Pain Medicine 2010; 11: 765–773
Wiley Periodicals, Inc.
PSYCHOLOGY, PSYCHIATRY & BRAIN
NEUROSCIENCE SECTION
Brief Research Report
God Image and Happiness in Chronic
Pain Patients: The Mediating Role of
Disease Interpretation
pme_827
765..773
Jessie Dezutter, dra,* Koen Luyckx, PhD,†
Hanneke Schaap-Jonker, Prof PhD,‡§
Arndt Büssing, Prof PhD,¶ Jozef Corveleyn,
Prof PhD,†§ and Dirk Hutsebaut, Prof PhD†
*Department of Psychology,
†
Psychology, Catholic University of Leuven, Leuven,
Belgium;
‡
Protestant Theological University, Kampen;
§
Educational studies, Free University of Amsterdam,
Amsterdam, The Netherlands;
¶
Medical Department, University of Witten/Herdecke,
Witten, Germany
Reprint requests to: Jessie Dezutter, dra, Department
of Psychology, Catholic University of Leuven,
Tiensestraat 102 postbox 3715, 3000 Leuven,
Belgium. Tel: 3216326127; Fax: 3216326144; E-mail:
[email protected].
all members of a national patients’ association,
completed the questionnaires.
Results. Correlational analyses showed meaningful
associations among God images, disease interpretation, and happiness. Path analyses from a structural equation modeling approach indicated that
positive God images seemed to influence happiness, both directly and indirectly through the
pathway of positive interpretation of the disease.
Ancillary analyses showed that the negative influence of angry God images on happiness disappeared after controlling for pain severity.
Conclusion. The results indicated that one’s emotional experience of God has an influence on happiness in CP patients, both directly and indirectly
through the pathway of positive disease interpretation. These findings can be framed within the transactional theory of stress and can stimulate further
pain research investigating the possible effects of
religion in the adaptation to CP.
Key Words. Quality of Life; Psychosocial Factors;
Psychology; Chronic Pain
Introduction
Abstract
Objective. The present study explored the role of
the emotional experience of God (i.e., positive and
negative God images) in the happiness of chronic
pain (CP) patients. Framed in the transactional
model of stress, we tested a model in which God
images would influence happiness partially through
its influence on disease interpretation as a mediating mechanism. We expected God images to have
both a direct and an indirect (through the interpretation of disease) effect on happiness.
Design. A cross-sectional questionnaire design
was adopted in order to measure demographics,
pain condition, God images, disease interpretation,
and happiness. One hundred thirty-six CP patients,
A recent study revealed that nearly one in five Europeans
suffer from chronic pain (CP) [1]. This pain condition has a
devastating impact on both the individual and the society,
leaving individuals depressed, unable to function properly
in daily life, and frequently held back in their work [1].
Despite this detrimental influence of CP on the quality of
life, very few studies exist on the role of psychosocial
factors, and especially religion, on individuals’ adjustment
to CP. However, the few existing studies indicate that
religion might indeed influence the well-being of CP
patients by, for example, mitigating stress or offering tools
for coping [2–5]. Because CP impacts heavily on the lives
of individuals, and because religion seems to play an
important role for these patients, further research in this
field is warranted. Consequently, we investigated how the
experience of God (i.e., God images) influenced the
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Dezutter et al.
well-being of CP patients. Further, we explored one possible underlying mechanism explaining this relationship,
that is, positive disease interpretation.
Religion: A Mitigating Role in the Confrontation
with CP?
Some researchers suggested that aspects of religion
may mitigate or buffer the negative consequences of
stressors on well-being [6,7]. This idea is inspired by the
transactional model of stress in which adjustment is
viewed as a dynamic and active process [8]. During this
process, individuals try to cope with various life demands
by using cognitive appraisals and by relying on certain
coping strategies. Within this view, the function of religion in the appraisal of events can be twofold. On the
one hand, it can influence the primary appraisals of
stressful events (i.e., evaluating the situation as harmful,
threatening, or challenging, such as evaluating the illness
as part of a broader divine plan). On the other hand,
religion can influence the secondary appraisals of stressful events (i.e., evaluating one’s abilities to handle the
situation, such as feeling supported by God to cope with
pain). In addition, religion can also provide specific tools
of coping behavior such as prayer. Park and Folkman [9]
elaborated further on the stress and coping framework
by emphasizing the process of meaning making when
confronted with a stressful life demand. They stated that
religion can be seen as a global meaning system which
can provide meaning to a stressor at several levels (i.e.,
personal significance, causal explanation, coping). Gall
and colleagues [10] used the basic tenets and the structural components of the transactional model as a framework for the integration of the research on spirituality and
health.
Although the role of religion in appraisal and coping with
CP is a valuable and interesting approach, studies implementing this perspective in pain research remain scarce
(see [11], for a theoretical argumentation). Despite this
paucity in research, we hypothesize that enduring pain
could evoke existential reflections concerning the
meaning and purpose of life, and could trigger the religious meaning system of CP patients. However, the small
amount of studies investigating the relation between religiosity and well-being in CP populations mainly focuses
on religious/spiritual coping with pain [12,13]. These
studies seem to indicate that religious coping is indeed
important for CP patients. For example, Keefe and colleagues [14] found that in a sample of rheumatoid arthritis
patients, the use of religious coping methods was associated with positive mood. Abraido-Lanza, Vasquez, and
Echeverria [15] revealed a direct effect of religious coping
on the psychological well-being of patients with arthritis.
Framing these studies in the transactional model of
stress, religion is operationalized in terms of religious
coping and, hence, as a possible type of coping behavior.
However, no attention is paid to aspects of religion that
can play a role in the appraisal of a chronic stressor such
as long lasting pain.
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Affective Aspect of Religion: God Image
Religion is a multidimensional concept and encompasses
cognitive, emotional, behavioral, and motivational
aspects, with each of these aspects relating differently to
well-being [16]. The main focus in research studying the
association between religion and well-being is on religious
behavior and religious attitudes [17]. However, the aspect
of God representation is an underinvestigated but valuable
aspect of religion and focuses on how the individual experiences God. In line with Rizotto’s earlier work [18] on God
representations, recent research [19,20] pointed out that,
besides a cognitive and intellectual understanding of God
(labeled God concept), people also have an emotional and
personal experience of God (labeled God images).
The spiritual framework of coping [10] pays attention to
the spiritual connection with a transcendent other (God)
and its role in the coping process. Indeed, recent studies
already pointed out that these God representations play a
role in coping with stress. For instance, Gall [21] revealed
that in a sample of breast cancer patients, a benevolent
God concept was associated with less psychological distress, whereas a negative God concept was related to
more emotional distress [22]. Further, Pargament and colleagues [23] found that individuals’ attributions of negative
life events to a punishing or angry God resulted in poorer
psychological outcomes. Some recent studies [24;
Schaap-Jonker H, Eurelings-Bontekoe E, Zock H, Jonker
E, Corveleyn J, unpublished data] stated that negative
God images were associated with high levels of psychological distress and negative affect, whereas positive God
images (POS GI) were associated with positive affect in
community samples.
Based on these research results, we hypothesize that God
images, being an essential aspect of the religious meaning
system, will influence the lives of individuals, by providing
possible anchors for appraisal and coping behavior. In line
with Gall and colleagues [10], we assume that the relationship with God can fulfill several functions such as provision
of comfort, a sense of belonging, empowerment, and
control. Furthermore, framed in the transactional theory of
stress, we assumed that the positive interpretation of a
disease might be a valuable mediator in the relationship
between God images and well-being. The presence of
POS GI may offer a deepened sense of coherence and
comprehensibility of reality and enhance the creation of
meaning [10,25]. Indeed, the experience of enduring pain
can have significance before an omniscient divinity and
therefore gain significance for the patient as well. Thus, the
God images can contribute to a sense of meaningfulness,
which can be expected to have a significant effect on
well-being [26]. For CP patients, this might be concretized
in the reframing or reinterpretation of their pain and disease
experience. Relatedly, Park and Cohen [27] found that
individuals who attributed negative life events (i.e., the
death of a close friend) to a loving God, were more likely to
report higher positive reinterpretation coping and, subsequently, higher personal growth. In line with this, Maton [28]
suggested that the use of spiritual support (for example,
God Image and Happiness in CP Patients
offered by the presence of a benevolent God image) can
influence well-being through enhancing positive, adaptive
appraisals of a traumatic event.
The Purpose of This Study
The present study explored the role of God images for the
happiness of CP patients. Happiness can be defined as the
positive affective aspect of subjective well-being [29].
Studies showed that positive affects are important for CP
patients because they seem to foster resilience when pain
is high [30]. Therefore, we tested a model in which God
images would influence happiness partially through its
influence on disease interpretation as a mediating mechanism. We expected the God images to have both a direct
and an indirect (through the interpretation of disease) effect
on happiness. The direct relations between God images
and happiness for CP patients were predicted as follows:
we expected 1) positive associations between POS GI and
happiness; and 2) negative associations between negative
God images and happiness. In terms of the indirect effect of
God images on happiness, we predicted that 3) POS GI
would be related to higher levels of positive interpretation of
disease and, subsequently, to higher levels of happiness;
whereas 4) negative God images would be related to lower
levels of positive interpretation of disease and, subsequently, to lower levels of happiness.
Protestant Christians, spiritual seekers). The religious
profile of the sample was representative for the Belgian
population.1
Instruments
Religiosity
Church attendance (“how often do you go to church”;
1 = never, 5 = several times a week) and Denomination
(“what kind of denomination do you have?”) were measured with a single item. Church attendance and Denomination were only assessed for the purpose of sample
description. In addition, participants filled out the Dutch
Questionnaire of God Images (QGI; [31]). The scale covers
both an affective component and a more cognitive component. The affective component is used in this study and
consists of three scales namely a positive emotional experience of God (e.g, closeness, security), a subscale focusing on anxiety in the experience of God (e.g., uncertainty),
and a subscale focusing on angry feelings when interacting with God (e.g., anger, dissatisfaction). Participants
rated the 17 descriptors of the QGI on a 5-point Likert
scale ranging from 1 (totally not descriptive) to 5 (totally
descriptive). Estimates of internal consistency (Cronbach’s alpha) were 0.98 for the positive subscale, 0.89 for
the anxiety subscale, and 0.86 for the anger subscale.2
Happiness
Method
Participants
The sample consisted of CP patients who are members of
a national patients’ association. The study was part of an
ongoing collaboration between the Center for the Psychology of Religion and two patient associations (i.e., the
Flemish Pain League and the Ray of Hope association).
The board of the patient associations distributed 250
questionnaires by mail to their members. One hundred
thirty-six patients filled out the entire questionnaire. Selection criterion of at least 6 months pain duration was
reached by all participants. Anonymity was guaranteed
and participants were informed that the return of the completed questionnaire indicated informed consent.
The majority of the sample was female (72%) and age
ranged from 22 years to 83 years (M = 51.34, standard
deviation [SD] = 10.96). The marital status was single for
21% of the participants, married for 63%, cohabiting for
9%, widowed for 3%, and divorced for 4%. The highest
educational level was primary school for 8.1%, secondary
school for 50.7%, and higher education for 41.1% of the
sample. Mean pain duration was 16 years (SD = 11.03,
range 2–60). Level of church attendance was weekly for
11% of the participants, monthly for 11%, on special
occasions for 41%, and never for 36%. The majority of the
participants were Catholics (31%), 24% were Christians
without affiliation with the Catholic church, 22% were
believers without any church affiliation, 14% were unbelievers, 4% were agnostics, and 5% were others (e.g.,
The 8-item Oxford Happiness Questionnaire [32] was
administered. Items were rated on a 6-point scale
(1 = strongly disagree, 6 = strongly agree). The scale measures the affective aspect of subjective well-being (e.g., “I
feel that life is very rewarding”). Cronbach’s alpha of the
scale was 0.71.
Pain
Besides pain duration (“since how long do you suffer from
pain”), pain intensity was measured with three questions
(“what is the level of pain at this moment,” “what was the
highest pain level last week,” and “what was the lowest
pain level last week;” [12]). A composite pain index was
obtained through calculating the mean of these items.
Cronbach’s alpha of the three items was 0.83.
1
Data from the European Value Study [52] showed that in a
Flemish sample of believers (N = 1,049), 91.1% were Christians,
0.2% Jewish, 4.8% Muslim, 0% Hindu, 0% Buddhist, 0.6% Orthodox, and 3.4% other. Belgium is a secularized country with a strong
Catholic history. Most Belgians denote themselves as Catholic or
as Christian, although active participation and involvement is low.
2
Although some participants denoted themselves as unbelievers
or agnostics, almost all participants (except five) filled out the
Questionnaire God Image. Due to the small size of this group,
these participants are kept out of the analyses. Analyses are thus
performed on the group of participants who filled out the entire
questionnaire (N = 136). We assume that the remaining part of
unbelievers/agnostics who filled out the questionnaire based
themselves on culturally constructed God images formed by
socialization processes.
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Measurement Model
The intervening role of positive interpretation of
disease in the relationship between God images and
happiness was examined by means of structural equation modeling using LISREL 8.54 [35] on latent variables.
These latent constructs were modeled based on the
items from the respective scales. Because gender, age,
and educational level were not systematically related
with happiness or disease interpretation, they were not
included in the model. To evaluate model fit, we
768
—
0.44***
—
-0.01
-0.09
—
0.51***
-0.19*
-0.20*
—
-0.06
0.29**
0.27**
0.37***
—
0.00
0.20*
0.11
-0.25**
-0.32***
—
0.02
0.18*
-0.05
0.03
0.00
0.11
POS GI
Pain
Severity
Pain
Duration
Education
Age
* P < 0.05; ** P < 0.01; *** P < 0.001.
POS GI = positive God images; ANGER GI = angry God images; ANX GI = anxious God images.
Primary Analyses
Correlations between the socio-demographic variables and the study variables
As hypothesized, the experienced God image was significantly related with happiness in CP patients. POS GI
showed a medium positive correlation with happiness
(r = 0.37, P < 0.001) and ANGER GI showed a small
negative correlation with happiness (r = -0.20, P < 0.05).
ANX GI was not significantly related with happiness.
Finally, positive interpretation of disease showed a
medium positive correlation with happiness (r = 0.44,
P < 0.001), a small positive correlation with POS GI
(r = 0.27, P < 0.01), and a small negative correlation with
ANGER GI (r = -0.19, P < 0.05).
Table 1
First, we investigated the relations among all study variables and the socio-demographic variables (age, gender,
and education). No significant mean-level differences were
found between men and women concerning levels of
positive interpretation of disease, happiness, POS GI,
anxious God images (ANX GI), and angry God images
(ANGER GI) (Hotellings’s trace = 0.05, F(7128) = 0.84,
P = 0.55). All correlations among the variables are shown
in Table 1. We used Cohen’s d [34] to describe the effect
sizes. POS GI was small but significantly related with age
(r = 0.29, P < 0.01), and ANX GI was small but significantly
related with educational level (r = -0.20, P < 0.05). Duration of pain showed a medium significant positive correlation with age (r = 0.41, P < 0.001) and a small correlation
with POS GI (r = 0.18, P < 0.05). Pain severity showed a
small negative correlation with positive interpretation of
disease (r = -0.25, P < 0.01), a medium negative correlation with happiness (r = -0.32, P < 0.001), and a small
positive correlation with ANGER GI (r = 0.20, P < 0.05).
ANGER GI
Preliminary Analyses
—
0.08
-0.15
0.02
-0.16
-0.20*
0.07
0.04
ANX GI
Results
—
-0.13
0.41***
0.01
0.28**
0.02
0.08
0.00
0.13
Positive Disease
Interpretation
To measure the way their illness is perceived, a subscale
of the Spiritual and Religious Attitudes in Dealing with
Illness scale [33] was administered. The subscale “Positive
Interpretation of Disease” consists of five items rated on a
5-point scale (1 = never, 5 = very often). The scale measures an appraisal coping in which illness is seen as an
opportunity to change life or to reflect upon what is essential in life (e.g., “illness encourages me to get to know
myself better”). Cronbach’s alpha was 0.76.
Age
Education
Pain duration
Pain severity
POS GI
ANGER GI
ANX GI
Positive disease interpretation
Happiness
Happiness
Positive Interpretation of Disease
—
Dezutter et al.
God Image and Happiness in CP Patients
.30**
Figure 1 Trimmed
partial
model representing positive
interpretation of disease as
mediator of the relation between
God image and happiness.
Coefficients are standardized
path coefficients. *P < 0.05;
**P < 0.01; ***P < 0.001. POS
GI = positive
God
images;
ANGER GI = angry God images;
ANX GI = anxious God images.
POS GI
.26*
Disease
interpretation
ANX GI
.47***
Happiness
-.25*
ANGER
GI
inspected the Satorra-Bentler Scaled chi-squared
(SBS-c2 [36]). A SBS-c2 to degree of freedom ratio
(SBS-c2/d.f.) lower than 3.0 indicates good model fit [37]
Combined cut-off values close to 0.95 for comparative fit
index (CFI) and close to 0.06 for root mean square error
of approximation (RMSEA) indicate good model fit [38].
Estimation of the measurement model indicated good
model fit (SBS-c2/d.f. = 322.20/269 = 1.20, RMSEA =
0.04, CFI = 0.99).
Structural Models
In our study, the following three models were estimated
and compared: 1) a direct effects model including the
direct effects of God images on happiness; 2) a full mediation model in which God images are indirectly related to
happiness through the hypothesized mediator (i.e., positive interpretation of disease); and 3) a partial mediation
model including direct paths from God images to happiness and indirect paths through positive interpretation of
disease. According to Cohen’s criteria [34], all significant
paths were medium in effect size.
The direct effects model showed a good fit to the
CFI = 0.99,
data
(SBS-c2/d.f. = 322.20/269 = 1.20,
RMSEA = 0.03). The path from POS GI to happiness
(b = 0.42, P < 0.001) was significant, whereas the paths
from ANGER GI to happiness (b = -0.22, P > 0.05) and
from ANX GI to happiness (b = -0.07, P > 0.05) were
not significant. Next, the full mediation model showed a
good fit to the data (SBS-c2/d.f. = 492.31/398 = 1.24,
CFI = 0.99, RMSEA = 0.04). The independent paths from
POS GI to disease interpretation (b = 0.32, P < 0.01) and
from ANGER GI to disease interpretation (b = -0.26,
P < 0.05) were both significant. The path from ANX GI to
disease interpretation (b = 0.02, P > 0.05) was not significant. As expected, the path from disease interpretation to
happiness was also significant (b = 0.62, P < 0.001). We
compared these findings with the partial mediation model,
in which the three direct relations from God images to
happiness were added to the model. This partial mediation model showed an adequate fit (SBS-c2/d.f. = 480.76/
395 = 1.22, CFI = 0.99, RMSEA = 0.04), and adding the
three direct paths from God images to happiness did
significantly improve the model fit (c2diff (3) = 15.20,
P < 0.001) as compared with the full mediation model.
This improvement was due to a positive path from POS GI
to happiness (b = 0.30, P < 0.01). The path from POS GI
(b = 0.26, P < 0.05) and ANGER GI (b = -0.25, P < 0.05)
to positive interpretation of disease remained significant. In
a final model, we trimmed the paths which did not reach
significance (i.e., paths from ANX GI to disease interpretation and to happiness). This final model (Figure 1)
showed a good fit to the data (SBS-c2/d.f. = 484.64/
398 = 1.22, CFI = 0.99, RMSEA = 0.04).
Ancillary Analyses
Because of the significant associations between pain
severity and both disease interpretation and happiness,
we performed an additional set of analyses in order to
control for the influence of pain severity by allowing paths
from this variable to all other variables in the model [39].
The direct effects model showed a good fit to the data
(SBS-c2/d.f. = 389.86/340 = 1.15, CFI = 0.99, RMSEA
= 0.03) with a positive path from POS GI to happiness
(b = 0.43, P < 0.001). Pain severity had a significant effect
on happiness (b = -0.32, P < 0.001) and ANGER GI
(b = 0.23, P < 0.05) but not on the other God images. The
full mediation model showed a good fit to the data (SBSc2/d.f. = 77.91/483 = 1.20, CFI = 0.99, RMSEA = 0.04)
with a significant path from POS GI to positive interpretation of disease (b = 0.32, P < 0.001), and a significant path
from disease interpretation to happiness (b = 0.56,
P < 0.001). However, in contrast with the previous model,
without pain severity, the path from ANGER GI to disease
interpretation did not reach significance. The partial
mediation
model
(SBS-c2/d.f. = 565.51/480 = 1.18,
CFI = 0.99, RMSEA = 0.04), which significantly improved
the model fit (c2diff (3) = 17.51, P < 0.001), showed an
additional direct significant path from POS GI to happiness
(b = 0.32, P < 0.01), whereas the paths from the other
God images to happiness were not significant. In the final
model (Figure 2), we trimmed the nonsignificant paths
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Dezutter et al.
.32*
POS GI
.26*
Pain severity
Disease
interpretation
ANX GI
.41*
Happiness
.23*
ANGER
GI
-.24*
-.23*
Figure 2 Trimmed partial model representing positive interpretation of disease as mediator of the relation
between God image and happiness, controlled for pain severity. Coefficients are standardized path coefficients. *P < 0.05; **P < 0.01; ***P < 0.001. POS GI = positive God images; ANGER GI = angry God images;
ANX GI = anxious God images.
resulting in a more parsimonious model with a good fit
(SBS-c2/d.f. = 572.66/484 = 1.18, CFI = 0.99, RMSEA
= 0.04).
Discussion
In the present study, we explored the relationship between
God images and happiness when one is confronted with
a severe stressor such as enduring pain. Results showed
indeed that happiness was positively related with POS GI
and negatively related with ANGER GI. These findings are
in line with the findings of others [16] indicating that distinct aspects of religion (i.e., aspects of the God image)
relate differently to well-being. In order to obtain a more
fine-grained view on these associations, we framed this
study in the transactional model of stress and focused on
the possible mediating role of disease interpretation in the
relationship between God images and happiness. Correlational analyses indeed confirmed that disease interpretation was related with both God images and happiness.
Path analyses further showed that, in the context of
enduring pain, disease interpretation had a mediating
function between God images and happiness. However,
because pain severity had a significant influence on both
the interpretation of disease and on happiness, we controlled for pain severity in an ancillary set of analyses. The
resulting model showed that especially POS GI were
important in the prediction of happiness. POS GI had both
a direct effect as well as an indirect effect (through the
path of interpretation of disease) on happiness, irrespective of the level of pain severity.
Our findings indicated that, when taking into account pain
severity, patients with POS GI (consisting of feelings of
kindness, love, and warmth) are more able to reappraise
their pain and illness experience in positive terms. They
770
probably focus more on the growth and learning possibilities in this situation and less on the threatening or harmful
character of it. This finding might point in the direction of a
mitigating role of affective aspects of religion when confronted with CP. The direct positive path from POS GI to
happiness can be framed in the coping literature as well.
There is a consensus in the field that perceived social
support enhances psychological well-being and buffers
the impact of life stress in particular [40]. Moreover,
Feldman, Downey, and Schaffer-Neitz [41] showed that
there is evidence of a buffering effect of support on distress in CP patients. Furthermore, Pollner [26] already
stated that individuals may also perceive social support
from persons who may or may not actually exist such as
a deity. We can thus assume that the presence of POS GI
relate to the well-being of CP patients, more precisely by
the support of a divine attachment figure with whom the
individual is in relationship.
Additional analyses revealed that the path from ANGER GI
to disease interpretation was not supported across all
conducted analyses. This path, which was found in the
initial path models, was probably due to the detrimental
impact of pain severity on both ANGER GI and disease
interpretation. As such, when controlling for pain severity
in the subsequent path models, this indirect pathway
became nonsignificant. Moreover, the impact of pain
severity on ANGER GI is in line with earlier research
showing that CP patients in greater pain report feeling
angrier [42] than patients experiencing less pain. Moreover, some researchers state that these patients have
greater difficulty expressing these angry feelings [43]. It
might be possible that some patients take the anger they
experience in reaction to the painful experience and
project that anger onto an unseen figure such as God. For
these patients, it might be safer to blame God for their
God Image and Happiness in CP Patients
pain condition and express their anger toward God
instead of toward others because they fear compromising
their relationships with people on whom they depend. An
alternative explanation might be that individuals feel disappointed in and develop angry feelings toward God. The
idea of God as the all-good, benevolent, and omnipotent
protector might turn out to be disappointing to some
patients if the pain is not relieved or if the patient’s prayers
are not answered. Exline and colleagues [44,45], for
example, stated that suffering persons may find it difficult
to resolve anger toward God because God will not apologize to them. This negative view of God can color one’s
perceptions of the world, leading to greater distress [46].
An important avenue for further research is whether
attachment to God is involved in the relationship between
God image and happiness as well. A line of studies, based
on the attachment theory of Bowlby [47] focuses on the
role of attachment to God and the possible correlates of a
secure or insecure attachment. Some studies have shown
that individual differences in attachment to God are related
with loneliness, depression, and general adjustment
[48,49]. We hypothesize that God image and attachment
to God are interrelated constructs. Therefore, it is important to determine whether the belief of how the individual
experiences God is important, or rather the security of the
perceived relationship with God [49]. In line with this,
Belavich and Pargament [50] stated that attachment to
God may clarify why individuals choose particular coping
strategies when responding to stressful events. Therefore,
it is plausible that a warm and secure relationship with
God can help individuals with reframing a negative stressor such as enduring pain in a way that it has some
meaning. However, in line with Granqvist and Kirkpatrick
[51], we can assume that our model may only apply to
patients who experience God as an attachment figure.
Limitations and Conclusions
Even though this study offers a significant contribution to
the underinvestigated areas of God images and CP, it has
several limitations. First, the domain of God representations still is a very complex field. Although some researchers [19,20] have recently advocated to differentiate the
emotional experiences of God and the intellectual understanding of God, it remains difficult to make a sharp distinction between the affect-laden God image and relatively
affect-neutral God concepts [31]. A further theoretical as
well as empirical study of these aspects of God representation is warranted. Second, longitudinal work is required
to investigate more thoroughly the direction of the associations. For example, it could be possible that being
happy might lead to a more positive experienced God
image and to framing pain in more positive ways. Next, it
is possible that the participants in this study, members of
a patients association, are a more active group of patients
than are patients in the general CP population. This active
attitude might be related with a more frequent use of
positive appraisal, which might subsequently influence the
results of the study. A replication study with a broader
group of CP patients, including patients in pain treatment
or in a pain hospital, might nuance our results. Finally,
although the fairly large sample size is a strength in this
field of research, replication with larger samples is necessary in order to confirm the stability of the model.
Further, these findings, when replicated, can have some
clinical implications. Framed within a multidisciplinary
approach toward the treatment of pain, a religious history
as part of an anamnesis or intake might be worth considering [16]. The clinician can obtain information about the
patient’s religious background and whether the patient
uses religion to help cope with his or her pain. This can
offer the clinician a broader view on the coping resources
of a patient. However, because of the paucity of research
on this topic, more empirical evidence is necessary before
clear guidelines can be offered.
In sum, this study offers a new perspective on the relationship between religion and well-being when one is confronted with a severe stressor such as enduring pain. The
results indicate that a positive God image has an influence
on the happiness of CP patients, both directly and indirectly through the pathway of positive disease interpretation. These findings can be framed within the transactional
theory of stress and can stimulate further pain research
investigating the possible mitigating or stress-buffering
effects of religion.
Acknowledgments
We highly appreciate the contribution of the Board of the
Flemish Pain League (Vlaamse Pijn Liga) and the Board of
the Ray of Hope association (‘t Lichtpuntje) who encouraged their members to fill out the questionnaires.
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