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Review of Key Studies on Spiritual Engagement and Meaning

To read a comprehensive review of each key study, simply click on each study's citation:

 

Bonelli, R., Dew, R. E., Koenig, H. G., Rosmarin, D. H., and Vasegh, S. (2012). Religious and spiritual factors in depression: review and integration of the research. Depression Research and Treatment 2012: 1-9.

Introduction
Depression has a far-reaching impact on diverse facets of an individual's life, from psychological quality of life to physical health. An estimate by the World Health Organization places major depression as the world’s second most debilitating condition by the year 2020, with only cardiovascular disease causing more disability (cited in Bonelli, et al, 2012). Thus, even in contemporary times, depression is  common among various populations around the world. Involvement in a religious or faith tradition is also quite customary today, with the World Gallup Poll's representative survey of individuals in more than 140 countries (n = 140,000) indicating that  92% of people in 32 developing countries suggested that religion was an important part of their daily lives (Bonelli, et al, p.2).

In the literature concerning religion and well-being, a variety of sources indicate that religious or spiritual (R/S) beliefs can be utilized to cope with stressful life challenges. Failing to cope with life stress is often a key underlying factor of depression, although depression can certainly be caused by other factors. If involvement in religion/spirituality can be utilized to aid individuals in coping with stress, it may help to avert the development of depression or increase the attenuation of depressive symptoms, and thus improve people’s well-being. However, R/S involvement may have more pernicious implications, including the concept that R/S beliefs or practices may contribute to the creation of high standards for individuals, and if people cannot live up to those standards, they may face failure, or even rejection from a religious community (Bonelli, et al., p. 2).

Although the religion-depression relationship has been studied using various research methods in the social and behavioral sciences, the extent to which R/S serves as a buffer against depression or serves to complicate depression remains unknown (Bonelli, et al., p. 2). The objective of this literature review was to summarize quantitative research, including randomized controlled trials, on the association between religion and depression.

This study has been identified as a key study due to its methodological rigor in reviewing quantitative research that focuses on the association between religion and depression.  The evaluated studies span from 1962 to 2010, allowing for a greater breadth of resources to be considered by Bonelli, et al.  Furthermore, in this study, Bonelli’s team also evaluates randomized controlled trials that investigate the therapeutic utilization of R/S resources for depressed patients.

Methods
In this review, Bonelli, et al. (2012), summarized research findings based upon two systematic literature reviews conducted in 2001 and 2010 and covering a period spanning between 1962 and 2010. The reviews were conducted using Medline and PsychInfo databases, which identified studies on the depression-religion relationship through the search words “religion,” “religiosity,” “religiousness,” and “spirituality.” These search terms were cross-referenced with the search term “depression.” Qualitative studies were excluded, and studies with sample sizes less than 15 were also excluded, unless they were experimental studies. 444 studies were identified in total. Bonelli, et al. (2012), also include recent reports from a study conducted by the Columbia University psychiatry research group.

The methodological rigor of each study was assessed by utilizing a scale from 1-10 based on a scheme that emphasized the definition of variables, validity, and reliability of measures, as well as the representative nature of the sample, quality of the research methods, the execution of the study compared to the design, the statistical tests, and the interpretation of results. This method was then tested for inter-rater reliability by using a subgroup of 75 studies. The direct correlation between two independent raters (Pearson’s r) was 0.57.

Results
A. Religious affiliation
Although Bonelli, et al. (2012), initially write that religious affiliation serves as a poor indicator of the degree of religious involvement/commitment, they do include data on the role of religious affiliation because it provides “general information about the prevalence of depression in broad religious groups” (Bonelli, et al., p. 2). Generally, research findings indicate that individuals of Jewish descent, Pentecostals, or those with no religious affiliation experience higher rates of depression than other religious groups. For people of Jewish descent in particular, both cross-sectional and longitudinal studies have suggested higher rates of depression (Bonelli, et al., p. 3). This may be due to the selective reporting of depressive symptoms, thus indicating that people of Jewish descent may be more likely to report depressive symptoms in hopes of seeking help from mental health professionals, rather than ignoring symptoms or turning to dangerous methods of coping with depression.

The higher rates of depression in Pentecostal individuals may be the result of self-selection to Pentecostal groups; namely, that because of the Pentecostal faith’s focus on overcoming emotional problems through socialization, positivity, evangelism, and faith, individuals with depressive/emotional problems may “self-select” into Pentecostal groups. Furthermore, the emphasis placed on “evangelism” may encourage individuals from lower socioeconomic groups to join the religion, and these individuals may experience a higher risk for depression or other mental illnesses (Bonelli, et al., p.3).

In terms of individuals who do not have a religious affiliation, the higher rates of depression may be due to an absence of social support from a religious community or a lack of commitment to a belief system that offers explanations for challenging life circumstances or stressful events. However, individuals who do not identify with a faith may have alternative sources of support and guidance from secular communities or belief systems, which could compensate for the absence of a religious community.

B. Religious/Spiritual Involvement
In terms of their research interest, Bonelli, et al. (2012), were particularly fascinated by the relationship between the level of R/S involvement (e.g., amount of time spent in religious activities, degree of commitment, and importance of belief) and depression. Between 1962 and 2010, at least 444 original, quantitative studies examined the R/S-depression relationship or the effects of an R/S intervention on depression. Of these studies, 414 were observational studies, and 30 were clinical trials. Furthermore, out of the 444 total studies, the results of 272 (61%) studies found less depression, faster recovery from depression, or a reduction in depressive symptoms in response to an R/S intervention. 28 studies (6%) found the opposite.

In terms of methodological rigor, out of the 178 highest-rigor studies (with a 7 or higher on the 1-to-10 scale), 119 (67%) studies had results that indicated less depression, faster recovery, or greater responsiveness to R/S interventions, and 13 studies (7%) reported opposite results. As the quality of the study increases, the proportion of studies reporting a negative association between R/S and depression remains at the same level or increases, albeit very slightly (67%).

The results of this review echo those suggested by a meta-analysis conducted by Smith, et al. (2003), which examined research findings on the relationship between religion and depression using data from 98,975 subjects in 147 studies. The average correlation was small (r = -0.10), albeit consistent, and it could not be explained by gender, age, or ethnicity. Interestingly, the effect was considered equivalent in size to the effect of gender on depression, and gender is considered a major risk factor for depression. For studies that included subjects who were experiencing high stress levels, the effect of religion was 50% stronger (r = 0.15).

Bonelli, et al. (2012), also examined the results of a team of psychiatric epidemiologists at Columbia University, who studied whether religiosity has a protective effect against depression in high-risk individuals. The team conducted a 10-year prospective study of 114 adult offspring of depressed (n=72) and non-depressed (n=42) parents. At baseline, religious measures included the personal importance of R/S, frequency of attendance at religious services, and religious denomination. Ten years after religious measures were assessed, researchers evaluated the presence of major depression. After gender, age, history of depression, and risk status were controlled, individuals who indicated that religion or spirituality was highly important to them were 73% less likely to be depressed. In the group of low-risk individuals (those without a history of depressed parents), religious variables did not have a predictive effect on the presence of depression at follow-up. In the high-risk group, those who indicated that religion or spirituality was highly important to them were 90% less likely to have major depression.

C. Reasons for Less Depression and Suicide
The consensus in the literature is that for individuals who are more R/S or who participate in an R/S clinical intervention, the majority of studies (61%) find less depression or faster recovery from depression (Bonelli, et al., p.4). One reason for this may be that involvement in a religion or spiritual community may aid individuals in coping better with stressful life circumstances; this possibility has been discussed in hundreds of research studies. In a study of 330 hospitalized patients at Duke University Hospital, researchers asked an open-ended question about what enabled them to cope with the stress of their illness. Forty-two percent of the patients reported, spontaneously, that it was an aspect of their religious faith or a religious activity that enabled their coping (cited by Bonelli, et al., p. 4).

In addition, involvement in religion/spirituality may decrease the chance that stressors will even occur in the first place. Individuals make daily decisions that often involve how to treat others or how to assess lifestyle practices or health behaviors. R/S involvement has been associated with greater gratefulness, forgiveness, altruism, less delinquency/crime, less substance abuse, better school performance, and more disease prevention activities (Koenig, et al (2012), cited by Bonelli, p. 4). Furthermore, one additional way that R/S is likely to help individuals cope is through social support, which has been shown in previous studies to buffer against depression and suicide.

D. Reasons for More Depression
In certain populations, the results from research studies do suggest that R/S involvement is related to higher rates of depression. In particular, this is true for religious/spiritual individuals involved in family issues related to child problems, marital problems, abuse, or care-giving. In several methodologically-rigorous studies published since 2000, results suggest a positive link between R/S and depression. For instance, a study of 22,570 older adults in countries in Western Europe revealed that for countries with high levels of orthodox beliefs or high percentage of Catholics, a cross-sectional positive association was revealed between disability and depressive symptoms (cited by Bonelli, p. 5). The results of other key studies indicate that R/S involvement appears to be positively associated with a greater risk of depression for individuals with family problems, psychiatric in-patients with substance abuse problems, or those living in Catholic nations in Europe with orthodox beliefs (Bonelli, p. 5).

E. Clinical Applications
In this review, Bonelli, et al (2012), also summarize the results of research studies that have investigated whether the therapeutic utilization of patients’ R/S resources could help to improve the speed of resolution for depression. Several randomized clinical trials demonstrate the benefits of integrating religious or spiritual psychotherapies in treating patients for depression.

In one such study focusing on the treatment of depressed religious patients, investigators studied the effectiveness of religious cognitive-behavioral psychotherapy (RCBT) compared to conventional CBT (CCBT), ordinary pastoral counseling (PC), and a wait-list, control condition (WLC). The subjects (n=59) were randomly assigned to these four groups, and each received 18 therapy sessions over the course of 3 months. Only subjects in the RCBT condition experienced significantly lower immediate post-treatment depression scores. RCT also resulted in significantly improved social adjustment scores (SAS) compared to the WLC (p<0.001) (Propst, et al., 1992).

The results of two additional randomized clinical trials reveal that psychotherapy, when supplemented with teachings from the Koran and Islamic prayer, was effective in treating either depression (n=64) or bereavement (n=30) among religious Muslims in Malaysia, when compared to traditional therapy (Azhar and Varma, 1995). Furthermore, since 2000, at least 22 clinical trials or experimental studies investigated the effects of religion/spirituality or psychospiritual interventions on depressive symptoms. Nearly two-thirds of studies (63%) reported significant benefits for individuals with depressive symptoms.

Conclusion
Although there are a variety of factors that influence the risk of depression, including environmental, genetic, or developmental factors, involvement in religion/spirituality is related to less depression in the majority of studies, particularly in terms of life stressors. This systematic review by Bonelli, et al. (2012), demonstrates that many more studies do show benefits from R/S compared to those that suggest possible harm (61% vs. 6% of studies) (Bonelli, et al., p. 6). However, it is also significant that there are high-quality studies indicating that R/S involvement may increase the risk of depression in certain populations or worsen the prognosis of depressions. In terms of clinical interventions, the results of R/S interventions have suggested that interventions utilizing the R/S beliefs of patients reduce depressive symptoms.

Noted Limitations/Future Directions
In the future, it is key that studies continue to investigate interventions that utilize the R/S beliefs of patients, particularly interventions that have been tested in randomized clinical trials.

Ellison, C. G. (1991). Religious involvement and subjective well-being. Journal of Health and Social Behavior 32: 80 – 99

Introduction
Previous research concerning religiosity and subjective well-being suggests that religion influences well-being through at least four main mechanisms: (1) providing social support and integration; (2) establishing a relationship with a divine being; (3) creating systems of existential meaning; and (4) promoting patterns of lifestyle and religious organization. These relationships are not exclusive, but rather merge often to create our understanding of how religion may influence well-being.

The body of literature on research and well-being is extremely multifaceted. In terms of social integration, some studies demonstrate that religion may enhance individual well-being by offering opportunities for social interaction in a given setting (such as a church, synagogue, or temple). Others argue that the religious institution provides opportunities for friendships with like-minded individuals, or that the institution allows for a larger and more reliable social network to be formed – thus giving the individual more support in a time of deep crisis. Religious communities also often promote norms for health behaviors, relationships, and other lifestyle choices, and those who do not obey may fear social isolation. In addition, other studies also suggest that personal religious practices, such as prayer or meditation, may also be responsible for psychological benefits, such as the mitigation of personal guilt or a reduction of self-condemnation.

In terms of religious denominations, the literature is often distinguished between “ ‘strong’ conservative Protestant groups” and “ ‘weak’ mainline and liberal Protestant churches” (Ellison, 1991, p. 82). The organizational culture – strong vs. weak – may influence well-being by fostering particular social network ties (a more intense familial atmosphere, for example). Furthermore, a “strong” church may have more stringent requirements towards lifestyle or health behaviors.

In regard to stress, religiosity, and well-being, Wheaton (1985) established the concept of stress-suppressing and stress-buffering effects. In the suppressor model, the level of religious activity depends upon the amount of stress. As stress increases, individuals are then more motivated to engage in religious activities more frequently, which thus produces a compensatory mechanisms in which religiosity could compensate for the negative effects of stress. The stress-buffering model, in contrast, states that the advantages of religiosity vary across levels of stress, and the strongest buffering occurs at the highest stress levels.

The objective of this seminal investigation is to further the current body of knowledge surrounding the relationship between religion and subjective well-being. The current study aims to accomplish this by first operationalizing religious coherence (and distinguishing its effects from those of collective participation). In addition, the study also provides information about denominational differences, age, and educational attainment in subjective well-being. Finally, the study also aims to explore the ways in which religiosity may serve as a mediator to the effects of stressful life challenges.

This study has been identified as a key study because it was one of the first to report on the relationship between religious/spiritual beliefs, life satisfaction, and personal happiness.  In this seminal investigation, Ellison also uniquely examined four different aspects of religious involvement in assessing religiosity/spirituality.

Methods
In this study, data are taken from the national, cross-sectional General Social Survey of 1988 (GSS). The GSS includes a set of questions concerning religious socialization, belief, and practices, as well as demographic and background information. The dimensions of subjective well-being that were assessed include “affective states” (personal happiness) and “cognitive states” (life satisfaction). Personal happiness was measured by one item, and was coded as either “not too happy,” “pretty happy,” or “very happy.” Life satisfaction was measured based on the respondent’s level of satisfaction with community life, non-working activities, family life, friendships, or physical health. It was coded on a scale of 1 (no satisfaction) to 8 (a very great deal of satisfaction).

Four aspects of religious involvement were examined for their impact upon well-being: denominational ties, social integration, divine relations, and existential certainty. Denominational ties were established through examining each individual’s religious preference (classification). Social integration was measured by the frequency of attendance at religious services, with 0 representing never, and 8 representing several times per week. Divine interaction was constructed by questions asking about the individual’s closeness to God and the frequency with which he or she prays. Existential certainty was measured by the frequency of doubts regarding religious faith.

Results/Discussion
Ellison (1991) first performed a preliminary analysis of the main/interactive effects of social interaction on life satisfaction and personal happiness to establish a baseline of sorts. The results indicate that individuals with high levels of religious faith are associated with higher levels of life satisfaction, greater personal happiness, and fewer negative consequences of trauma. In terms of denominational variations, there are strong variations in life satisfaction, but not in personal happiness. Specifically, members of “nontraditional” groups, such as Mormons or Jehovah’s Witnesses, along with nondenominational Protestants and liberal Protestants, report greater levels of life satisfaction than do participants who were not affiliated with a religion.

Conclusion
This research study is one of the earliest to report on the relationship between religion, life satisfaction, and personal happiness. By examining four different aspects of religious involvement, this study avoided the trap of equating frequency of church attendance with complete religiosity.

Noted Limitations and Future Directions
Ellison (1991) writes that future research may seek to consider the association between the strength of religious/spiritual belief and other aspects of well-being. In addition, he also suggests that further research is needed to better examine religious coping strategies among different denominations and social factors within each religion.

Galen, L.W., & Kloet, J. (2011). Mental well-being in the religious and the non-religious: evidence for a curvilinear relationship. Mental Health, Religion, & Culture 14, 6:3-68.

Introduction
Previous research in the social sciences has suggested that the relationship between religiosity and mental health is one that is linear, in which greater religiosity is equated with greater well-being. However, these results do often vary because of the diverse ways in which religiosity and mental health are conceptualized according to the study. One literature review by Koenig and Larson (2001) found that 80% of studies (out of 100) indicated that religious beliefs or practices were positively associated with life satisfaction. The mechanisms, however, are still speculative, and many different factors could mediate this effect, including social networks or social support, existential meaning, or a particular lifestyle.

Many studies that espouse the linear relationship between religiosity and mental health often combine weakly religious participants with the completely non-religious (or atheist) participants. Among the few studies that have distinguished between the non-religious and weakly-religious, they espouse a curvilinear relationship, with the completely non-religious participants showing significantly greater levels of well-being than the participants that are weakly religious. For example, a study by Buggle, Bister, Nohe, Schneider, and Uhmann (2000) demonstrated that in a sample of German adults, the least depressed were the strictly religious group or the “determined atheist” group. Thus, it is crucial that studies distinguish between weak religiosity and non-religiosity, and that they also assess the certainty of belief.

In the current investigation, Galen and Kloet (2011) examine the mental well-being of individuals whose beliefs fall at the non-religious spectrum of belief and practice. The full range of belief certainty is examined, and Galen and Klout also use different measures of belief (certainty and self-labeling). The studies include multiple measures of well-being, such as life satisfaction and emotional stability/neuroticism.

This study has been identified as a key study due to its focus on the curvilinear (rather than linear) relationship between religiosity and well-being (with non-religious participants showing significantly greater levels of well-being than weakly-religious participants).  Galen and Klout also uniquely examine the full range of belief certainty in building upon the curvilinear hypothesis.

Methods
Study 1
In the first study, Galen and Klout (2011) compared members of a secular humanist group with church members; members of both groups lived in the same Midwestern city. A total of 658 participants provided complete data on the dependent measures. The secular group sample was composed of 333 participants and was 64% male. The mean age was 44. In the church sample, there were 325 participants. The sample was 30% male, and the average age was 46 years.

In terms of measures, the Satisfaction with Life Scale was utilized, as was the Social Provisions Scale. Participants were asked about how certain they were of their religious/philosophical beliefs, and about the religious/philosophical label with which they most identified.

Study 2
In the second study, the researchers examined the spectrum of non-religiosity specifically, which ranges from “atheist” to the intermediate region of “agnostic” to “spiritual.” Participants (n=5382) were recruited from secular organizations in the United States and abroad. The sample was 74% male, and the average age was 49. The measures were identical to those described in Study 1.

Results
Study 1
The results of Study 1 revealed that the church sample and the secular sample did not differ significantly on the Life Satisfaction Scale, as both groups were within the “normal” range. Statistical analysis (t-tests) demonstrated that the church sample received a higher score on the emotional stability personality scale than did the secular group, and emotional stability was correlated with life satisfaction.

Interestingly, a one-way ANOVA suggested that Life Satisfaction varied as a function of belief certainty. That is, individuals who believed certainly that God exists as well as individuals who believed absolutely that God does not exist both had significantly higher life satisfaction than compared to individuals who somewhat believed that God exists (intermediate belief). In addition, a one-way ANOVA also indicated that Emotional Stability varied as a function of belief certainty.

Thus, the results partially supported the curvilinear relationship between belief certainty and well-being. Participants with more certain religious beliefs (either strong beliefs in God’s existence or the lack of existence) had greater emotional stability than those who were unsure. The strong believers and strong non-believers also were highest in life satisfaction, and those who were unsure received intermediate scores. However, social and demographic variables were more strongly related to well-being than belief in God.

Study 2
Statistical analysis with a one-way ANOVA indicated that Life Satisfaction did vary as a function of belief certainty. Participants who believed absolutely that God exists and participants who believed in the lack of God’s existence had significantly higher satisfaction in life than those who were unsure that God exists. Those who were unsure were in the “intermediate” region of Life Satisfaction. These results thus support the curvilinear hypothesis.

Furthermore, a one-way ANOVA also indicated that Emotional Stability varied as a function of belief certainty as well. Specifically, participants who were unsure about the existence of God had lower emotional stability than all other categories of belief certainty, which partially supports the curvilinear hypothesis.

Conclusion
This research study is unique in its ability to build upon previous research that also espoused the curvilinear hypothesis. Furthermore, the results obtained demonstrate how crucial it is for other research studies to re-examine the ways in which religious categories are distinguished and defined.

Noted Limitations/Future Directions
Because the secular sample was recruited from a secular organization, these results may apply only to those who are affiliated with a particular organization or group. However, the majority of religiosity/mental health research similarly recruits participants from churches (thus another symbol of a group). Further research may also seek to elucidate the direction of causality in the relationship between religiosity and well-being.

Goldstein, E. D. (2007). Sacred moments: Implications on well-being and stress. Journal of Clinical Psychology 63(10): 1001-1019.

Introduction
Contemporary research indicates that the cultivation of a sense of sacredness in one’s life is important in contributing to a lifestyle rooted in well-being and health (McCorkle, Bohn, Hughes, and Kim, 2005). However, there is a dearth of empirical evidence as to the actual psychological interventions that aid in cultivating sacred moments and the impact of these interventions upon life satisfaction, stress, or positive relationships with others.

In the literature, “sacred moments” are defined in a variety of ways. However, one key aspect of a sacred moment is that it has a “sense of timelessness, purpose, and transcendence” (Goldstein 1002; Pargament and Mahoney, 2005). In this study, sacred qualities are those that have spiritual qualities and are imbued with descriptive qualities (such as “precious” or “blessed”). The individual cultivating the sacred moment must be present in the moment and aware of the transient qualities of the sacred moment. Mindfulness was utilized in the present study to support participants in becoming more aware of their thoughts and feelings during the intervention.

In this research investigation, Goldstein introduces a new clinical intervention aimed at cultivating sacred moments in daily life, and also examines its effects upon stress, subjective well-being (SWB), and psychological well-being (PWB). The first objective in this study was to quantitative measure the psychological effects of taking a “time out” in daily life for 5 minutes (minimum) per day, for the entire week, lasting for three weeks, in which the individual would be aware of a sacred object that was personally chosen. The second objective was to use qualitative, semi-structured interviews, to investigate whether participants were experiencing any sacred qualities in their sacred moments.

This study has been identified as a key study due to its focus on empirical clinical evidence (as well as qualitative interviews) that reveal the psychological importance of cultivating sacred moments in daily life.

Methods
Participants (n=83) were recruited and enrolled through advertisements on email flyers sent from professional contacts, Web sites, or blogs. Out of the 83 participants, 55 were women and 28 were men. The participants had to meet a set of criteria, such as not having a current, daily, and active practice of cultivating sacred moments – but had indeed experienced them in the past. Seventy-three participants successfully completed the study. 56% came from a Judeo-Christian background.

The participants were randomly assigned into one of two groups: either the intervention group (n=41) or the control group (n=42). All participants completed preassessments and questionnaires at baseline. After the three-week intervention, post-assessments were administered via email. After the post-assessments, Goldstein completed semistructured interviews with participants of the intervention group via telephone. Six weeks after the 3-week intervention had ended, the same post-assessment was again administered.

Participants in the intervention group were taught how to cultivate sacred moments, as well as how to be in the present moment. They were instructed to choose a meaningful object that represented something special to them. On the fourth day of the intervention, they sanctified their object by seeking to imbue the object again with a sense of what was divine or cherished to them. The participants then spent 5 minutes (at least) per day, for 5 days a week practicing mindfulness techniques and then paying attention to the sacred object.

Participants in the control group performed a writing task for 5 days a week over the course of 3 weeks. They wrote about their daily activities.

In terms of measures, it is important to first distinguish between psychological well-being and subjective well-being. Psychological well-being (PWB) is more concerned with meaning, purpose, and existential issues. Subjective well-being (SWB) is focused more on positive/negative affect and life satisfaction. SWB was measured through the PANAS (Positive and Negative Affect Scales) and the SWLS (Satisfaction with Life Scale). PWB was assessed with the Psychological Well-Being Assessment, which measured six different dimensions of well-being. Stress was measured through the Perceived Stress Scale, and spiritual experiences were measured through the Daily Spiritual Experience Scale.

Results
The quantitative results indicated that in terms of influencing well-being and stress, the sacred moment intervention was as effective as the writing method (the control). Both groups had significant changes in stress reduction and daily spiritual experiences. These results may have been due to the nature of the writing exercise, which may have allowed participants to appreciate the moment of writing, or because the participants may have thought the writing was a spiritual discipline.

The qualitative findings demonstrated a variety of new themes articulated by participants in the intervention group, such as “quiet and calm,” “peaceful,” or “holy” (Goldstein, p. 1011). Eighty-nine percent of participants who were interviewed reported that the cultivation of sacred moments had led to a stronger awareness of what was sacred in life after the three-week intervention had ended.

Conclusion
This research investigation provides a perspective rooted in both theory and empiricism to demonstrate that the cultivation of sacred moments in daily life is an intervention that positively influences subjective well-being and psychological well-being. However, therapeutic writing could also serve as an intervention. This research will hopefully serve as a foundation upon which other investigations can examine interventions that are both clinical and religious/spiritual in nature, that have the potential to improve psychological and subjective well-being.

Noted Limitations and Future Directions
One limitation faced by this research is that the participants in the control group (writing exercise group) were not qualitatively interviewed. By performing a qualitative interview, the participants’ thoughts regarding the spirituality of the exercise may be assessed. Future studies also ought to control for physiological variables, such as sensation awareness or the choice of an object.

Halama, P., and Dedova, M. (2007). Meaning in life and hope as predictors of positive mental health: do they explain residual variance not predicted by personality traits? Studia Psychologica 49 (3): 191 - 201.

Introduction:
In the literature concerning optimal mental functioning, there are two key streams of thought. In the first, basic personality traits and temperament, which are both usually considered as genetic factors, are highly emphasized in predicting mental health and well-being. The Five Factors Theory establishes that five traits predict different positive and negative aspects of mental health, including depression, well-being, self-esteem, etc. This theory states that neuroticism, extraversion, and conscientiousness are all consistently associated with mental health. In the second stream of research, which concerns positive psychology, the role of human strength in improving mental health and functioning is emphasized. This view considers the traits to be socially learned ad developed. In this view, meaningfulness and hope are intensively studied, because of the strong evidence that meaningfulness in life is highly associated with positive and negative mental health. For example, Moomal’s seminal work (1999) demonstrated that meaningfulness in life is correlated negatively with depression, paranoia, psychopathic deviation, anxiety, social introversion, and schizophrenia.

There is also a consensus in the literature that there is a relationship between personality traits and positive human strengths, especially concerning meaningfulness and hope. In 2005, Halama demonstrated that meaningfulness and hope correlate negatively with neuroticism and correlate positively with extraversion and conscientiousness.

The objective of this investigation was to demonstrate the ways in which different personality characteristics predict optimal human functioning, particularly in terms of the associations between personality traits, level of meaning in life, and hope. Halama and Dedova (2007) also sought to examine whether the level of meaning in life, as well as hope, could explain residual variance in predicting positive mental health.

This study has been identified as a key study due to its unique emphasis on examining whether meaning in life and hope are associated with positive mental health among the adolescent population.

Methods:
One hundred and forty-eight adolescents were recruited from a secondary grammar school in Slovakia. The mean age was 16.84 years. The students completed questionnaires during school lessons. The level of life meaningfulness was the predicting variable and was assessed with the Life Meaningfulness Scale. In addition, the level of hope was measured with the Hope Scale, and the overall sense of hope was utilized here as the predicting variable. Personality traits were assessed using the Five Factor Theory, in which five personality traits were defined as: neuroticism, extraversion, openness to experiences, agreeableness, and conscientiousness. Positive mental health was assessed with the Satisfaction with Life Scale (SWLS) and the Self Esteem Scale (SES).

Results:
A Pearson correlation analysis was conducted to analyze relationships between personality traits, meaning in life, hope, and mental health (life satisfaction and self-esteem). The two personality traits of neuroticism and conscientiousness were correlated with positive mental health. Extraversion and agreeableness were positively associated with life satisfaction, but not with self-esteem. Both meaningfulness and hope have a positive correlation with positive mental health, and meaningfulness had a higher correlation.

Two hierarchical regression analyses were conducted to determine whether meaningfulness or hope could uniquely predict positive mental health. Meaning in life had the highest correlation with positive mental health, and it did indeed explain the unique variance of positive mental health, when defined by life satisfaction and self-esteem. This finding was echoed by the work of Mascara and Rosen (2005), who found that meaning in life negatively predicted later levels of depression.

In addition, the results of the current study indicated that hope did not independently predict life satisfaction, although it did correlate positively with both aspects of mental health. Hope was found to independently predict self-esteem.

Conclusion:
This research study provides further support for the significance of meaningfulness and hope in being associated with positive mental health. Hope independently predicts self-esteem, but not life satisfaction. In contrast, meaningfulness in life had the highest correlation with positive mental health.

Noted Limitations and Future Directions:
Future research may seek to establish the direction of causality between the level of meaningfulness and positive mental health. Furthermore, positive mental health may be further conceptualized beyond life satisfaction and self-esteem, especially in the cases of individuals coping with disease or trauma.

Ivtzan, I., Chan, C. P. L., Gardner, H. E., Prashar, K. (2013). Linking religion and spirituality with psychological well-being: Examining self-actualisation, meaning in life, and personal growth initiative. J Relig Health 52: 915-929.

Introduction
The consensus in the social sciences literature is that the constructs of religion and spirituality share a positive association with psychological well-being, especially if the constructs are carefully delineated or defined (Hill and Pargament, 2003). Religion can play a positive role in people’s lives by providing opportunities for social support with like-minded people, an existential framework, and even a sense of identity. However, religion can also have a detrimental influence on individuals if it leads to religious doubts, stress, or social alienation.

Contemporary research has been concerned with the question of the specific ways, or mechanisms, through which religion/spirituality may influence psychological well-being. A variety of psychosocial factors may mediate this link, depending on the respective roles of religion or spirituality.

The objective of this investigation is to examine the roles of religion and spirituality in an individual’s ability to reach his fullest potential – that is, by linking religion and spirituality with psychological well-being through three measures: (1) self-actualization, (2) meaning in life, and (3) personal growth initiative. Ivtzan et al (2013) hypothesized that groups with a higher level of spirituality would exhibit higher levels of psychological well-being, regardless of whether the spirituality was experienced within the context of religious activity (Ivtzan et al., 2013, p. 921).

This study has been identified as a key study because it uniquely distinguishes between the roles of religious involvement and spirituality in investigating how each influences psychological well-being, in terms of self-actualization and life meaningfulness.

Methods
Participants (n=205) were recruited from various religious institutions, meetings, and spiritual groups within London. The sample was composed of 114 men (55.6%) and 91 women (44.4%). The sample was 32.2% Christian, 17.6% Muslim, 14.6% Quaker, 10.2% Jewish, 9.3% Buddhist, and 16.1% “none” (non-affiliated).

A measure of organizational religiosity was utilized, as was the Spiritual Transcendance Scale. The Short Index of Self-Actualization (SISA) was used to measure self-actualization. Meaning in life was assessed with the Meaning in Life Questionnaire, and personal growth initiative was measured with the Personal Growth Initiative Scale (PGIS). PGIS is supported by data that demonstrates that it is positively related to psychological well-being, internal locus of control, and assertiveness.

The participants were assigned to one of four groups: (1) a high level of religious involvement and spirituality, (2) a low level of religious involvement with a high level of spirituality, (3) a high level of religious involvement with a low level of spirituality, and (4) a low level of religious involvement and spirituality. Questionnaires were administered to each group, and were returned by mail.

Results
The four groups were compared on the basis of psychological well-being, in terms of levels of self-actualization, meaning in life, and personal growth initiative. The first two groups (Group 1 and Group 2) scored higher on all three measures of psychological well-being. Thus, the results demonstrate the significance of spirituality on psychological well-being. Interestingly, there was also a lack of correlation between spirituality and religiosity, thus strengthening the conceptualization that they are clearly distinct from one another. Group 3 also scored significantly lower in regard to Self Actualization when compared to Groups 1 and 2, thus confirming the work of Tamney (1992) that religion is negatively correlated with personal orientation. There were no significant differences between Groups 1 and 4 and Groups 2 and 4 in terms of Self Actualization.

Scores in terms of PGIS (Personal Growth Initiative) were significantly different between Groups 1 and 3 and Groups 1 and 4. This thus suggests that when one is highly religiously involved and highly spiritual, personal growth initiative is highest, when compared to individuals who are either low in both religious involvement and spirituality or high in religious involvement and low in spirituality.

Conclusion
The findings of this research study are crucial in considering the distinction between the roles of religious involvement and spirituality in influencing psychological well-being. Higher levels of spirituality (with or without religious involvement) were correlated with higher levels of self-actualization and life meaningfulness. In contrast, higher levels of personal growth initiative were only found for the group exhibiting high levels of religiosity with high levels of spirituality.

Noted Limitations and Future Directions
Due to the results of this research study, it is imperative that future research promotes an in-depth investigation into the effects of different elements of spirituality upon psychological well-being, rather than focusing on formal religion or frequency of church attendance as sole measures of religiosity or spirituality.

Lim, C., and Putnam, R. D. (2010). Religion, social networks, and life satisfaction. American Sociological Review 75 (6): 914 - 933.

Introduction:
A variety of studies explore the question of happiness and life satisfaction, and an important contribution to the literature lies in research that has improved the reliability and validity of different ways to measure subjective well-being, such as self-rating-based questions. These diverse measures allow subjective well-being and quality of life to be quantified and analyzed. The literature reports that varied factors can shape subjective well-being; for example, many studies provide evidence that religion is closely associated with life satisfaction and happiness (Greeley and Hout, 2006; Inglehart 2010). However, there is a dearth in the available literature as to the mechanism by which religion shapes life satisfaction and well-being. Previous studies suggest that the social networks within religious organizations are the source of well-being (Krause, 2008), whereas other suggest that the private, personal aspects of religion are those that are most responsible (Greeley and Hout, 2006). Most of the current literature is based on cross-sectional data, and even if sociodemographic factors or other correlates of subjective well-being are controlled, other individual, unnoticed characteristics may still be responsible for shaping the influence of religion on well-being. To better understand the impact of religion on well-being and life satisfaction, it is crucial that these possibilities are addressed.

In this study, Lim and Putnam (2010) attempt to examine the mechanisms by which religion shapes life satisfaction, an association that has often been documented as one that is positive and significant. Lim and Putnam utilize a new panel dataset from the Faith Matters survey to suggest that the social and participatory mechanisms of religion are responsible for influencing life satisfaction. Specifically, their results indicate that the reason religious practitioners are often reported as being more satisfied with their lives is due to their regular attendance at faith services and their establishment of congregation-based social networks. When other variables are controlled, their results suggest that independent of attendance and congregation-based friendship, other subjective components of religion do not affect life satisfaction. Furthermore, Lim and Putnam (2010) note that the social networks that individuals build in their religious congregations are responsible for mediating most of the effects of service attendance on life satisfaction.

This study has been identified as a key study  due to its focus on social networks as the key mediator of the oft-reported positive relationship between religious service attendance and life satisfaction.

Methods:
Lim and Putnam (2010) utilize data collected from the Faith Matters Study in 2006 and 2007. The study is one that examines the religion-social capital relationship across America. A representative sample of 3,108 adults received interviews with a representative, and in 2007, the adults were re-contacted for a second interview, with 1,915 being interviewed.

Subjective well-being was the key outcome variable of this study, and it was assessed with self-rating questions concerning life satisfaction. Religious involvement was assessed with a common classification scheme, which grouped the nine religious traditions separately. The measure of religious involvement also took into account the frequency of religious service attendance, as well as the private and more subjective aspects of religion. Social resources were then assessed through questions regarding the range number of friends and social or civic involvement.

Results:
First, panel data analysis was utilized to explore whether religious service attendance improved life satisfaction. This study confirmed the consensus in the literature that religious service attendance (in each of the traditions) is positively related to life satisfaction. Even upon including social networks into the statistical model, the relationship between religious service attendance and life satisfaction still remained significant and substantial, thus indicating that social involvement might not mediate the relationship between religion and well-being.

Upon adding the number of close friends that respondents have in the congregation, the results indicate that friendship within a congregation is significantly associated with life satisfaction. In addition, congregational friendship and social networks within the place of worship also account for the effect of religious service attendance on life satisfaction. This demonstrates that “only when one forms social networks in a congregation does religious service attendance lead to a higher level of life satisfaction” (Lim and Putnam, 2010, p. 920).

In terms of religious identity, Lim and Putnam’s data analysis demonstrates that individuals with a strong religious identity have a higher level of life satisfaction than those without such an identity, even after controlling for service attendance and social networks within the congregation. Lim and Putnam (2010) also found that private religious practices, such as prayer, do not show a significant association to life satisfaction, demonstrating that the collective, congregation-based experience is more closely linked to life satisfaction than private or personal religious practices.

Conclusion:
In this research study, Lim and Putnam (2010) provide two major findings concerning the association between religiosity and life satisfaction. The first is that although the literature espouses that religious people have higher levels of life satisfaction (compared to non-religious people), further evidence needs to be established by the authors of such studies. The second finding is that even with the new data set, the mechanisms that underlie the religiosity-life satisfaction association still remain unclear.
One of Lim and Putnam’s most notable findings here is that the social networks within a congregation are responsible for mediating most of the impact that religious service attendance has on life satisfaction.

Noted Limitations and Future Directions
Because of the discrepancy with previous studies, future studies may seek to replicate the findings of this study, especially in terms of the aspects of religion that remain most private or personal, such as prayer or meditation.

Koenig, H. G. (2012). Religion, spirituality, and health: the research and clinical implications. International Scholarly Research Network - Psychiatry 278730: 1-33.

Introduction
This systematic review by Koenig (2012) provides a comprehensive examination of research conducted on religion/spirituality (R/S), mental health, and physical health. Here, Koenig reviews data-based, quantitative research published between the years 1872 and 2012. He first provides a concise historical background, and then reviews research on R/S and mental health, which he then follows with a description of the mechanisms through which R/S may influence mental health. Next, Koenig reviews research on R/S and health behaviors, as well as R/S and physical health outcomes. He also describes the mechanisms through which R/S may influence physical health. Koenig then concludes by recommending actions health professionals may find helpful in light of these findings.

This review has been identified as a key study because of the breadth of research findings (particularly randomized controlled trials) that are evaluated, as well as the focus that Koenig places on integrating his findings with actions by health professionals.

Methods
To summarize the research findings between R/S and different facets of health (mental health outcomes, health behaviors, and physical health outcomes), Koenig reviews peer-reviewed, original, quantitative reports published through 2010 that were summarized in the Handbook of religion and Health. To identify the studies, the research team first systematically searched online databases, utilizing the key words “religion,” “religiosity,” “religiousness,” and “spirituality” to find studies that investigated the relationship between R/S and health. Next, the team asked well-known researchers studying this relationship to alert them to any published research regarding this topic. The team also investigated all studies cited in the reference lists of the studies that were located. Overall, Koenig identified more than 1,200 peer-reviewed, quantitative publications during the period 1872-2000, and 2,100 studies examining the association between R/S and health from 2000 - 2010. Koenig estimates that this review captures about 75% of the published research.

In assessing the methodological quality of the studies, a single examiner rated each of the 3,300 studies on a scale of 0 (low) to 10 (high). Scores were determined according to eight criteria: (1) study design, (2) sampling method, (3) number of R/S measures, (4) quality of measures, (5) quality of mental health outcome measure, (6) contamination between R/S measures and mental health outcomes, (7) inclusion of control variables, and (8) statistical method. To ensure that the ratings were reliable, the team compared the examiner’s ratings on 75 studies with the ratings of an independent, outside reviewer. The ratings were moderately correlated (Pearson r = 0.57). Furthermore, the kappa of agreement between the two raters was 0.49, where good agreement is indicated by kappas of 0.40 - 0.75.

Results
Of the research reviewed by Koenig, approximately 80% of studies on R/S and health are those related to mental health. In considering well-being/happiness, Koenig writes that by mid-2010, at least 326 peer-reviewed, data-based studies had examined the relationship between R/S and well-being. Of those 326 studies, 256 (79%) found only significant positive associations between R/S and well-being. Only three studies (<1%) reported a significant inverse relationship between R/S and well-being.

Out of the 326 studies investigating the association between R/S and well-being, 120 were found to have the highest methodological rigor (on a scale of 0-10, these studies had a “7” or higher). Ninety-eight (82%) of these rigorous studies reported positive relationships between R/S and well-being/happiness. One study reported a negative relationship, although at a trend level (Dalgalarrondo et al. 2008).

Koenig explains the influence of R/S on mental health through a variety of mechanisms. The first is that religion/spirituality provides resources for coping with stress; these resources may increase the frequency of positive emotions and may it less likely that the stress a person experiences may further contribute to emotional disorders. Cognitions, or strongly-held beliefs, are an example of coping resources that provide a sense of purpose, as well as a sense of subjective control over an event. A second mechanism of influence is that through religion, an individual’s existential “angst” can be reduced because faith traditions often impart answers to certain existential questions, and by doing so, these traditions provide role models (in religious scriptures) to people suffering with similar challenges. Koenig also notes that religious beliefs can potentially alter the way in which a person cognitively appraises a negative life event or a stressor, thus making such a stressor seem less distressing.

Another mechanism is demonstrated in the rules and regulations inherent in most religions. By abiding by the doctrines and regulations provided by a certain religion, individuals also decrease the likelihood that they will experience a stressful life event, such as divorce or incarceration. In addition, the prosocial behaviors of most religions (in which members meet together during religious social events) also encourage members to focus “outside of the self” and engage in activities that are meant to help others, thus increasing positive emotions.

Conclusion
In his systematic review of the literature, Koenig notes that there are many possible ways that religiosity/spirituality may have an impact on an individual’s mental or social health. He places particular emphasis on the fact that this positive impact is not always the case. R/S is sometimes the basis for a variety of pernicious or dangerous behaviors, such as hatred, prejudice, excessive guilt, or antagonistic relationships with others. On the whole, however, R/S is associated with greater mental or social health, well-being, and improved coping with life stressors. These mental health associations are then often translated into improved physical health outcomes.

Noted Limitations and Future Directions
Although the consensus in the literature is that religiosity/spirituality is associated with enhanced well-being, numerous questions remain about the relationships between R/S, well-being, and happiness. One key question concerns the characteristics of religious involvement (such as social networks) that influence well-being among practitioners of a certain faith. Furthermore, more randomized clinical trials and high-quality prospective cohort studies (occurring over a long period of time) are needed to examine the R/S-happiness relationship among diverse communities (particularly including non-Christian and high-risk communities) and in varied locations. Koenig also raises an interesting question when he writes that “further work is needed to understand what subjective psychological well-being means to those in other religions and other cultures” (Koenig 143). It is key to “translate” the Western concept of subjective psychological well-being to individuals with other diverse worldviews.

Krause, N. (2006). Religious doubt and psychological well-being: a longitudinal investigation. Review of Religious Research 50: 94-110.

Introduction:
A variety of studies in the social science literature have investigated whether religious doubt contributes to the erosion of feelings of psychological well-being. However, the findings have been inconsistent, because of non-representative samples, the inclusion of cross-sectional data, and most importantly, that researchers have not fully examined the ways in which doubt affects people differently. In this study, Krause examines the relationship between religious doubt and three measures of psychological well-being: (1) life satisfaction, (2) self-esteem, and (3) optimism. This study is also unique in its focus on improving upon the limitations faced by other studies; specifically, Krause utilizes data from a longitudinal, nationwide sample of older adults, as he suggests that utilizing cross-sectional data makes it more difficult to determine the direction of causality between religious doubt and well-being.

This study has been identified as a key study due to its longitudinal nature, as well as its focus on investigating the role of religious doubt (rather than religious belief) in contributing to decreased psychological well-being.

Methods:
The data sample comes from a national, longitudinal survey of White adults and African American adults (N = 1,500) who were at least 66 years of age, resided in the contiguous United States, and who were either: currently practicing Christianity, not practicing any religion (but had practiced Christianity in the past), or had not practiced any religion during their lifetime.

Baseline interviews took place in 2001, and the second wave of the survey was completed in 2004, with 1,024 of the original 1,500 participants being successfully re-interviewed. Thus, the re-interview rate was 80%. Different statistical analyses were then conducted to determine the effects of religious doubt and education upon diverse psychological well-being outcome measures.

Religious doubt was assessed using a 5-item measure designed by Krause (2002), and life satisfaction was assessed using the Life Satisfaction Index A. Self-esteem, optimism, education, and demographics were also measured.

Results:
The results from this study ultimately suggest that (1) older adults with more education are more likely to have doubts about religion; (2) religious doubt is associated with a decreased sense of well-being over time; and (3) older individuals with more education are less likely to experience the negative effects of doubt when compared to individuals with fewer years of schooling.

In regard to life satisfaction specifically, the results from this study suggest that older adults with more doubts about their religion do not experience significant changes in life satisfaction over time; however, the influence of religious doubt on changes in life satisfaction depends upon the adult’s level of educational attainment. For older adults with only six years of schooling, the data demonstrates that greater religious doubt is associated with a decrease in feelings of life satisfaction over time. Among older adults who completed an eighth-grade level education, a similar trend is noted, but the amount of change in life satisfaction is not as large. However, for adults who completed a college-level education, religious doubt did not influence changes in life satisfaction over time.

In terms of self-esteem, the results suggest that religious doubt is associated with a decrease in feelings of self-worth for older adults with only six years of schooling. A similar trend is observed for individuals who completed eight years of schooling; however, the effects are reduced by 19%. Among older individuals who completed a college education, religious doubt is not suggested to lower feelings of self-worth over time. A similar trend is observed in the findings with respect to optimism; Krause writes that “the deleterious effect of religious doubt on change in optimism declines steadily as we move from older people with less education to older adults with more schooling” (Krause 2006, p. 104).

Krause identifies two key mechanisms describing why older individuals with less education may be at a greater risk for experiencing decreased well-being because of religious doubt. The first is that older individuals with fewer years of schooling may be unable to “reason their way through religious doubt,” and may thus resort to denying or repressing their doubt (p. 104). The second mechanism is that upon having doubts about their faith, older adults with less education are more likely to feel that it is wrong to have doubts, and may thus feel guilt, shame, or other negative emotions that make self-forgiveness less involved.

Conclusion:
This study is unique in that the data was provided by nationally representative sample of older adults and that it was a longitudinal investigation, with interviews occurring at multiple points across an individual’s lifespan. Furthermore, this study also demonstrates that older individuals with more education are more likely to have religious doubts, and that religious doubt is associated with decreased well-being over time for this sample.

Noted Limitations and Future Directions:
One limitation of the study is that psychological well-being may not be the best way to assess growth that occurs from experiencing religious or spiritual doubt; rather, by experiencing doubt, an individual may not seek to feel content, but to instead feel as though they are continually learning. In addition, more research is needed on the responses that trusted peers or loved ones may have to an individual’s religious doubts, as the social responses could influence elements of their psychological well-being.

Ryan, M. E., and Francis, A. J. P. (2012) . Locus of control beliefs mediate the relationship between religious functioning and psychological health. Journal of Religion and Health 51 (3): 774 - 785.

Introduction:
Previous research in the social sciences has demonstrated that religious-based or spiritual-based beliefs and practices are predictive of physical and mental health, although the pathways for this association still remain speculative. In addition, other studies have also investigated how “locus of control” (LOC) of reinforcement may serve as a predictor of health. A locus of control is a belief regarding whether certain rewards are the byproduct of one’s own actions, or whether an external entity (or force) produced the rewards, rather than the individual himself (Ryan and Francis, p. 775). Currently, it is unknown how LOC, health, and religious functioning are related.

In this research study, Ryan and Francis (2012) examine the associations and mediating pathways between religious functioning, locus of control beliefs, and psychological health. They hypothesize that higher scores on variables of internal LOC, God LOC, and awareness of God would correlate with enhanced psychological and physical health. They also hypothesize that an external LOC or instability would be related to decreased psychological or physical health.

This study has been identified as a key study due to its unique investigation of the association between locus of control, religious functioning, and psychological health.  The work of Ryan and Francis (2012) was seminal in postulating that an internal locus of control mediates the relationship between awareness of God and psychological health.

Methods:
One hundred and twenty-two Christians completed questionnaires measuring (1) psychological and physical health, (2) the religious variables of awareness of God, and (3) God, internal, and external locus of control (LOC) domains. The sample was composed of 65% women and 35% men, and most participants resided in Melbourne, Australia.

The participants completed a variety of questionnaires related to health, locus of control (internal, external, and God LOC dimensions), and religious functioning.

Results:
Their results suggested that higher levels of an awareness of a transcendental force (“God”) had a moderately positive relationship with improved psychological health (but not physical health). Internal LOC was found to mediate the relationship between awareness of God and psychological health. Ryan and Francis (2012) thus postulate that an awareness of God fosters an internal LOC, and an internal LOC leads to improved health. Furthermore, the results from this study also support the consensus in the research literature that religiosity or religious functioning can reduce symptoms of poor mental health or could serve to prevent/avoid mental health challenges in general.

Conclusion:
This study is unique in that it reveals the health effects of religious functioning, particularly in terms of locus of control pathways. The findings are very applicable to clinical therapists, who may need to address with patients other elements of belief systems in hopes of improving upon detrimental symptoms of mental health.

Noted Limitations and Future Directions:
It is crucial that further research clarifies the construct of the God locus of control, as it must be operationalized in one consistent manner. Furthermore, future research could also investigate other religious traditions to determine health benefits.