The International Journal of Psychosocial Rehabilitation

 YEUNG Wai-keung, Jerf
 Research Associate
 Department of Applied Social Sciences
The Hong Kong Polytechnic University
Email : ssjerf@polyu.edu.hk

 CHAN Yuk-chung
 Associate Professor
 Department of Applied Social Sciences
The Hong Kong Polytechnic University
Email : ssycchan@polyu.edu.hk

Abstract

However, the postulations of Freud and other mental health scholars concerning the neurotic influences of religion have had an enormous impact on the field of mental health in the 20^th century. Freud had been skeptical, if not antagonistic toward religion. He suggested that the less religious people were more mentally healthy (Ellis, 1980, 1988). Wendell Watters, another well-known psychiatrist, also stated that religious beliefs were responsible for the development of low self-esteem, depression, and even schizophrenia (Watters, 1992). In fact, during much of the 20^th century, mental health professionals tended to either deny the religious aspects of human life or consider religiousness as old-fashioned or pathological. They anticipated that religious issues would disappear as mankind matured and developed. Scientific and systematic research lending support to a positive relationship between religiousness and mental health emerged only in past twenty years.

Recently, ideas about the relationship between religiousness and mental health have changed dramatically. Obviously, a great multitude of psychological, psychiatric, medical, public health, sociological and epidemiological studies conducted during the past two decades proved the beneficial and protective effects of religious involvement (the term “religious involvement” will be used interchangeably with other terms such as “religious engagement” and “religiousness” in this review, and this will be elaborated in the part on method later in this paper) on people’s mental and physical health as well as on their longevity. These studies also showed religion is an important aspect of human life. Evidence supporting these findings emerges from both cross-sectional and longitudinal studies, as well as from studies based on both clinical and community samples (George et al., 2002; Plante & Sherman, 2001). This empirical evidence apparently contrasts with the skeptical and hostile attitudes towards religion of Freud and earlier mental health scholars, which were largely formed and based on their negative experiences with religion and their encounters with the psychiatric patients (Meissner, 1984; Zilboorg, 1958; Koenig, 2001).   

Over the past two decades, a lot of studies have uncovered a strong positive association between religiousness and mental health. This association has extended across various populations, including samples of the young, adults, older people, general community residents, immigrants and refugees, college students, the sick, addicts, homosexuals, persons of parenthood,  individuals with mental health problems and personality disorders (Alvarado, et al., 1995; Baline & Croker, 1995; Braam et al., 2004; Chang et al, 1998; Donahue & Benson,1995; Idler & Kasl, 1997; Jahangir et al., 1998; Kendler et al., 1996;  Koenig, George & Titus, 2004; Levin & Taylor, 1998; Mickley et al., 1995; Miller et al., 1997; Pardini et al. 2001; Plante et al. 1995, 2001; Richards et al. 1997; Selway et al., 1998; Thearle et al., 1995; Woods et al, 1999).

Past research and reviews on the religiousness-health relationship tended to have focused more on the physically healthy populations, such as adolescents and youths, family members, college students and the general public (Koenig & Larson, 2001; Gall & Grant, 2005; Mahoney, 2005; Marks, 2005; Regnerus, 2003). There is a lack of the review on this relationship among the physically vulnerable populations, such as the old, the ill, and the disabled. If religious involvement contributes to health outcomes among the healthy populations, would this effect be equally relevant to the physically vulnerable groups?  As people become ill and physically vulnerable, they experience great stress as a result of the changes in life caused by adverse conditions they are undergoing. Research pointed out that many people who were not religious previously might turn to religion for comfort (Koenig, 2001; Koenig, & Larson, 2001). This often involves in beliefs in a living and caring God, private religious activities, reading religious scriptures for direction and encouragement, or looking for support from pastors or members of faith community. In fact, many studies commonly reported that religiousness was powerful resources of hope, meaning and purpose in life, comfort and solace. These protective and beneficial effects are particularly strong in people with illness and disability (Ehman et al., 1999; King, 2000; Koenig et al., 1998; Koenig et al., 2004; Mueller et al., 2001).

Due to the special meaning and importance of religion to the physically vulnerable populations, this literature review would focus on research studies investigating the relationship between religiousness and mental health among the vulnerable populations. They include people who are ill, aged, and people with disabilities. The review also addressed current theories that depict the relationship between religiousness and mental health. Finally, the implications of this review on therapeutic treatment and future research on the relationship between religiousness and mental health will be discussed.

Method
The current review is not a meta-analysis, which is typically characterized by tables of positive and negative effect sizes. This article aims mainly to summarize the more representative studies investigating the relationship between religiousness and mental health among people who are ill, aged, and people who are disabled. Relevant studies were searched and collected through a number of databases, including the Social Sciences Citation Index, the Medline, the PsyInfo, and the PAIS International,  using keywords like ‘religion and mental health’, ‘religiousness and mental health’, ‘religiosity and religious effects’. After relevant research articles were identified, further efforts were made to scan through the references of these articles as a ‘springboard’ to locate other relevant research articles for the review. Among all the studies that were identified, those with standard quality and representation in terms of design, method and sampling were included in the review.

Although a substantial number of empirical studies addressing the association between religiousness and mental health were identified through the aforementioned databases, most of the studies did not fulfill the purpose for review. Studies which are excluded are those that do not fall into either the targeted populations (the ill, the aged and the disabled), those which do not treat religiousness as a predictor variable, or those which apparently do not control for confounders and other covariates. In addition, empirical research articles adopted for this review were defined as studies that included  in their methods and findings with at least the application of one inferential or correlation statistics to investigate the association between religiousness and mental health. All identified articles must include one or more measures of religiousness or religion-related spirituality as predictors and one or more mental health measures as outcome variables. Among these, those which only used descriptive statistics, percentages or frequencies, or those which did not treat religiousness as a predictor variable were excluded. Consequently, not all pertinent studies would be addressed in this review for the reasons that they were either not highly relevant, or were to our knowledge questionable in design, or simply a result of our negligence of them. The final sample for this review consists of twenty-one empirical studies across the years from 1987 to 2006 (asterisks marked at the articles in the reference). The classification of these 21 articles is presented in Table 1.




Review refers to a broad range of religious engagement and involvement. Apparently, related research to date has rudimentarily focused on the seven dimensions of religious involvement. They are public religious participation (e.g. church attendance), religious affiliation (e.g. involvement in a religious organization/ denomination), private religious practices (e.g. prayer and reading religious materials), and religious coping (turn to his/her religion/belief system for assistance), daily religion-related spiritual experiences (e.g. one’s subjective perception of the transcendent in daily life), religious commitment (times and resources involved in religious activities and beliefs), and self-rated overall salience of religion (importance of religion in one’s life)(George et al., 2002; Mueller et al., 2001). Religiousness is often delineated with reference to these dimensions. As such, religiousness may connote religious involvement in the context of this review. Interestingly, recent studies showed that these dimensions are apparently correlated (Francis, et al., 2004; Nooney, 2005). As for the term ‘mental health’, it refers to both the positive aspects of psychology, such as life satisfaction, optimism, sense of hopefulness, meaning and purpose of life, mental as well as emotional adaptiveness,  and the negative aspects of psychology, such as depressive symptoms, anxiety, suicidal ideation and attempt, illness-related burden, psychological instability and emotional negativity.

This review had not taken a rigid that discerns religion-related spirituality from the scope of religious involvement. Taking this stance is thought to more appropriately tally with theoretical rationale and empirical findings in previous literature. In fact, many characteristics that are common to religiousness may also be found in spirituality (Jones, 2004; Idler, 2003). In addition, other social researchers espoused that a search for the sacred can be deemed as the common ground between religion and spirituality (Gall & Grant, 2005; Idler et al., 2003; Koenig et al., 2001; Muller et al., 2001). Hence, spirituality and religion have been often used interchangeably in prior research and less is known about spirituality outside the context of religion. It is apparent that at its core spirituality is related to all the value orientations, beliefs, actions and behaviors or activities by which adherents attempt to link their lives to God, the Divinity, or a higher power. More than that, religion is the outward substantiation of one’s spiritual system of beliefs and values and is reckoned as the podium of expression of spirituality (Speck, 1988; Sloan, Bagiella & Powell, 1999). Essentially, the sacred core is what is central to both religious and spiritual experience (King, 2000; Koenig et al., 2004; Zinnbauer, 1999). Therefore, three empirical studies of the ill population included in this review consist of religion-related spirituality (Koenig et al, 2004; Pargament et al., 2004; Rppentrop et al., 2005). The spiritual measures used in these studies contain concrete and obvious religious elements. For instance, the subscale Daily Spiritual Experiences (DSE) of Brief Multidimensional Measure of Religiousness/ Spirituality (BMMRS) employed in the research by Rippentrop et al. (2005) to measure spirituality is comprised of certain religious elements, which mainly taps in one’s perception and experience with the transcendent (God or the divinity).  

Findings
The old
Recent research revealed that people become more religious when they are getting older. In comparison with young people, older people think that religion is more important for them, especially for those who are toward the end of life (Koenig et al., 2004; Moreira-Almeida, 2006).  There exist different explanations as to why older persons are apparently more religious than younger people, such as for psychological compensation after retirement. Whichever explanations are more salient in depicting the relationship, religious involvement is obviously a critical factor for older people to cope better and have better social and psychological adjustments while facing the debilitating process of aging. Undoubtedly, there have been increasing empirical evidence in gerontological, medical, social psychological and psychiatric literature that support the positive effects of religiousness on mental health in the older population (Ayele et al., 1999; Braam et al., 2004; Strawbridge et al, 2001), especially the positive relationship between religiousness and depression in old ages.   

Braam and his colleagues conducted two notable studies investigating the relationship between religious involvement and depression in the older population (Braam et al., 1997, 2004). One study confirmed the inverse association between the elderly religious involvement and depression (Braam et al., 1997).  Controlling for socio-demographics, physical impairment and social network of the elderly participants did not affect this inverse association. Besides, the researchers identified two subgroups of elderly whose religious involvement was of particular importance in attenuating their depression. They were aged people with small social network and those with low sense of mastery.

Another recent and more salient longitudinal study of aged residents in Amsterdam by Braam et al. (2004) also reported an inverse relationship between religious involvement and depression. The findings reveal that religiousness, in terms of church attendance and religious importance, was inversely related to depression in a representative sample of 1840 community-dwelling older people. The relationship remained significant even after adjusting for physical health, self-perceptions, social integration, urbanization, and level of alcohol use. Over the 6-year period, depressive symptoms were significantly lower or reduced in frequency for those who attended church more frequently, compared to those elderly participants who had less church attendance or never attended church. Controlling for possible confounding variables did not change this relationship. For this, Braam et al. (2004)  explained that :
 “Religion may offer a frame of reference toward questions of life, suffering and death, and may help to accept a decrease in physical functioning in light of religious and spiritual values (p. 485).”

Similarly, the study by Ellison (1995) also found a negative relationship between church attendance and depressive symptoms measured by the Diagnostic Interview Schedule (DIS) in a sample of older Americans. The result was significant after controlling for the respondents’ physical diseases and perceived illnesses. Likewise, the study by Idler (1987) pointed out a significant negative relationship between religiosity and levels of depression measured by the Center for Epidemiologic Studies Depression Scale in older women (CES-D), after adjusting a number of psychosocial factors and demographic characteristics, such as measures of intimate relationship, optimism and pessimism, physical health, and social contact. Moreover, although religious denomination was not an apparent and consistent predictor of the inverse relationship between religiousness and depression in the elderly (Idler & Kasl, 1992; Schnittker, 2001), people’s perceived importance of religion was (Braam et al., 1997, 2004; Koenig et al., 1998). This result was consonant with other studies pointing that intrinsic religiousness was more powerfully predictive of depression and remission of depression after experiencing stress from critical life events, et al., 2002; Coryn & Benda, 2000; Koenig & Larson, 2001).

Bienenfeld et al. (1997) surveyed a group of retired Catholic sisters, examining the contributions of psychosocial factors and religiousness to life satisfaction, psychological distress, and depression. As a result, they found that sense of mastery, social support, physical functioning, and religious commitment were important factors contributing to life satisfaction in the older population. The finding supported that elderly religiousness was conducive to mediating the psychological impact of impaired functional status.

A number of studies pointed out that suicide ideation and attempt are more prevalent in the older population (Koenig, McCullough & Larson, 2001; Seidlitz et al., 1995). Religiousness is an important factor to prevent suicidal thought and ideation in older people. A study by Nisbet et al. (2000) using logistic regressions as a method of data analysis found that church attendance could reduce the likelihood of the elderly participants to commit suicide. In comparison, elderly people who did not engage in any religious activities at all were four times higher than those who took part in religious activities daily to commit suicide. The relationships did not alter even controlling for other confounding factors, such as socio demographic characteristics and social contact. Another study revealed that older people who viewed religiousness as salient in their lives were more likely to disagree with statements approving suicidal decisions and attitudes (Seidlitz et al., 1995). Their disagreement toward approval of suicide remained significant after controlling for participants’ socio-demographic differences, self-rated health and contentment with interpersonal relationship by multivariate logistic regression analysis. The study concluded that religious salience in one’s life was a concrete predictor of disapproval of suicide.           

The ill
Being ill, especially for those with severe and chronic illnesses, is a life-threatening experience that taxes on a person’s psychological and social resources and coping capacity. Religiousness could help a patient to withstand psychological, physical and social impacts resulted from these adverse experiences (Mueller et al., 2001; Pargament et al., 2004).     

In a study by Koenig’s et al. (1998), the researchers attempted to investigate the effect of religious belief and activity on remission of depression in medically ill hospitalized older patients. The depressed patients were followed up by telephone at 12-week intervals four times after hospital discharge. Consequently they found that religious variables were significant predictors of reducing depressive symptoms over time. More evidently, depressed patients with higher intrinsic religiosity scores had more rapid remissions from depression than patients with lower scores. Therefore, the researchers concluded that religiousness was a predictor of successful recovery from depression in the ill elderly.

In another research by Koenig (1998), 455 cognitively unimpaired patients admitted to the general medicine, cardiology and neurology services were studied. Information on their religious affiliation, religious attendance, private religious activities, intrinsic religiosity and religious coping was collected for purpose of investigating the prevalence of religious beliefs and practices among the medically ill hospitalized older persons and examining how these factors were related to social, psychological and health characteristics. The results showed that religious attendance was associated with less burden in medical illness and lower depressive symptoms in the patients. Moreover, the results in this study pointed out that religious practices, attitudes and coping behaviors were prevalent among hospitalized medically ill older adults and were significantly predictive of social, psychological and physical health outcomes.  

Similarly, Ma et al. (1998) examined the effect of religious activity on depressive symptoms among community-dwelling elderly persons with cancer. In this two-wave longitudinal study, measures of religiousness in the form of service attendance, religious devotion, and watching or listening to religious programs were adopted. The findings indicated that religious activity was related to lower levels of depressive symptoms in participants with cancer. However, the effects of religious activity on alleviating depressive symptoms were stronger among Blacks than Whites in the study.

Recently, Ai et al. (2002) investigated the use of private prayer as a way of coping and the relationship between prayer and optimism among 246 patients waiting for cardiac surgery. The measure of prayer included three aspects in the study; they were 1) belief in the importance of private prayer, 2) faith in the efficacy of prayer on the basis of previous experiences, and 3) intention to use prayer to cope with the distress associated with surgery. Data on patients’ religious and controlling variables were collected 2 weeks before the surgery, and those on optimism were measured the day before the surgery. The findings showed that private prayer was predictive of optimism in the cardiac surgery patients. The result did not alter even after controlling for age, socioeconomic resources, and healthier affect.

In a more recent study, Koenig (2004) surveyed 838 patients admitted to the general medical service wards. Various religious and spiritual measures were recorded. The measures of religiousness and religion-related spirituality included organizational religious activity (ORA), non-organizational religious activity, intrinsic religiosity (IR), self-rated religiousness, and observer-rated religiousness (ORR), observer-rated spirituality (ORS), and daily spiritual experiences. In this study, the self-rated and observer-rated social support, depressive symptoms, cognitive status, cooperativeness, and physical health among the patients were used as dependent variables. After analyses by regression models controlling for age, the results revealed that religiousness and spirituality consistently predicted greater social support, fewer depressive symptoms, better cognitive function, and greater cooperativeness in the patients. In addition, the association between religiousness and spirituality on the one hand, and physical health on the other, was weaker than the psychological one, although there existed between them a significant relationship. At the same time, patients who categorized themselves as neither spiritual nor religious had severer self-rated and observer-rated health problems and greater medical co-morbidity. Conclusively, the findings showed that religious and spiritual involvement was prevalent in hospitalized patients, and they were apparently associated with greater social support, better psychological health, and to some extent, better physical health. Awareness of these relationships may improve health care.

Although there have been substantial efforts on examining relationship between religiousness and mental health outcomes in medically ill patients, there is comparatively lack of studies addressing the role of religiousness in those patients with chronic illnesses. Harrison (2005) recently conducted a study and found that patients with sickle cell disease (SCD) who were more religious demonstrated better quality of life. It this study, it has been shown that church attendance was significantly associated with measures of pain. The patient participants who attended church once or more weekly appeared to have the lowest scores on pain measures in comparison of those with less frequency of church attendance. This positive association remained significant after controlling for patients’ age, gender and disease severity.

Another recent research took a group of 122 chronically ill patients suffering from musculoskeletal pain as study sample to investigate the relationship between religiousness and religion-related spirituality on the one hand, and physical and mental health on the other (Rippentrop et al., 2005). Hierarchical regression analyses revealed that there were apparently significant linkages between patients’ religiousness and spirituality (measured by Brief Multidimensional Measure of Religion/Spirituality) and their mental health as well as physical health. In this study, religious coping, forgiveness, daily spiritual experiences, religious support and self-rated of religious/ spiritual intensity were significantly related to the mental health status of the patients.     

It needs to point out that religiousness does not necessarily bring about positive mental health outcomes in patients. A two-year longitudinal study with a sample of 268 medially ill hospitalized elderly indicated that use of negative religious coping, such as viewing God or a higher power as punitive, would have hazardous effect on  patients’ psychological and physical health (Pargament et al., 2004). On the other hand, patients who adopted positive religious coping to deal with their illness, such as seeking spiritual support and religiously benevolent reappraisal of their situations, showed concrete improvements in mental and psychical health two years later. The relationships between positive religious coping and better mental and physical health outcomes was significant after controlling for demographic characteristics, the baseline health measures, and selective attrition as well as mortality.    

The number of research studies exploring how religiousness functions in patients with critically life-threatening illnesses is very limited. A recent study examined the effects of religious coping on quality of life in 170 patients with advanced cancer (Tarakeshwar, et al., 2006). After taking patients’ socio-demographic variables, lifetime history of depression, sense of self-efficacy into account, it was found that positive religious coping was linked to better overall quality of life (QOL), and the existential and support dimensions of QOL. The use of negative religious coping was predictive of poor overall QOL, and its existential and psychological dimensions. The findings of this study are consonant with a review by Koenig et al. (2001), in which the authors reckoned that positive aspects of religiousness were substantially conducive to maintaining mental health in medically ill patients, especially among those with serious illnesses. In the review, the authors concluded that when people became medically ill, they might turn to rely on religious beliefs and practices to alleviate psychological instability, obtain sense of control and hope as well as life meaning, which were beneficial to their mental and physical adjustments and prevented them from being defeated by these negative health experiences.

The disabled
Although there is a well-established literature on the positive relationship between religiousness and mental health, little is known about how people use religious beliefs and practices to establish meaning for and respond to life with disability. Previous studies have put more emphasis on how the role of religiousness in alleviating emotional stress and enhancing the well-being among caregivers of disabled persons rather than to investigate the role of religiousness in influencing mental health of the disabled themselves. Most of these studies revealed that negative psychology was common among caregivers of disabled persons, and religious involvement was important and useful in reducing their emotional negativity and promoting their perceived well-being (Chang, Noonan, & Tennstedt, 1998; Zunzunequi et al., 1999). However, little is known about whether religious involvement would contribute to better adjustments and well-being among those who are religious but are with disability.

A 12-year longitudinal study found that engagement in religious services was a strong predictor of better physical functioning among a large, prospective and representative sample of elderly residents in New Haven (Idler & Kasl, 1997). This positive association was still significantly evident even when taking confounding variables of health practices, social ties and perceived well-being into account in the analysis. In the study, the researchers reckoned that religious involvement had particular significance for well-being and health of elderly people with disability. Another longitudinal study of Idler and Kasl (1992) showed that public religious involvement was a protective factor against disability among elderly men and women, and private religious involvement was a beneficial and protective factor for recently disabled men to fend off depression resulted in their functional disability.

Another 3-year prospective study conducted by Ringdal (1996) found that higher levels religiousness measured by the importance attached to religion, and the use of religious coping were related to higher life satisfaction and sense of hope in a sample of 253 patients who had been seriously disabled by suffering from cancer. The researcher employed multiple regression analyses to control covariates and evidenced that religiousness might be important in maintaining mental health among the seriously disabled patients who were suffering from life-threatening illnesses.   

In addition, Koenig et al. (1992) examined the beneficial effects of religiousness on depression in 850 older patients with disability and other chronic health problems. The results indicated that religious coping was significantly and inversely related to depressive symptoms in the sample even after controlling for a set of confounding variables. More notably, the interaction term between the extent of disability and religious coping was significant, which denoted the negative association between religiousness and depression was strongest for patient participants who were with more serious disability.

Furthermore, there has been limited number of explorative qualitative research available for investigating how disabled individuals employed their religious faith to cope with challenges and difficulties they encountered. One research conducted by Treloar (2002) reported that religiousness stabilized the lives of the disabled, providing meaning for the experience of disability, assistance with coping and bolstering other benefits to the participants with physical disabilities. In addition, the participants reported that increased assistance by the church in promoting theological understanding of disability and religious support in using a continuing model of caring were important in keeping them feel mentally healthy. Although this kind of qualitative studies are disadvantageous in their generalizeability, they could provide insightful implications for mental health professionals in the issues of holistic care. 

Theoretical Implications and Conclusion  
This review aims to draw studies that are more representative, typical, and sound in deign and method for an overview of the beneficial effects of religiousness on mental health in certain physically vulnerable populations. As a result of their efforts in the past two decades, social scientists have gradually come a consistent view on the positive relationship between religiousness and mental health. Koenig et al. (2001) have recently completed a systematic review of studies on religion and mental health in their Hand Book of Religion and Health. They identified 850 relevant studies conducted in the 20^th century addressing the relationship between religious involvement and mental health. Although they used a broad term to define mental health and well-being, which include psychologically perceived well-being, life satisfaction, hope, optimism, purpose and meaning in life, depression, anxiety, and suicidal ideation, most of the studies reported the positive role of religious involvement in maintaining mental health. For example, about two-thirds of the 93 observational studies examining the relationship between religiousness and depression identified by the authors revealed that the more religious individuals had lower levels of depressive symptoms. Of another 22 prospective cohort studies that had identified and examined this relationship, 15 studies found that religiousness was significantly and inversely related to depression. Besides, five out of the 8 identified clinical trials reported that religious intervention hastened the recovery processes in depressed participants compared with those who only received secular intervention methods.

Among the 850 studies identified by Koenig et al. (2001), one hundred investigated the association between religiousness and perceived well-being. Seven-nine of these 100 studies reported that religiousness was significantly related to higher life satisfaction, more positive affect, and greater happiness. Among these studies, 12 belonged to prospective cohort studies, 10 out of these 12 studies found a positive relationship between religiousness and well-being. Moreover, the association of these two dimensions was reported to be stronger than the relationship between well-being and other psychosocial factors, such as social support and martial satisfaction. The rest of the identified studies that did not find a significantly positive association between religiousness and mental health are apparently underrepresented in number compared to those with a positive relationship. In addition, these studies either reported a mixed relationship, or found no relationship, or demonstrated a negative relationship between the two dimensions.  However, most of these studies were documented as with substandard quality in design, measurement, method and lack of control for covariates (Koenig, 2001).

Empirical evidence on the relationship between religiousness and mental health is very concrete in current literature. However, there is still much room for further research about this relationship in certain vulnerable social groups, such as the ill, the disabled and the aged. In fact, over the past two decades, although there have emerged a large number of research supporting the relationship between religious involvement and mental health, relevant theories to elucidate this relationship are still in its tentative and developmental stage (George, et al., 2002; Jones, 2004). A more noticeable theoretical explanation proposed by Smith (2003) suggested that the beneficial effects of religious involvement on health outcomes were through nine distinct factors that are clustered under three dimensions of social influence. The first dimension is Moral Order, which consists of the factors of moral directives, spiritual experiences and role models. The second dimension is Learned Competencies; it includes the factors of community and leadership skills, coping skills, and cultural capital. The last dimension called Social and Organizational Ties consists of the factors of social capital, network closure and extra-community skills. Although originally developed for elucidating the relationship between religiousness and health outcomes in children and youths, most of the theoretical contents could be adopted as a paradigm to delineate the relationship between religiousness and mental health in various populations.

According to Smith (2003), moral order provides people’s normative ideas about what is good and bad, right and wrong, worthy and unworthy, just and unjust and the like, which are beyond an individual’s own desires and standards, and could be conducive to the developments of oneself and the society as a whole. Learned competencies may enhance people’s social skills and knowledge, which are in turn contributory to their overall well-being and life chances. For the dimension of social and organizational ties, religious people could meet many other members in their religious communities who care about and give guidance to them. This constructive relational network would be helpful for human growth and developments in long run. Obviously, Smith puts more emphasis on the socialization process of religious involvement.                        

On the other hand, George et al. (2002) also suggested the thesis of the health-promoting effects of religiousness. They proposed four psychosocial mechanisms through which religious involvement could promote positive health outcomes. These mechanisms are health practice, social support, psychological resources (e.g. self-esteem and self-efficacy), and belief structure (sense of coherence). Their conclusion on these four psychosocial mechanisms was based on the findings of prior relevant studies, and regarded religiousness that might facilitate and enhance these four mechanisms. Apparently they regarded these four mechanisms could act as robust mediators to influence a variety of health and behavioral outcomes.

Similarly, Jones (2004) also proposed a set of mediators through which religiousness could enhance mental and physical outcomes. They are the increase in ‘relaxation response’ to stress, decrease in unhealthy behaviors, increase in social support, more compliance with physician’s treatment, a sense of coherence, more positive self-concept (e.g. higher self-esteem and less anxiety), and the positive interaction between mental and physical well-being (a potentiating  interaction effect). However, Jones (2004) did not regard all religious positive effects consisted in the attainment of good health outcomes through these mediators. He considered that religion must have unique contributions to human well-being, which is beyond the explanation of aforementioned ordinary/ secular mediating channels. Hence, he corresponded his theoretical work to many recent prospective studies (e.g. Mahoney et al., 1999; McCullough et al., 2000), many of which, after controlling for most of these mentioned secular mediators, the relationship between religiousness and health outcomes was still significant. Conclusively, Jones (2004) deemed that there must be some unique religious effects that were beyond the recognized social-psychological factors and could not be accounted by secular mediators. These unique religious effects might be thought as something peculiar to religion only, such as ultimate concern, eternal life after death, spiritual character and significance, spiritual support, religious coping and the like. They were regarded as unique psychological-spiritual contents.

It is possible to accept that religious involvement may exert its positive effects through both the psychosocial and unique psychological-spiritual processes (Jones, 2004). Hence, it is not strange that secular models cannot totally account for the variance of religious effects on health outcomes, especially for mental health. So, it is why we find that certain social groups who are apparently under deprived, distressful and undesirable circumstances could still keep mentally healthy. For the purpose of explaining this association based on the theoretical implications mentioned above, a diagram depicting the mediational channels through which religious involvement exerts its positive effects on promoting mental health is presented in Figure 1.

Figure 1 :   Mediational channels of the positive effects of religious
                   involvement on mental health



Religiousness can promote various resources, including spiritual, cognitive, psychological and social resources. Not only do these resources have unique positive effects on mental health, they also interact and mutually reinforce each other. Spiritual resources could be something particular to religious involvement. They may be hope, ultimate concern, eternal life after death, spiritual support, and assistance and solace from an omnipotent and caring God. These spiritual resources could be helpful and beneficial enough to change one’s worldview and cognition from an apathetic, competitive and meaningless worldview to a world with hope, warmth, and meaningfulness.

To see the world and lives in it as hopeful, optimistic and warm and meaningful can become people’s cognitive resources, which may be helpful in keeping them mentally healthy when encountering stressful and critical life events. Such a worldview confers religious people a sense that the world they are living in it is desirable, warm and friendly, and life is meaningful. Hence, when problems and difficulties in life come up; they may see these adverse encounters as solvable and surmountable through assistances from an omnipotent and caring God. For people with a religion, they tend to regard God’s help, grace and blessing, and mercy, as well as unfailing love may be powerful enough for them to withstand any adversities in lives they face. Taken together, these cognitive resources may cause them to have greater self-confidence, internal locus of control, positive affect and better self-image while facing and undergoing stressful life events. Research show that positive individual traits may assist people to foster the development of more extensive and supportive social network and relationships (Brissette et al., 2002; Lakey, 1989), which are conducive to buffer against stress resulted from adversities. Therefore, more social resources, such as greater supportive social network derived from one’s faith and beliefs, will further enhance people’s religious involvement and in turn reinforce their spiritual resources. It is because people having greater sense of belonging and having close relationships in the faith community they belong to will be more willing to conform and follow the religious values, norms, teachings and traditions, which may in turn further intensify and magnify their reliance and beliefs in the God/ a higher power.      

However, such an interdependent and mutual reinforcement process among the respective resource dimensions (from spiritual resources to social resources through cognitive and psychological resources) may not necessarily emerge and proceed in a counter-clockwise direction. It could also be clockwise. For example, through engaging in a faith community and beginning to profess and pursue a set of religious beliefs, not only people will increase their spiritual resources, such as the concepts and notions of ultimate concern, God’s omnipotence and grace and delivery, eternal life after death. They will also augment their supportive social network and relationships simultaneously through their contact and interaction with other adherents with the same beliefs. Having a more cohesive and supportive social network and interpersonal relations derived from their religious involvement and spiritual resources will in turn enhance their psychological and cognitive resources because a cohesive and supportive social network will strongly socialize an individual to have similar psychological and cognitive characteristics (Hewitt, 1991; Peterson & Hughey, 2004). Therefore, people will learn to be more confident, optimistic and hopeful, and see the world less apathetic and more joyful, even when life stressors emerge. This explains why the mutual reinforcement process of the respective religious resource dimensions that need not be unidimensional/ one-dimensional, or either clockwise or counter-clockwise, but could be in an interdependently and mutually reinforced nature.

Through this review and analysis of the related literature, it is hoped to illustrate that religious involvement would result in a set of religious resources, such as spiritual, cognitive, psychological and social resources, which will mutually interact and reinforce one another through the ‘chain reaction’. Through this process of mutual interaction and reinforcement, religiousness is considered hypothetically to contribute to mental health in believers. Though these theoretical explanations are at best hypothesis to be tested at the present stage, something more concrete is that most religious resources are thought to be beneficial in human mental health. Nevertheless, there is much room for researchers to conduct research to find out a clearer picture about mediational mechanisms linking the relationship between religious involvement and mental relationship. Theoretical concepts suggested in this paper may be or may not be one of the mediational relationships between religiousness and mental health.           

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