. Distinction between sacred and mundane. Belief in afterlife. Moral code. Promotion of inner harmony Fontana, 2003 A way of being and experiencing that comes about through awareness of a transcendent dimension and that is characterized by certain identifiable values in regard to self, life, and whatever one considers to be the Ultimate. Elkins et al, 1988 (p. 10): A transcendent dimension within human experience... discovered in moments in which the individual questions the meaning of personal existence and attempts to place the self within a broader ontological context. Shafranske and Gorsuch, 1984 (p. 231): That vast realm of human potential dealing with ultimate purposes, with higher entities, with God, with love, with compassion, with purpose. Tart 1975 (p. 4) The presence of a relationship with a Higher Power that affects the way in which one operates in the world. Armstrong,1995 (p. 3) That which is involved in contacting the divine within the Self or self. Fahlberg and Fahlberg,1991 (p. 274) A subjective experience of the sacred. Vaughan, 1991 (p. 105) The human response to God's gracious call to a relationship with himself. Benner, 1989 (p. 20)

19. Definitions of religion Dimension from collective construction of meaning, over individuals meeting the transcendent to relation between man and God A system of believes in divine or superhuman power, and practices of worship or other rituals directed towards such power. Argyle, 1975 (p. 1) Beliefs and behaviours about: Spiritual reality, God, morality, purpose and the communication of these Loewenthal, 2000 Religion is the serious and social attitude of individuals or communities toward the power or powers which they conceive as having ultimate control over their interests and destinies Pratt, 1930 Religion – referring to beliefs, practices and experiences pertaining to organized religions or belief systems Levin, 2001 Religion is a unified system of beliefs and practices relative to sacred things that is to say, things set apart and forbidden – beliefs and practices which unite into one single moral community called a Church, all those who adhere to them. Durkheim, 1912 A covenant faith community with teachings and narratives that enhance the search for the sacred. Dollahite, 1998 (p. 5) Commitments to beliefs and practices characteristic of particular traditions. Peteet, 1994 (p. 2): Systems of belief in and response to the divine, including the sacred books, taltic rituals, and ethical practices of the adherents. O'Collins and Farrugia, 1991 (p. 203): Human recognition of superhuman controlling power, and especially of a personal god or gods entitled to obedience and worship. Oxford English Dictionary...what people normally understand by religious behavior and religious belief… always implicit, never explicit Grensted, 1952 The representations, behavior and experiences that in man refers to any form of extrasensory and metaphysical reality. Holm, 1993 …whatever we as individuals do to come to grips personally with the questions that confront us because we are aware that we and others like us are alive and that we will die. Such questions we shall call existential questions. Batson 1993 (p 8) …the feelings, acts, and experiences of individual men in their solitude, so far as they apprehend themselves to stand in relation to whatever they may consider the divine. James, 1902 (p 36)..a careful consideration and observation of certain dynamic factors that are regarded as ”powers”: Spirits, demons, gods, laws, ideas, ideals or what name man has given such factors in the world, which he has found powerful, dangerous or helpful enough to be contemplated thoroughly, or vast, beautiful or meaningful enough to be attentively worshiped or loved. Jung, 1938 Religion is the state of being grasped by an ultimate concern, a concern which qualifies all other concerns as preliminary and which itself contains the answer to the question of a meaning of our life. Tillich, 196 (p.4) A set of symbolic forms and acts that relate man to the ultimate conditions of his existence. Bellah 1970 (p. 21) The relationship between man and the superhuman power he believes in and feels himself to be dependent on…the theme of religion is redemption from the powers that prevent man from communing with the divine. Schoeps, 1959 The inner experience of the individual when he senses a Beyond, especially as evidenced by the effect of this experience on his behaviour when he actively attempts to harmonize his life with the Beyond. Clark, 1958 (p. 22) Religion is the connection between man and God Levin, 2001

20. The common continua: - all three domains of definitions have the same movement from constructivist (all human centred) definitions to definitions centred on the other, whether this is nature, the transcendent, or a personal God being the defining substance.

21. AGAIN: The two questions: 1.For the domains of meaning making: - systematic reviews of definitions of the three conceptual domains or layers Perspective: We can talk meaningful of existential orientation, spirituality and religiosity, when we (always) do a notion of how this is meant (in relation to other understandings). 2. For the dimensions of meaning making: - analysis of previous systematic suggestions for categorizing dimensions of expressed meaning making

22. Question 2. The dimensions Organising the many expressions of “meaning making” into dimensions - many efforts have been made before Most prominent examples: 1.”Measures of Religiousity ” (Hill & Hood, 1997): 17 dimensions 2. Fetzer/NIA group (1999) (religion broad): 12 dimensions Affiliation Beliefs and values Public practices Private practices Spiritual experience Religious intensity Meaning History Support Coping Commitment Forgiveness

23. 3. Hall, Meador & Koenig (2008) (religion even broader): 23 dimensions listed Religious values Religious beliefs/creedal assent/concepts of God Religious knowledge Non-belief (denial of religion) Certainty – orthodoxy – fundamentalism Quest – doubts - seeking Religious views on afterlife Divine intervention Organised activity/participation/attendance Organisation involvement/- membership/activity Study/discussion/prayer in groups Ritual participation Private reading/prayer/devotionalism/non- organised religiosity Religious television/radio/internet Religious experience Salience/selfrated religiosity Intrinsic/extrinsic orientation Financial support Religious wellbeing Coping possibilities/support History Development/maturity Attitudes/consequence of attitudes

24. Existential orientation dimensions Jacobsen (1998): 11 dimensions (values) Work Economy Family good experiences Society Religion Health Inner harmony Intellectual improvement Helping others Dignity McCracken and Yang 2008 (ACT existential values): 6 dimensions Family Intimate relations Friends Work Health Growth and learning Religious + existential dimensions: All to many!

25. Our suggestion for conceptual coherence (The Grid) Meaning making Knowing: Cognitions Doing: Practice Being: Importance Secular existential orientation Spirituality Religiosity Dimensions Domains

26. Final model: Hall et all.’s dimensions distibuted into the grid Meaning making Knowing: Cognitions Doing: Practice Being: Importance Secular existential orientation Existential values Existential beliefs/concepts Existential knowledge Organisation/membership Certainty/orthodoxy/fundamentalism Quest – doubts – seeking Existential views on after-life Intervention by higher principles Organised activity/participation/attendance Organisation involvement/-membership/activity Study/discussion/activity in groups “Ritual” participation Private reading Existential television/radio/internet Salience/selfrated commitment Existential experience Intrinsic/extrinsic orientation Financial support Existential wellbeing Coping possibilities/support History Development/maturity Attitudes/consequence of attitudes Spirituality Spiritual values Spiritual beliefs/concepts Spiritual knowledge Organisation/membership Certainty – orthodoxy – fundamentalism Quest – doubts - seeking Spiritual views on afterlife Spiritual intervention Organised activity/participation/attendance Organisation involvement/-membership/activity Study/discussion/meditation/prayer in groups Ritual participation Private reading/prayer/meditation/mysticism Spiritual television/radio/internet Salience/selfrated spirituality Spiritual experience Intrinsic/extrinsic orientation Financial support Spiritual wellbeing Coping possibilities/support History Development/maturity Attitudes/consequence of attitudes Religiosity Religious values Religious beliefs/creedal assent/concepts of God Religious knowledge Non-belief (denial of religion) Certainty – orthodoxy – fundamentalism Quest – doubts - seeking Religious views on afterlife Divine intervention Organised activity/participation/attendance Organisation involvement/-membership/activity Study/discussion/prayer in groups Ritual participation Private reading/prayer/devotionalism/non- organised religiosity Religious television/radio/internet Salience/selfrated religiosity Religious experience Intrinsic/extrinsic orientation Financial support Religious wellbeing Coping possibilities/support History Development/maturity Attitudes/consequence of attitudes

27. Examples Meaning making Knowing: Cognitions Doing: Practice Being: Importance Secular existential orientation Hard core enviromentalist Work hours at GreenPeace and time spent in nature Essential to identity, able to provide meaning during illness Spirituality ”Think positive”- person Time in meditation Obtaining personal strength during daily life Religiosity MuslimRamadan, daily prayers Belonging to the muslim brotherhood/com munity

28. Examples of questions on meaning making and illness relating to the structure of the conceptual grid Meaning making Knowing: Cognitions Doing: Practice Being: Importance Secular existential orientation To what extent do you find life meaningful even in the condition of pain? How and why - or why not? During your illness, to what extent are you able to do the activities that you value most in life? Are there obstacles to spend time with the activities you really value? To what extent are you trying to live our life according to your ideals – even during this period of pain? Does these ideals still provide meaning for you? Spirituality During your illness, to what extent are your thoughts of life governed by energies or forces greater than you? How do you understand or reject such principles? After being ill, do you have a greater need to confirm your being-in-the- universe, for example by meditation, listening to music or being alone in nature? Do you spend time in such activities? If you consider you have a spiritual side, how important does such such spirituality seem to be during this period of crisis? Do you obtain any personal comfort or strength from these dimensions of life? Religiosity Has suffering from illness influenced the way you think about religious issues? If any, on which issues have you grown less certain and on which issues have you grown more certain? While being ill, have you felt a greater need to attend church, to pray or to read religious scriptures? Have you actually changed your time spent in such activities? If you have any religious elements in your worldview, to what extent can this strengthen or weaken your ability to go through this period of illness? If any, what elements of religion are particularly important for you in this situation?

29. www.tro-helbred.org

30. Perspectives - This is an attempt to contextualize research and theory - We do not propose either clear-cut borders or specific definitions connected to the model, but merely want to draw a possible frame for theory and research with the purpose to be more aware of own status and limitations. www.tro-helbred.org

31. Our suggestion for conceptual coherence (The Grid) Meaning making Knowing: Cognitions Doing: Practice Being: Importance Secular existential orientation Spirituality Religiosity Dimensions Domains