April 2008 - Volume 2, Issue 2

SPIRITUALITY AND SPIRITUAL COPING STRATEGIES IN IRANIAN INSTITUTIONALIZED ADOLESCENT GIRLS: A QUALITATIVE STUDY

Maryam Rassouli, PhD candidate, Shaheed Beheshti Medical University, Faculty member of nursing department, University of Social Welfare & Rehabilitation Sciences. Address: Nursing department, University of Social welfare & Rehabilitation Sciences, Kudakyar Ave., Daneshju Blvd., Evin street, Tehran. Email: rassouli.m@gmail.com   Farideh Yaghmaie, PhD, Associated professor, nursing school, Shaheed Beheshti Medical University. Mansureh Saeedolzakerin PhD, Assistant Professor, nursing school, Shaheed Beheshti Medical University.

Corresponding author Farideh Yaghmaie Shahid Beheshti Nursing & Midwifery School, Shariati Street. Email: farideh_y2002@yahoo.com

ABSTRACT Background: Spirituality in Iranian community, as an important aspect has a historical background. According to holistic approach, providing spiritual care for clients in different settings, considered as a nurse's responsibilities. Despite the number of institutionalized adolescents, there are a few studies to assess spirituality in this group. Objective: This qualitative study was carried out to explore spirituality and spiritual coping strategies in institutionalized adolescent girls. Method: In this qualitative study, 15 adolescent girls were interviewed during January-June 2006 about the role of spirituality and spiritual strategies in coping with stresses of living in institutes. Interviews were analyzed using content analysis method. Results: The main themes emerging from this study included spiritual attitude toward life, trust in God, differentiation between spirituality and religiosity, spiritual coping strategies, spirituality in difficult life conditions and situations to apply spirituality. Conclusion: The findings of the study provide in-depth understanding of Iranian institutionalized adolescent girls' experiences of spirituality and spiritual strategies in coping with stress which can be useful for nurses and other health care professionals for adolescents specially institutionalized adolescents. The findings can provide a framework for nursing care plans based on teaching spiritual coping strategies to decrease stresses of living in institutes.

Key words and phrases: spirituality, spiritual coping, spiritual strategies, institutionalized adolescents.

INTRODUCTION

According to the 2006 census, 37.46% of the Iranian population were aged 19 or less. At that time, there were 8,726,761 adolescents between 15 to 19 in Iran that nearly half of them,4,283,860, were girls⁽¹⁾. As per records of the Social Welfare Organization of Iran, there were approximately 18,000 children and adolescents in the age group 0-18 living in orphanage care in this country, which is known as "children and adolescents homes". 8,375 of these youngsters were placed in institutes, 9,072 in foster care, and a small number had been adopted⁽²⁾.

Adolescence is one of the most dynamic and complex transitions in the lifespan⁽³⁾ which is recognized to be a time of rapid change that can be stressful and difficult, drawing on all of one's resources⁽⁴⁾.

The experience of an adolescent in an institute is very different from that of an adolescent in a family and institutes do not allow for individualized attention ⁽⁵⁾. In this regard, one of the major areas which should be assessed in institutionalized children is their coping skills⁽⁶⁾.

Significant interest in the coping process has been evident in the research literature over the last 30 years however the role of religion and spirituality in coping has received relatively little attention as a specific area of study⁽⁷⁾. In addition, very little research has specifically examined how institutionalized adolescents cope with stress.

Religious belief is an important mechanism for coping with many crises⁽⁸⁾ and spirituality and religion are important factors for coping with life stressors ⁽⁹⁾. Faith and spirituality have been proposed as resilience factors in adolescents. Resilience has been described as "good adaptation under extenuating circumstances" which is associated with healthier living and the ability to overcome adverse situations⁽¹⁰⁾.

Spiritual-religious coping refers to how one's spiritual or religious beliefs, attitudes, and practices affect one's reaction to stressful life events. Religious coping measures the internal resources and reactions (⁽¹¹⁾. Spiritual coping appears to be most useful in situations of extreme stress that are out of one's control and may operate primarily as a form of emotion-focused coping⁽¹²⁾. Empirical studies have shown a clear connection between stressful life events and various forms of spiritual-religious involvement. In times of crisis people translate their general religious orientation into specific methods of spiritual-religious coping (⁽¹³⁾.

The prevalence of spiritual coping generally depends on the type of stressor, sample characteristics and situational factors⁽⁷⁾. In pediatric coping studies, which include sex as a variable of interest, some sex differences in the use of specific strategies are emerging. Girls are more likely than boys to seek social support and engage in emotion-focused avoidance to cope with illness or pain⁽¹⁴⁾. As spiritual coping is often conceived as emotion focused ⁽⁷⁾, it seems that girls apply this kind of coping more often than boys.

Although research has indicated that spiritual coping strategies are associated with adaptation to out of control stresses (like living in institutes), there is no information about how Iranian institutionalized adolescent girls cope with such a condition compared. Therefore, the purpose of the current study was to obtain a more in-depth understanding of the spiritual coping strategies used by Iranian institutionalized adolescent girls so that culturally sensitive healthcare and culturally relevant coping strategies may be promoted by healthcare providers.

METHOD

A descriptive design with purposive sampling was used to understand the nature of the phenomenon under study. The data were collected through in-depth interviews with participants, which were tape-recorded and transcribed verbatim. The sample size was determined by data saturation.

Participants were 15 Iranian institutionalized adolescent girls between 14 and 20, during the period January-June 2006. All of them residing at institutes in Tehran and were Muslim. The average of their age was 17.8. The participants were informed about the study and assured of confidentiality and anonymity.

Content analysis was used to study the data. The interviews were transcribed verbatim and analyzed concurrently with data collection. Throughout the study, issues of rigor and trustworthiness in qualitative methodology were addressed.

RESULTS

Six main themes were derived from analysis of data collected by interviewing the girls in institutes with respect to spirituality and spiritual approaches when facing with problems. Table 1 outlines the themes and their elements.

Spiritual attitude toward life: One of the reflections of spirituality in the life of adolescent girls was their attitude toward life in a way that they accepted their condition as a destiny or preference from God. For example, one of them said, "I'm satisfied with my life because God wants it like this; surely, it's been His wisdom, God wills it with thoughtfulness and we also shape our life." Another point in the statements of girls, reinforcing their spiritual attitude toward life was their belief in a holy and supreme aim in the existence. One of them said, "The aim of life is to reach to God and ourselves. …The main aim of life is to find the real self and God."

Belief in God as the sole reliable existence: Lack of a trustful person beside the adolescents is one of effective factors in their tendency toward God as a trustworthy entity. This repeated theme was evident in the statements of a girl, "There is nobody here to keep your secret. I wish I had somebody with whom I share my secrets and rely on it and express my feelings but nobody is here; it is a lack. This relates to the faith that God can only be trusted."

Distinction between spirituality and religion: The adolescents made distinction between the two concepts of spirituality and religion and considered themselves spiritual rather than religious although both aimed at reaching to God. …, "I know myself as a spiritual youth not religious. Maybe, a spiritual guy thinks more and a religious one acts more. The spiritual one, for example, thinks of God but the religious one prays and reads His holy book. Spirituality and religion are with each other. I like to be both spiritual and religious. By having both, I reach to God."

Spiritual coping mechanisms: One of common features in the girls was trust and reliance on God in problems and in facing with stresses of life. One of them said, "Somebody like me with no father, no mother, and in all nobody, has some guys around but nobody helps in problems. If she does not believe in God to help her in problems,… Many had to take drugs and got psycho. When I believe in God and feel sure to be guided and be helped, my problems become so easier. I always feel there is God helping me. When I see my past life, I see it."

Differences between the ideas resulted from the types of help the girls asked from God to cope with problems, which were classified in the three following groups.

• Belief in God's support
  Some girls believed that due to their special conditions in terms of family and deprivation from some blessings such as having parents, God has a particular kind of attention to them. "All men relates themselves to somebody, the one who can be better for them or solve their problems, the one who is nearest to them and love them and be the most pathetic. Well, God is like this."
  
• Collaborative opposition
  Another group of the adolescents while believing the concept of "reliance" considered faith in an effort to solve problems as important. One of the girls stated, "Spirituality is so effective. When a problem occurs, we should think of its spiritual aspects and not limit our thoughts to its looks. So, we can solve it better and life seems better. I see life more positively but it is better to note both outside and inside…for example, if we just say that this problem is a test from God and don't solve it, life not only does not get better but the problem also gets bigger and makes the things worse."
  
• Belief in God's will
  The other group of interviewees believed that, in some circumstances, God does not solve problems in spite of having the ability to do it. One of the girls said, "I believe in God. The ultimate power is God. Maybe it takes a second for God to do something that lasts many years for us! Of course, He doesn't do it but if I were God, I do the things much sooner. God acts very late."

Spiritual approaches: Adolescent girls referred to a range of ways considered spiritual from their view points. One of them asserted that spiritual approaches were effective in her coping process in the occurrence of problems. …"I leave it to God. Whatever is, let's happen. I cry, talk with my friends, vow too much, burn candle in holy places, and pray…Music makes me very easy. I myself play instrument… I think praying makes people very near to God. I talk with Him and He plays a major role in my life."

One of the spiritual coping mechanisms largely influential according to most subjects was praying. One of them defined praying as "praying is saying what we want and need from God. It's a request from God and it's good because it gives rest."

The adolescent girls considered faith as an important factor in coping with problems. One of them defined it as "a sincere link with God which is very interesting and not at all complex. It's so good because it protects us from bad events." The girls mentioned that peace would be the result of faith. One of them said, "If you have less contact with God, you surely have less peace. When I think to God much and feel a strong friendship with Him, I have more peace but when I am busy of things and feel disturbed."

Conditions for applying spirituality

• All conditions
  Some girls thought of spirituality as an available means in all situations and made no special condition for applying spiritual approaches. One of them said, "Spirituality needs no condition. It is available all the time. Spirituality is not always related to physical things."
  
• Hard conditions
  Another group of the girls emphasized that although spirituality can be applied in all conditions, people seek for it in hard conditions. One of them said, "When you need help and have problem in life which cannot do anything about it, spirituality is helpful. If you have no problem, you can be spiritual but it is stronger during problems."
  
  

DISCUSSION

This study is the first qualitative research regarding the role of spirituality and spiritual coping with stresses of life in adolescent girls between 14 and 20 residing at institutes. According to the results, the subjects had some spiritual attitude toward life and looked at their special situation with such a view point. It seems that such attitude toward life is present among Iranian women. In a study regarding coping process in women with breast cancer, findings showed that religious attitude was one of essential factors in reducing fear⁽¹⁵⁾.

The girls having distrust to others considered God as the sole reliable existence in their life and tried to make a profound relation and connection with Him. According to Erikson's developmental psychosocial theory, the most important outcome of childhood in the first year of life is to attain trust. Trust is formed during relations and interactions with others and the most critical period in shaping this sense is this period. Attaining this sense requires unconditional support and care from a sole caregiver during this time; the particular problems of these girls can be, therefore, attributed to the lack of formation of it.

In this study, the girls generally believed that spirituality is a more extended concept than religion and can contain other notions such as being religious. Accordingly, what was considered more important for them was faith to God and effective relation with Him which could be achieved by various rituals and convictions. Distinction between spirituality and religion as well as realization of its vastness over religion is in conformity with literal and related literature. Spirituality is a more broad term than religion. Although, many express their spirituality in the form of religious manners. Thus, although all humans may not be religious, everybody searching for the meaning of actualization is necessarily spiritual⁽¹¹⁾.

The girls thought that relying on God and applying spiritual approaches to face with problems and tensions in life were very effective and believed in their efficiency. Spiritual-religious coping may be psychologically helpful because it leads to emotional peace and personal capabilities ⁽¹⁶⁾. A group of the girls while believing the permanent presence of God and receiving His special support (resulted from their particular familial condition) were certain that God would solve their problems in any circumstances and only relying on Him could be sufficient for this. In contrast, another group while considering that reliance on God would be essential in problems believed in effort and struggle of man to confront difficulties of life. Besides the above groups, another group of the girls had different ideas and looked at the issues with uncertainty. They believed that God would be inattentive and somehow indifferent to their situation.

Pendleton and coworkers (2002) explained spiritual coping mechanisms in children with cystic fibrosis, which agrees with the findings of this study. They identified: a) spiritual-religious collaborative coping in which the child together with God as members of a group tries to cope with stress; b) belief in God's support, i.e., a conviction that God will certainly help the child, protect it and make it peaceful; and c) belief in God's intervention, that is, believing that God with His infinite power can reduce its stress ⁽¹⁷⁾.

In current study, the girls enumerated different approaches by which they could somehow cope with stresses they encountered. These approaches are the same as those referred in other studies. For instance, Mauck and Schmidt (2004) named such spiritual approaches as praying, therapeutic touch, Yuga, meditation, music and art⁽¹⁸⁾. Similarly, one of the most important spiritual approaches unanimously stated by the girls because of its efficiency and importance was praying. They believed that praying is relation with God and expression of desires and needs to Him which its ideal and valuable outcome is to achieve peace. In many instances, praying is considered as "facing of humans with themselves" or as "an attempt to relate with God."

Social scientists think that religious conducts have a buffering role in reducing stress. It seems that praying reinforces religious adaptation and this leads to reduction of the effects of negative factors on mental health. In addition, religion has more effects on mental health of those with higher levels of stress. Accordingly, praying should be regarded as one of behavioral guidelines to control hard circumstances⁽¹⁹⁾.

Findings showed that the girls believed faith is one of significant factors in coping with life stresses, leading to hope, peace and a positive feeling toward life and future. Sowell et al (2000) contend that such beliefs as faith in God, destiny, fate and … regarding the rules of nature are ones that enable an individual to create a conception out of hard conditions of life and to maintain his hope. These beliefs as an immense and powerful resource can suppress negative emotional responses in stressful events⁽²⁰⁾.

According to the girls, the conditions to apply spirituality or the appropriate time to utilize spiritual approaches range from all possible situations to only hard circumstances of life and stressful events. According to the studies of Fetzer institute (2003), there is an evident relationship between stressful events of life and different forms of spiritual as well as religious involvement. In the event of crisis, individuals modify their religious tendencies into different spiritual-religious approaches. Although spiritual and religious variables in individuals are assumed stable, spiritual experiences and spiritual-religious coping mechanisms may be influenced by daily vicissitudes. For example, studies have shown that higher levels of religious coping are associated with confrontation with more severe and stressful negative life events⁽¹³⁾.

Findings of this study may provide a detailed description of the role of spirituality and spiritual coping approaches to face with life stresses in institutes for adolescent girls. In fact, most of them suggested a positive role for spirituality and its approaches that were considered valuable by the girls. It seems that these findings can be used by health care providers including nurses as a framework for providing care in such centers. The care may be aimed to promote adaptation in the adolescents and, based on education and reinforcement of spiritual approaches, to confront with hard conditions of life.

Acknowledgements

The researchers wish to express their gratitude to all involved, the adolescents, and managers as well as staff of the centers.

REFERENCES

1. Statistical Centre of Iran. http://www.sci.org.ir/portal/faces/public/ecensus85 (accessed 11 November 2007).
   
2. Social Welfare Organization. http://behzisty.epr.ir/archives/cat. (accessed 11 November 2007)
   
3. Story M, Neumark-Sztainer D, French S. Individual and environmental influences on adolescent eating behaviors. Journal of the American Dietetic Association 2002;102(3),540-551.
   
4. Mi Sung K, Puskar KR, Sereika S. Psychosocial factors and coping strategies of adolescents in a rural Pennsylvania high school. Public Health Nursing 2006; 23(6), 52.
   
5. Gribble K.D. A model for care giving of adopted children after institutionalization. Journal of Child and Adolescent Psychiatric Nursing 2007; 20(1),14-26.
   
6. Committee on Early Childhood, Adoption and Dependent Care. Developmental issues for young children in foster care. Pediatrics 2000; 106(5), 1145-1150.
   
7. Thune-Boyle IC., Stygall JA., Keshtgar MR, & Newman SP. Do religious/spiritual coping strategies affect illness adjustment in patients with cancer? A systematic review of the literature. Social Science & Medicine 2006; 63, 151-164.
   
8. Batten M.& Oltjenbrunse K.A. Adolescent sibling bereavement as a catalyst for spiritual development: A model for understanding. 1999;23(6), 529-546.
   
9. Jacobs-Pilipski MJ, Winzelberg A, Wilfley DE, Bryson SW, Taylor CB. Spirituality among young women at risk for eating disorders. Eating Behaviors 2005; 6(4), 293-300.
   
10. Cotton S, Larkin E, Hoopes A, Cromer B, & Rosenthal S. The impact of adolescent spirituality on depressive symptoms and health risk behaviors. Journal of Adolescent Health 2005; 36(6),520-544.
    
11. Sulmasy DP. A biopsychosocial-spiritual model for the care of patients at the end of life. The Gerontologist 2002; 42,24-37.
    
12. Mohr WK. Spiritual Issues in Psychiatric Care. Perspectives In Psychiatric Care 2006; 42(3),174.
    
13. Fetzer institute. Multidimensional measurement of religiousness/spirituality for use in health research. Kalamazoo: 2003.
    
14. Lynch AM, Kashikar-Zuck S, Goldschneider KR, Jones BA. Sex and age differences in coping styles among children with chronic pain. Journal of Pain and Symptom Management 2007; 33(2), 208-216.
    
15. Taleghani F, Parsa Yekta Z, & Nikbakht Nasar Abadi AR. Coping with breast cancer in newly diagnosed Iranian women. Journal of Advanced Nursing 2006; 54(3), 265-273.
    
16. Keefe FJ, Affleck G, Lefebvre J, Underwood L, Caldwell DS, Drew J, Egert J, Gibson J, Pargament K. Living with rheumatoid arthritis: the role of daily spirituality and daily religious and spiritual coping. The Journal of Pain 2001; 2(2), 101-110.
    
17. Pendleton SM, Cavalli KS, Pargament KI, Nasr SZ. Religious/spiritual coping in childhood cystic fibrosis : a qualitative study . Pediatrics 2002; 109(1) ,8-23.
    
18. Mauk KL & Schmidt NK. Spiritual Care in Nursing Practice. Philadelphia: Lippincott Williams & Wilkins;2004.
    
19. Ai AL, Dunkle RE, Peterson C, Bolling SF. The role of private prayer in psychological recovery among midlife and aged patients following cardiac surgery, The Gerontologist 1998; 38(5), 591-601.
    
20. Sowell R, Moneyham L, Hennessy M, Guillory J, Demi A, Seals B. Spiritual activities as a resistance resource for women with human immunodeficiency virus . Nursing Research 2000; 49(2),73-82.