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OBM Integrative and Complementary Medicine

(ISSN 2573-4393)

OBM Integrative and Complementary Medicine is an international peer-reviewed Open Access journal published quarterly online by LIDSEN Publishing Inc. It covers all evidence-based scientific studies on integrative, alternative and complementary approaches to improving health and wellness.

Topics contain but are not limited to:

  • Acupuncture
  • Acupressure
  • Acupotomy
  • Bioelectromagnetics applications
  • Pharmacological and biological treatments including their efficacy and safety
  • Diet, nutrition and lifestyle changes
  • Herbal medicine
  • Homeopathy
  • Manual healing methods (e.g., massage, physical therapy)
  • Kinesiology
  • Mind/body interventions
  • Preventive medicine
  • Research in integrative medicine
  • Education in integrative medicine
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The journal publishes a variety of article types: Original Research, Review, Communication, Opinion, Comment, Conference Report, Technical Note, Book Review, etc.

There is no restriction on paper length, provided that the text is concise and comprehensive. Authors should present their results in as much detail as possible, as reviewers are encouraged to emphasize scientific rigor and reproducibility.

Publication Speed (median values for papers published in 2023): Submission to First Decision: 5.9 weeks; Submission to Acceptance: 14.7 weeks; Acceptance to Publication: 8 days (1-2 days of FREE language polishing included)

Current Issue: 2024  Archive: 2023 2022 2021 2020 2019 2018 2017 2016
Open Access Review

Spirituality as an International Coping Method during Covid-19

Beren Crim Sabuncu 1,†, Ankica Kosic 2,†, Amy L. Ai 3,†,*

  1. College of Social Work, Florida State University, Tallahassee, Florida, USA

  2. Dipartimento di Psicologia dei Processi di Sviluppo e Socializzazione, Faculty of Medicine and Psychology, Sapienza-University of Rome, Rome, Italy

  3. Colleges of Social Work, Medicine (Social Medicine and Behavioral Science), and Nursing, Florida State University, Tallahassee, Florida, USA

† These authors contributed equally to this work.

* Correspondence: Amy L. Ai

Academic Editor: Vsevolod Konstantinov

Special Issue: Mental Health and Substance Use Disorder During the COVID-19 Crisis

Received: January 20, 2024 | Accepted: September 26, 2024 | Published: October 15, 2024

OBM Integrative and Complementary Medicine 2024, Volume 9, Issue 4, doi:10.21926/obm.icm.2404059

Recommended citation: Sabuncu BC, Kosic A, Ai AL. Spirituality as an International Coping Method during Covid-19. OBM Integrative and Complementary Medicine 2024; 9(4): 059; doi:10.21926/obm.icm.2404059.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

The Covid-19 pandemic has brought forth global challenges in socioeconomic, political, and public health dimensions. For many, spirituality was a powerful source of support during this pandemic experience. The current review provides an apt overview of spirituality as a coping method to mitigate the mental and emotional impact of global turmoil of Covid-19 within the context of Europe. Using select studies from Czechia, Italy, and Turkey which have low, middle, and high religiosity indexes respectively, the potential positive effects of spirituality are examined across differing samples, geographical contexts, and traumatic events. We conclude that while spirituality is not a one-size-fits all method to mitigate the impact of trauma, exploration of potential interventions that also include spirituality might be beneficial for the field at large, and those affected by myriads of different acute or chronic traumatic events.

Keywords

Spirituality; character strengths; pandemic; protective factors; perceived spiritual support

1. Historical and Modern Conceptualization of Spirituality

Despite the modernity and advanced technologies of our age, two factors have remained important across centuries: religion and spirituality [1]. Both have been explored extensively within the context of coping with trauma, and while scientific interest in the former declines, an increasing number of scientists are exploring the latter [2]. Though religion and spirituality are used interchangeably in colloquial language and by some scholars [3,4,5,6], others suggest that these two concepts are to be differentiated [7]. There are differences in the conceptualization of spirituality and religion; while the former often refers to an intrinsic interconnectedness to transcendence, the latter refers to group identity comprised of social feelings and beliefs about the genesis of the world [7,8,9,10].

Having drawn a broad distinction between religion and spirituality, attention may be directed to spirituality as a standalone concept. Conceptualizations of the idea differ from one another and depending on the context. A study by prolific scientists of this field found that Danish theologians (i.e. specified to be clergymen) associated spirituality with the internal manifestation and practices of religion, whereas laypeople connected the idea to interconnectedness and transcendence [2]. The authors used their findings to underscore the contextual nature of the word, suggesting interpretations are bound to be shaped by time, place, and person. Another study, also spearheaded by La Cour, examined a large number of texts and associated writings on spirituality and supported that there exists a continuum of understandings: some centering on self-focused perspectives, others on universal interconnectedness, and yet others on a personal relationship with higher power(s) [11]. Margulies summarizes these three orientations effectively; “individualist spirituality is centered on the within. collectivist spirituality is centered on the institutions of religion. dialogical spirituality is centered on the realm of the between of an i and a thou.” [12].

The common thread in all definitions of spirituality is their focus on intra- or inter- related connectedness. In the 19th century, Friedrich Schleiermacher, a German scholar of theology, coined its original term as einunmittel barres existentialverhältnis in his quest of religious or spiritual experiences through consciousness and feeling [13,14]. This term means a direct existential relationship that embraces one's own resources. Having explored the divergence of connectedness directionality in the conceptualization of spirituality, it is of importance to define one of the foci of the current work. Among other, more common terms in spirituality research, this entry is also focused on a measurable factor of spirituality, perceived spiritual support (PSS). PSS is a concept that has emerged during exploration of spirituality as a potential resource for coping with substantial crises and intellectually digesting mortality [15,16,17]. The term refers to an ancient phenomenon that centers on an internalized resource of humans borne from their internal relationship with a higher power prior to the establishment of institutional religion [15]. PSS refers to what La Cour would name “a vertical connectedness” [2]. Demonstrating the vertical nature of PSS, interdisciplinary researchers Ai and colleagues have defined PSS as “a function of believing one has intrapersonal support from a deep connection with a higher power or a spiritual relationship, which includes intimacy, emotional, cognitive, and resource aspects of this relation” [15].

Some of the earliest studies on the topic examined PSS as a function of religion, focusing on its stress-buffering and meaning making role. Multiple studies on the topic recruited patients with high health related stress, such due to Alzheimer's, advanced cancer, long-term dialysis, or parenting a child who has cancer [18,19,20,21,22]. Some other seminal studies contrasted the stress-buffering impact of perceived spiritual support amongst high and low reported stress samples, such for college students who have differing amounts of life stress, or elderly with different self-rated health statuses [23,24]. Majority of the studies, barring Barbarin and Chesler’s [22], reported that PSS played an important role in coping with high stress. The Barbarin and Chesler study was later criticized for using a single-item spirituality criterion with unknown reliability and validity [23]. Yet still, all aforementioned studies were instrumental in establishing that spirituality, religion, or PSS could potentially have stress-buffering benefits. This awareness increased empirical attention on these concepts as potential coping methods that lead to increased wellbeing.

The above attempt at offering a historical precedent to spirituality and related concepts is hoped to serve as a springboard for the readers as they delve deeper into literature examining spirituality as a coping method. A number of previous reviews, some systematic and some including meta-analyses, have examined the potential of religion and spirituality as a coping method during the Covid-19 pandemic [25,26,27,28]. Conversely, the current work will not attempt any statistical or systematic analyses. Our aims are to reflect on the historical origins of spirituality (i.e., as attempted above), narratively synthesize extant literature on spirituality as a coping method, and contrast findings from three different religious contexts, namely Turkey, Italy, and Czechia, on the efficacy of spirituality as a coping method during Covid-19.

2. Why Examine Spirituality as a Coping Method

Several studies have demonstrated that spirituality, religion, or PSS, can serve as character strengths when processing high stress and high impact situations [13,15,17,29,30,31,32,33,34]. Spirituality has been examined in a wide variety of contexts, ranging from natural disasters, national crises, and acute or chronic medical conditions, to academic wellbeing [15,35,36,37,38,39]. In studies that have found spirituality to have statistically important benefits, these ranged from positive impact on participant mental health and wellbeing, to facilitating coping and mitigating the negative outcomes of a traumatic event [29,40,41,42,43]. The most substantial of the demonstrated mental health benefits of spirituality have been lower levels of anxiety and lessened depressive symptoms/severity in response to a wide range of potentially traumatic experiences.

The aforementioned benefits (i.e., mental health and coping) span from potentially traumatic events linked from birth to death, covering the entire range of human experiences. In fact, there have been many studies with extremely diverse samples, whether by virtue of geographical location or other demographics (ex. age). In an effort to showcase the extensive exploration of spirituality throughout the life course, reviewing some selected studies that demonstrate said diversity would be of use. Exploring the impact of spiritual wellbeing on post-partum depression in a sample of 200 Iranian mothers, Akbari and collaborators found that spiritual wellbeing was predictive of lesser depressive symptoms when controlling for social support [36]. Another study, examining post-traumatic resilience in Ugandan child soldiers demonstrated that posttraumatic resilience was associated with higher PSS [44].

Questioning the impact of religion and spirituality within a sample of adolescent psychiatric patients in the United States, Dew and collaborators found that negative religious support, loss of faith, and negative religious have statistically important relationships to level of depression. Further, their longitudinal analysis supported that loss of faith predicted less improvement in depression scores over 6 months [45]. Negative relationships between both depression or perceived stress, and spiritual well-being were retained for a sample of 518 Korean nursing students [46]. Of note, this study differentiated between religious, spiritual, and existential well-being, adding that existential well-being had a more substantial inverse relationship with stress and depression than religious well-being. The inverse relationship between depression and spiritual well-being was retained also for a sample of North American patients living with HIV/AIDS (n = 450) [47]. The distinction between religion and spirituality remained apparent for this sample, as personal religiosity and having a religious affiliation was not associated with depressive symptoms when controlling for other factors.

For patients with advanced illness, such as chronic obstructive pulmonary disease, heart disease, or cancer, spirituality was connected to lowered depression and anxiety as well as facilitating coping with illness-related hardship across three studies in Iran, Italy, and the United States respectively [48,49,50]. For elders, there emerged a relationship between higher spiritual wellbeing and lower depression, a finding supported by two studies from Taiwan and the United States respectively [51,52]. Lastly, spiritual health was a negative predictor of death anxiety for a sample of 385 Iranian participants, as it explained 26.7% of the variance in death anxiety in this sample [53].

All of mentioned studies underscore the significance of spirituality within the context of coping, mitigating less favorable mental health outcomes, and facilitating transitional periods such as birth, traumatic events, acute and chronic illness, and death. Especially worthy of note, the above studies have been conducted in geographically and culturally dissimilar environments with demographically dissimilar samples. Spirituality has not only aided people’s capacities to reduce psychological distress, but also to cope with trauma, and improve their quality of life [54,55,56]. The statistical relationships that have retained across such diversity are further support for the potential of spirituality as a coping method. It remains that spirituality is not a solution for substantial life crises, neither is it a one-size-fits-all remedy for extreme psychological distress. Spirituality, as a coping method, has been demonstrated to be of statistical importance mainly in cases of high stress inducing events or experiences. This trend is consistent with the assumptions of one of the earliest studies on PSS as a stress-buffering factor [23].

3. Methods

The current manuscript has taken shape in accordance with the Scale for the Assessment of Narrative Review articles [57]. The review was undertaken as spirituality is an underrepresented coping tool that has the potential to benefit both research and practice, and the Coronavirus pandemic is a globally shared trauma of unforeseeable proportions. Further, Europe is the continent with the second highest death toll, housing countries with widely differing cultural and religious contexts [58]. Considering the unique nature of the pandemic, wide diversity of Europe, and the importance of a country’s religious context, the review adopted the above described parameters of our study. Literature searches occurred between November and December of 2023. Sources were derived from the authors’ personal libraries (which is noted to be appropriate for narrative reviews) [59], as well as database searches using the terms of “spiritual coping”, “Covid-19”, “pandemic”, “Turkiye or Turkey”, “Czechia or Czech Republic”, and “Italy”, connected using Boolean operators. Databases consisted of APA Psycinfo, Academic Search Complete, and Web of Science. The time frame was limited to between 2019-2023. Important to note, as narrative reviews do not adhere to the strict structure of systematic reviews, the current manuscript had its findings synthesized and presented with other research illuminating the mental health or other pertinent contexts of a country. Further, the results presented below do not represent an exhaustive search, but rather an overview of studies appropriately representing spirituality as a multifaceted coping tool that may apply in certain contexts.

4. Spirituality, Europe, and Covid-19

The Covid-19 pandemic has caused a global devastation of unprecedented proportions. The first confirmed case was on January 9th, 2020, the World Health Organization (WHO) declared it to be a global pandemic on March 11th, 2020, and the following years were shaped by lockdown and stay-at-home mandates [60]. According to most recent data released by the WHO, Covid-19 has disastrously resulted in 6,974,473 deaths, and of these 2,252,210 occurred in Europe, making it the continent with the second highest death toll [58]. It could be argued that the pandemic was the most devastating global disaster in modern history, and worded lightly, the global pain and suffering has caused an increase in mental health distress and other social and economic concerns for many [61].

Though the current work will focus on a European context, the mental health impact of Covid-19 has been demonstrated globally. A rapid scoping review reporting on the mental health toll of Covid-19 in its first 7 months found that the prevalence of all forms of depression was 20%, anxiety 35%, and stress 53% in the combined study sample of 113,285 people, with studies collected from China, India, Spain, Italy, and Iran [62]. Beyond the overall stress of a global pandemic, the implications of stay-at-home orders were multifold, impacting every domain of our lives. Due to requirements of social distancing, students were instructed to continue their education at home. This impacts the way students interact, the time they spend with family, and the mental health distress experienced by the students and staff [63].

With families having to spend more time in the same space, cases of child abuse and domestic violence also increased, adding to the mental health distress caused by a global pandemic [64,65]. Conversely, those who had less family exposure or otherwise low social capital experienced an increase in mental health distress, namely anxiety and depression [66,67]. Though the common global stressor was the pandemic, underrepresented and minoritized demographics experienced additional or identity-specific stressors; students, women, front-line workers, child-free individuals, those who have more than 2 children, individuals with unsteady family income, and individuals with pre-existing mental or physical health conditions and risk factors all experienced higher levels of anxiety and depression [68,69,70,71,72,73].

There have been a number of studies exploring the impact of spirituality within the context of Covid-19. A systematic review with a combined sample of 3,455 participants found that spirituality within the context of Covid-19 was related to ameliorated health outcomes, and also personal meaning making and posttraumatic growth [25,26]. These findings are consistent with the above-mentioned evidence assessed within differing contexts and with highly varying samples. Another review, further underscoring the differences between spiritual and religious practices, found that some religious communities played detrimental roles as a response to the pandemic. Calling the influences of religion a “double-edged sword”, supporting that some religious communities spread misinformation about the virus, religious travel (i.e. to shrines or rituals) contributed to virus transmission rates, and religious commitment was found to be associated with mistrust in science [74]. The same study showcased numerous other ways in which religion was of importance and protective, so it cannot conclusively be stated that religiosity is exclusively related to medical risk behaviors.

Though the global impacts of Covid-19 have been briefly detailed above, there are multifold reasons and rationales for focusing on a European context for the purposes of the current narrative review. Europe is of particular importance as it is the continent housing countries with arguably the widest modernization divides, closest geographical proximity, and vastly different political, cultural, and social spheres, which reflects on its religious diversity [75]. Further, the continent experienced the second highest rate of death, closely following the Americas despite a difference in size and population [58]. Given its unique geopolitical composition and religious diversity, an exploration on the impact of PSS in Europe would present a unique contribution to PSS research.

In an effort to provide an overview of the impact of spirituality across the different European countries, the current work will include three countries according to their religiosity index (RI), and specifically, the percentage of citizens that believe in a personal God, an indicator closely resembling PSS, or belief in a vertical transcendence [11,75]. These countries, as asserted above, consist of Turkey, Italy, and Czechia. Turkey has an RI of 90.6%, making it the second highest after Georgia [75]. As there have not been numerous Georgian studies focusing on the relationship between spirituality and coping during the pandemic, Turkey will be used as an example of a country with a high position in the RI. Before providing an overview of the pertinent research in Turkey, it is important to briefly summarize the levels of mental health distress therein. A study reporting on data collected from 1,267 people across more than 70 cities in Turkey found that 34% scored above the clinical cutoff for anxiety, 30.9% for depression, supporting an increase in both after the pandemic [76]. Other studies have further supported said increase in anxiety and distress in the Turkish population [77,78,79].

Findings from Turkey are consistent with their RI. A study with a sample of 1,780 Turkish elders found that there was an inverse relationship between spirituality and the fear of the Coronavirus [80]. Another, also with an older adult sample (n = 476), demonstrated an inverse relationship between spiritual support and loneliness during the pandemic [81]. Spirituality had a direct inverse relationship with pandemic-related hopelessness in another sample of 418 Turkish individuals [82]. The relationship between hopelessness and spirituality was supported by a second study, which further added that spirituality was positively correlated with resilience in their sample of 546 participants from the general Turkish population [83]. Lastly, according to results derived from a sample of 336 pregnant women, spiritual well-being was related to lessened depressive symptoms and ameliorated coping with stressors related to the pandemic [84]. There are numerous additional studies supporting the positive impact of spirituality with respect to pandemic related distress in Turkey [85,86,87,88,89]. The findings appear to support the pattern of above examined studies on traumatic life events and natural disasters.

Italy has an RI of 58.9%, placing it on the upper middle cluster of countries on the index [75]. Similar to the above justification on Turkey, Italy is selected due to the number of available studies conducted with the country’s population. An Italian health survey reports that, following the pandemic, mild-to-severe anxiety and depression climbed to 36 and 32 percents respectively [90]. Concerns about Covid-19 and related distress was linked to low PSS for a sample of 218 participants [91]. Another study, also examining PSS, found that higher spiritual support was linked to lower mental distress in Italy (n = 235) [92]. The same study reported that there was no relationship between spirituality and anti-coronavirus-vaccine attitudes. Another reported that while the protective impact of spirituality was retained in their sample of 1,250, the participants also reported lower levels of spiritual wellbeing compared to their pre-pandemic experience [93]. A unique contribution to the literature, a study explored the experiences of Chinese immigrants in Italy, finding that PSS moderated the relationship between; a) concerns about Covid-19, and b) psychological distress and chronic tendency to worry [94]. There are relatively less studies exploring the impact of spirituality on pandemic-related distress in Italy than in Turkey, which seems to be reflecting their respective RIs.

Lastly, Czechia was included due to its low RI of 10.2%, the lowest on the RI [75]. A Czech study assessing the psychosomatic and emotional outcomes of the pandemic reported that there were increases in adverse outcomes for between 3.2-17.3% respondents and 9.9-33.3% respondents respectively (n = 1,431) [95]. One study reported that spiritual participants were more likely to report increased levels of physical activity, sex, and self-education during the first wave of the pandemic (n = 1,434) [96]. They further reported that that spiritual and religious participants were less likely to feel hopeless, and that spirituality alone did not lead to lower hopelessness to the extent of religion and spirituality combined. Another study, solely assessing religion and spirituality factors in a sample of 459 Czech participants, found that spirituality was associated with believing in religious conspiracy theories and vaccine refusal [97]. Another, conducted after the previously examined study, reported that vaccine refusal was connected to a number of demographic factors, two of which were governmental distrust and being a non-affiliated believer (vertical spirituality) [98]. The same study noted that Czechia was one of the most affected countries in the world.

5. Conclusions

An overview of spirituality as a protective factor supports that the stress-buffering effects of spirituality have been documented within multiple differing contexts and populations. The Coronavirus led way to what was the most disastrous global pandemic in modern time. Considering that spirituality and its positive impacts remained statistically important globally, and further, when comparing three vastly different countries in Europe, is an indication of its potential use in mental and physical healthcare services. There are inherent limitations to a narrative review, such as the non-use of systematic methodologies. Authors of the current work do not claim to have identified all pertinent literature. However, some patterns have emerged in our findings which allow us to make general recommendations for future research.

For future research, it is of the highest level of importance to explore some other potential protective aspects of spirituality that may emerge. It would be beneficial to explore the impact of spirituality as a stress-buffering method globally, statistically exploring the differences in impact across countries grouped by gross domestic product, religiosity, or mortality. Future studies must aim to bridge these critical gaps by employing longitudinal research designs and expanding their participant pool to include more representative samples or diverse populations. This approach will enable a more comprehensive understanding of the intricate interplay between spirituality and coping in the face of potentially traumatic events.

We are living in a world particularly characterized by worsening manmade and natural disasters, deteriorating mental health across the globe, and inequity. Further exploration has the potential to pave the way for a multitude of prospective research endeavors aimed at establishing inter- or intra- personal psychological interventions designed to alleviate the tremendous stress experienced by us all. It is also crucial to emphasize, as afore cautioned, that we must not oversimplify spirituality as a one-size-fits-all solution for coping with disasters, trauma, or pain. We should approach it as a dimension of human nature that would benefit from a more sophisticated and comprehensive exploration.

Author Contributions

B.C.S., A.K., and A.L.A. were all instrumental in conceptualizing, conducting a literature review, and writing the manuscript.

Competing Interests

The authors have declared that no competing interests exist.

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