Religious/Spiritual Coping Among Women

Trauma Survivors With Mental Health and

Substance Use Disorders
Roger D. Fallot, PhD
Jennifer P. Heckman, PhD

Abstract
This study examines the types of religious/spiritual coping used by women trauma survivors
with co-occurring mental health and substance use disorders. Analyses based on data from 2 large
racially diverse samples indicate that women from the study population rely considerably more on
positive, than negative, religious coping, and that their reliance on religious coping, in general, is
significantly higher than that of the general population. Numerous significant relationships were
also found between the severity of trauma-related and mental health symptoms and more negative
religious coping. This studyfurther suggests that more frequent childhood abuse and childhood sexual
violence are especially associated with negative religious coping in adulthood. Findings support the
importance of spiritual coping for women trauma survivors with co-occurring disorders and suggest
the value of increased attention to spirituality in behavioral health services, especially in assessment
and therapeutic relationships.

A growing body of literature has examined the complex set of relationships between religion and
spirituality and the trauma of physical and sexual violence. 1-5 Two broad questions have informed
this work to date. First, what is the impact of trauma on spirituality? And second, what are the
relationships between spirituality and indicators of well-being? This study, drawing on results from
surveys in Washington, DC, and Stockton, Calif, examines these questions in a unique population:
women trauma survivors with co-occurring mental health and substance use disorders. The following
brief review of the current literature places this study in context.

Trauma and Spirituality

Most studies exploring the impact of interpersonal violence on spirituality and religion have
compared individuals with abuse histories with those who do not report abuse. This research reports
fairly consistent evidence relating trauma to more negative aspects of an individual's spiritual or
religious life. For example, studies indicate a relationship between childhood sexual abuse and lower
levels of religious involvement, 6 more expressed anger at God, and experiences of God as more
distant) Doehring also found that representations of God were most negative among those with
more severe abuse histories.1 Evidence, however, also suggests that spirituality remains an important

Address correspondence to Roger D. Fallot, PhD, Co-Director, Community Connections, 801 Pennsylvania Ave, SE,
Washington, DC 20003. E-mail: rfallot@ccdcl.org.
Jennifer E Heckman,PhD, is a senior research associate at ETR Associates, Scotts Valley, Calif.
Journal of Behavioral Health Services & Reseamh, 2005, 32(2), 215-226. (~) 2005 National Council for Community
Behavioral Healtheare.

Religious Coping and Trauma FALLOT,HECKMAN 215

part of trauma recovery for many survivors. Even in study samples that report negative relationships
between trauma and spirituality, respondents often simultaneously note the importance and value of
spirituality in their lives and in their recovery.4'5

Religious Coping, Traumatic Stress, and Well-being

The prevalence of religious ways of coping with stressful events has been well established in
the literature.7 In a number of studies, Pargament and his colleagues have identified positive and
negative religious styles of coping with distressing situations or events. 8 This typology offers the
possibility of understanding how "spirituality" can apparently function in ways that support, as
well as undermine, trauma recovery. On the positive side, among others, are coping attempts that
strengthen spiritual connection; foster a sense of collaborating with God; or enhance feelings of
spiritual support. Negative religious coping reflects spiritual struggle in some way. For example, an
individual may believe that the event represents God's punishment or abandonment or may elect to
deal with the situation without God's assistance.
The current study examines factors that relate to positive and negative religious coping for women
trauma survivors who also have co-occurring mental health and substance use disorders. A deeper
understanding of the religious coping styles in this population may be particularly relevant, as prior
research has demonstrated relationships between religious coping styles and measures of well-being.
Regarding mental health, cross-sectional data in diverse study populations have demonstrated that
positive religious coping is related to less depression, anxiety, and hostility, and a better quality of
life and more positive affect.9 Conversely, negative religious coping is related to more depression and
anxiety, higher levels of psychological distress, and more post-traumatic stress disorder symptoms. 9
In terms of substance use, although current research suggests that spirituality serves a role in addiction
recovery, its precise function is unclear. Several studies suggest that religious/spiritual involvement
provides an important coping mechanism for dealing with challenging (and sometimes unfathomable)
situations and thus may be helpful in recovery, l°-12 Whether spirituality is directly predictive of
recovery, however, remains open to question. 13This study begins to unravel the complex relationships
between women survivors' mental health and trauma symptoms, their substance abuse, and their
religious/spiritual coping styles.

Methods
This article is based on data generated through the SAMHSA-funded Women, Co-occurring Dis-
orders and Violence Study (WCDVS) and focuses specifically on religious/spiritual coping data
collected at 2 of the 9 sites participating in this larger study. (For the purposes of this study, "re-
ligious coping" and "spiritual coping" are synonymous.) The WCDVS's purpose was to evaluate
the effectiveness of trauma-informed, comprehensive and integrated services for women with sub-
stance use and mental health disorders and physical and/or sexual abuse histories. In addition to
the data collected for this larger study, Community Connections (the Washington, DC site) and the
Allies/Women's Health Study (the Stockton, Calif site) elected to collect religious coping data to
further understand the prevalence, nature, and role of religiousness/spirituality in this population.
The analyses presented herein represent these sites' pooled WCDVS intervention and comparison
group data and are referred to throughout as the Washington, DC, and the Stockton, Calif, samples.

Participants
The 666 participants in this current study represent all of the participants at these 2 WCDVS
sites. WCDVS eligibility criteria required that all participants were women, 18 years or older, with
alcohol, drug, and mental health disorders and physical and/or sexual abuse histories. Participants

216 The Journal o f Behavioral Health Services & Research 32:2 April~June 2005
were further required to have Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV) 14 Axis I and/or II disorders and to have experienced 2 or more substance abuse or mental
health treatment episodes during their lifetimes (with one currently active and the other active within
the past 5 years). The samples were quite similar on many dimensions: education (approximately
50% had not completed the 12th grade); employment (less than 20%); food stamp assistance Oust
under 50%); histories of homelessness (around 75% lifetime and 40% in the past 6 months); and
parental rights had (at some point) been terminated (about 25%).
The DC women were slightly older (42.0 vs 36.0 years) and were more likely to have been referred
to the study from mental health settings (70.1% vs 10.8%). Stockton women were more likely to have
been referred from substance abuse settings (82.4% vs 10.9% in DC). The DC sample was largely
African American (82.2%), with 15% white women. In contrast, the largest racial/ethnic group in
Stockton was white (62.5%); African Americans comprised 18.4% of the sample. The Stockton
group also included considerably more women of other races (American Indian or "other") than
did the DC sample (26% and 5.2%, respectively), and many more women identified themselves as
Hispanic (17.4% vs. 3.3%, respectively).

Procedures
Fieldwork procedures were identical across both sites. Religious coping data were collected via
in-person structured interviews with participants immediately following their WCDVS baseline
interviews. Research staff, trained in these protocols, conducted all interviews.

Measures
Religious coping measure
The religious coping scales used in this study, which were also administered as a part of the
random national General Social Survey 1997-98 (GSS),/5 were drawn from the Fetzer Measure
of Religiousness and Spirituality. lo The particular scales selected for use at the DC and Stockton
sites included 6 items in common: 3 measuring positive and 3 measuring negative religious coping
styles, j6 Participants were asked to "think about how you try to understand and deal with major
problems in your life. To what extent is each of the following involved in the way you cope?" The
3 positive items are as follows: "I think about how my life is part of a larger spiritual force"; "I
work together with God as partners"; and "I look to God for strength, support, and guidance." The
negative religious coping items were: "! feel God is punishing me tor my sins or lack of spirituality";
"I wonder whether God has abandoned me"; and "I try to make sense of my situation and decide
what to do without relying on God." Four-point response options ranged from "Not at all" to "A great
deal." For the purposes of this article, scores were coded so that higher numbers reflect more use of
that particular coping style.

Demographics and personal history variables

The demographics and personal history variables were developed by the WCDVS Steering Com-
mittee's Evaluation Subcommittee.

Mental health symptoms measure

The Brief Symptom Inventory (BSI) consists of 53 items yielding an overall mental health symp-
toms measure (the Global Severity Index or GSI) and 9 subscales: somatization, obsessive compulsive
traits, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and
psychoticism.17

Religious Coping and Trauma FALLOT,HECKMAN 217

Alcohol and drug use measure
The Addiction Severity Index (ASI) was used to measure alcohol and drug use. 18 Using the
standard ASI protocol, composite scores for alcohol and drug use were generated (5 and 13 items,
respectively).

Trauma history and symptoms measures

Trauma history was measured by the Life Stressor Checklist-Revised (LSC-R). 19 This 30-item
instrument measures lifetime exposure to stressful events (eg, a serious disaster or accident, death of
someone close, physical neglect, physical abuse, sexual abuse, etc) and includes 4 subscales: lifetime
frequency of interpersonal abuse, frequency of childhood abuse, current exposure to interpersonal
abuse, and current exposure to other stressors. Trauma-related symptoms were measured by the
17-item Post-traumatic Stress Diagnostic Scale (PDS) 2° and an additional 3-item scale, developed
by the WCDVS Steering Committee's Trauma Subcommittee, to measure dissociation ("My mind
feels spacey"; "I feel detached from the world around me"; and "I feel fragmented, as if there are
separate parts of me that take control of my life").

Data Analysis and Results

Sample comparability in religious coping styles
Analyses were conducted to assess the comparability of religious coping styles in the DC and
Stockton samples and between these samples and the women's data from the randomized national
GSS (1997-98) data set 15 (Table 1). Independent samples t tests indicate that in both study samples
significantly higher levels of positive and negative religious coping existed than in the GSS women-
only population sample. Because African Americans may draw more heavily on spiritual resources
than whites 7 and are more heavily represented in the study samples than in the general population,
this higher level of religious coping may be attributable to racial/cultural factors. To examine this
possibility, independent t tests were used to compare African American and White participants.
In the combined DC and Stockton sample, no significant differences were found between these
groups in either positive (African American: mean = 3.10; white: mean = 3.02) or negative (African
American: mean : 1.74; white: mean = 1.66) religious coping. However, 2 significant differences
existed between the site samples. Independent samples t tests show that Stockton women were
significantly more likely than DC women to experience positive religious coping (P < .001) and that
DC women were significantly more likely than Stockton women to experience negative religious
coping (P < .01).
Across both study samples (and in the GSS sample), women reported more positive than negative
religious coping. To further understand this consistent tendency toward more positive religious
coping, difference scores were computed whereby negative coping scale scores were subtracted
from positive coping scale scores. Difference score values of less than zero were labeled as "negative
copers," values equaling zero were labeled as "balanced copers," and values greater than zero were
labeled as "positive copers." In both samples, the large majorities of women (85.4% in Stockton and
79.8% in DC) fell into the "positive coping" group, while relatively small percentages of the women
(9.2% in Stockton and 13.8% in DC) fell into the "negative coping" group.

Trauma exposure, trauma symptoms, and religious coping

Table 2 presents Pearson correlations (2-tailed tests) indicating the relationships, in both the
Stockton and DC samples, between women's exposure to traumatic events and related symptoms
and positive and negative religious coping. Lifetime exposure to stressful events (the LSC-R total

218 The Journal of Behavioral Health Services & Research 32:2 April~June 2005
 Table 1
Positive and negative religious coping: The Stockton, Calif, Washington, DC, and General Social
Survey (GSS) 1997-98 women's population sample

Independent
samples t tests

Religious coping scales n Mean SD t statistic df

Stockton, Calif
Positive religious coping 416 3.15 0.82
Negative religious coping 413 1.63 0.66
Washington, DC
Positive religious coping 247 2.93 0.74
Negative religious coping 247 1.78 0.75
GSS: women-only sample
Positive religious coping 750 2.76 0.87
Negative religious coping 754 1.45 0.47
Positive religious coping: sample differences
Stockton, Calif, and Washington, DC 3.55* 661
Stockton, Calif, and GSS women-only sample t 7.61" 903.85
Washington, DC, and GSS women-only sample t 2.93 ~ 487.26
Negative religious coping: sample differences
Stockton, Calif, and Washington, DC --2.60 ~ 658
Stockton, Calif, and GSS women-only sample t 5.03" 647.64
Washington, DC, and GSS women-only sample t 6.58* 311.02
*P < .001.
t Unequal variances assumed.
~P < .01.

scale score), frequency of interpersonal abuse, and current exposure to trauma (ie, interpersonal
abuse or other stressors) were not related to religious coping approaches; however, some small to
moderate relationships were found between frequency of childhood abuse and religious coping. In
the DC sample, women with higher frequencies of childhood abuse reported less positive and more
negative religious coping than those with more limited or no childhood abuse (P < .05). A consis-
tent (yet slight) relationship between frequencies of childhood abuse and negative religious coping
(P < .05) was found in the Stockton sample; no relationship existed in this sample between childhood
abuse frequency and positive religious coping.
Trauma symptoms, more than trauma exposure, were related to religious coping, particularly to
negative religious coping. In both samples, the intensity (measured by frequency of post-traumatic
symptoms reported on the PDS and Dissociation scales) was related to negative religious coping. In
other words, the more frequently women experienced the symptoms of trauma, the more likely they
were to indicate negative religious coping.

Mental health symptoms, substance abuse, and religious coping

Other mental health symptoms followed a pattern similar to that for trauma: more reported symp-
toms were related to more negative religious coping. As shown in Table 2, significant relationships
existed in both samples between the BSI GSI and negative religious coping (Stockton; r = 0.293,

Religious Coping and Trauma FALLOT,HECKMAN 219

O

Table 2
Pearson correlations of the relationship between religious coping and trauma exposure and symptoms, substance abuse, and mental health symptoms

Pearson correlations
Positive religious coping Negative religious coping
Measures Stockton, Calif Washington, DC Stockton, Calif Washington, DC
Trauma (n = 368-416) (n = 241-247) (n = 387-413) (n = 241-247
Trauma exposure
Life Stressor Checklist (Revised)
Lifetime exposure to stressful events 0.061 -0.077 0.022 -0.049
Lifetime frequation of interpersonal abuse 0.056 -0.104 0.045 0.057
Frequency of childhood abuse 0.038 -0.159" 0.113" 0.155"
Current exposure to interpersonal abuse -0.055 0.001 0.034 0.068
T Current exposure to other stressors -0.064 -0.004 0.023 0.125
Trauma symptoms
PTSD Symptom Scale (PDS) -0.019 -0.121 t 0.241~ 0.180 ~
Dissociation Scale -0.089 -0.153" 0.219 ~ 0.2062
Mental health (n = 416) (n = 246--247) (n = 413) (n = 246--247
BSI global severity -0.009 -0.188 ~ 0.293§ 0.241 ~
Substance abuse (Addiction Severity Index [ASI]) (n = 3 5 9 4 1 5 ) (n = 226--247) (n = 357--413) (n = 226--247
ASI drug composite 0.029 -0.088 -0.001 -0.028
ASI alcohol composite 0.0961i -0.092 0.000 0.039
.~. , p < .05.
tp = .061.
~P < .01.
~. §P < .001.
lip = .051.
bo
 Table 3
Independent samples t test of the relationship between religious coping and high versus low
frequencies of childhood abuse

Frequency of childhood abuse*

Independent
Low High samples t tests

n Mean SD n Mean SD t statistic df

Positive religious coping
Stockton, Calif 144 3.11 0.82 148 3.19 0.83 -.854 290
Washington, DC 85 3.04 0.72 91 2.84 0.80 1.717 174
Negative religious coping
Stockton, Calif 141 1.57 0.52 148 1.74 0.75 -2.28 * 287
Washington, DC 85 1.68 0.70 91 1.96 0.88 -2.34 t 174
*This scale measures the frequency with which a participant experienced physical abuse, forced sexual touch,
and/or forced sex prior to 18 years of age. Each of these 3 abuse variables were coded 0-3 (ie, 0 = Never; 1 =
Once; 2 = A few times; and 3 = A lot), with the total childhood abuse frequency scale score ranging from 0
to 9. Subjects with scores of 0-2 were coded as having experienced "low" frequencies of childhood abuse and
those with scores of 6-9 were coded having experienced "high" frequencies of childhood abuse.
P < .05.

P < .001; DC: r = 0.241, P < .01) and in the DC sample between the GSI and positive religious
coping (r = -0.188, P < .01); that is, the fewer the mental health symptoms, the more positive (and
less negative) the religious coping. No significant relationships were found between substance abuse
variables and religious coping styles.

Childhood physical and sexual abuse and religious coping

Two additional strategies were used to further explore the relationship between childhood physical
and sexual abuse and religious coping. A scale score, ranging from 0 to 9, was created to represent the
total frequency of childhood abuse (physical abuse, forced sexual touch, and forced sex). Independent
samples t tests were then conducted to assess whether significant differences in coping strategies
existed for women who experienced "high" (scores of 6 to 9) versus "low" (scores of 0 to 2)
frequencies of childhood abuse (Table 3). Significant differences between the "high" and "low"
frequencies of childhood abuse groups and positive religious coping were not found; however,
significant differences were found between these groups and negative religious coping (P < .05). In
both samples, women who indicated high frequencies of childhood abuse exhibited more negative
religious coping than those who indicated low frequencies of such abuse.
Independent samples t tests were also conducted on the data from both samples to assess whether
significant differences existed in religious coping between those who had experienced physical,
sexual, and/or emotional abuse prior to the age of 18 and those who experienced such abuse for the
first time as adults (Table 4). Significant differences in negative religious coping were found between
women who experienced forced sex prior to 18 years of age and those who first experienced this
abuse as adults: DC women (P < .0I) and Stockton women (P < .05) who were forced to have sex as
children scored significantly higher on negative religious coping than did women who experienced
this sexual abuse for the first time as adults. Concurrently, DC women who experienced this abuse
as children were significantly more likely than those who experienced this abuse for the first time as

Religious Coping and Trauma FALLOT,HECKMAN 221

 Table 4
Independent samples t tests of the relationship between religious coping and age at first abuse

Age at first abuse

Childhood Adulthood Independent

(younger than 18 y) (18 y or older) samples t tests
Nature of abuse and
religious coping n Mean SD n Mean SD t statistic df
Emotional abuse
Positive religious coping
Stockton, Calif 327 3.17 0.82 40 3.23 0.75 -0.45 365
Washington, DC 181 2.88 0.73 20 2.93 0.88 -0.59 199
Negative religious coping
Stockton, Calif 325 1.65 0.68 40 1.48 0.52 1.56 363
Washington, DC 181 1.79 0.74 20 1.90 0.88 -0.62 199
Physical abuse
Positive religious coping
Stockton, Calif 256 3.20 0.82 117 3.10 0.78 1.18 371
Washington, DC 140 2.87 0.77 49 2.97 0.72 -0.77 187
Negative religious coping
Stockton, Calif 256 1.66 0.71 116 1.60 0.58 0.81 370
Washington, DC 140 1.85 0.78 49 1.63 0.70 1.76" 187
Sexual abuse: forced sexual touch
Positive religious coping
Stockton, Calif t 239 3.13 0.84 60 3.17 0.68 -0.38 108.9
Washington, DC 140 2.86 0.76 36 3.00 0.77 -0.98 174
Negative religious coping
Stockton, Calif t 239 1.68 0.70 58 1.49 0.47 2.56~ 125.5
Washington, DC 140 1.80 0.78 36 1.61 0.55 1.63 75.7
Sexual abuse: forced sex
Positive religious coping
Stockton, Calif 194 3.11 0.81 123 3.25 0.76 -1.55 315
Washington, DC 133 2.81 0.77 61 3.09 0.68 -2.40~ 192
Negative religious coping
Stockton, Calif t 195 1.69 0.70 121 1.54 0.59 2.00~ 285.3
Washington, DC t 133 1.90 0.83 61 1.60 0.58 2.98§ 160.1
*P = .08.
tUnequal variances assumed.
~P < .05.
§P < .01.

adults to experience less positive spiritual coping. Stockton women who experienced forced sexual
touch as children were also significantly more likely than the "adult" group to experience higher
degrees of negative religious coping (P < .05). In neither sample were significant differences found
between those participants who first experienced emotional or physical abuse in childhood versus
those who first experienced such abuse in adulthood.

222 The Journal of Behavioral Health Services & Research 32:2 April~June2005
Demographics and other sample characteristics and religious coping
Demographically, the samples were of comparable educational levels and age. Pearson correla-
tions demonstrate that educational levels were not related to either positive or negative religious
coping in either sample. Comparably, in both samples, age was not related to negative religious
coping; however, age was slightly (Stockton; r = 0.132; P < .01) to somewhat (DC: r = 0.209;
P < .001) related to positive religious coping. In other words, there was a tendency in both sam-
ples for older women to access more positive religious coping styles than was true for younger
women.
Although age and educational levels were comparable across the samples, the racial compositions
were not. The large majority of DC women identified themselves as African American (82.2%),
while a smaller majority of Stockton women identified themselves as white (62.5%). Although the
combined samples showed no racial/cultural differences in positive religious coping, independent
samples t tests demonstrate that in each sample taken separately, African American women reported
significantly more positive religious coping than white women. In DC, the mean level for African
American women was 3.00 (SD = 0.71) and for white women was 2.60 (SD = 0.79); independent
samples t = 3.03, P < .01. In Stockton, these respective means were 3.37 (SD = 0.68) and 3.08
(SD : 0.84), yielding t = 2.73, P < .01. Negative religious coping did not differ significantly between
these 2 groups at either site.
To explore possible racial differences further, Pearson correlations were calculated to assess the re-
lationships, for these 2 racial groups in each sample, between religious coping tendencies and trauma
exposure, trauma and mental health symptoms, and substance abuse. When the racial subgroup corre-
lations were compared to those of the complete study site samples, the associations between negative
religious coping and the trauma, mental health, and substance abuse measures were quite comparable
to those in the total samples. The associations found for the racial subgroups between positive reli-
gious coping and the trauma, mental health, and substance abuse measures were also similar to those
of the total samples, with a few notable differences. For example, in the Stockton (total) sample, no
significant associations were found between positive religious coping and the mental health, trauma,
or substance abuse measures, with the exception of a very slight (nonsignificant) association between
alcohol use and positive religious coping (r = 0.096, P = .051). However, in the racial subgroup
analyses of African American Stockton women, positive religious coping was significantly related
to fewer mental health symptoms (r = -0.241, P < .05) and approached a significant relationship
with the Dissociation Scale (r = -0.224, P = .053).
Because other early experiences (in addition to the trauma exposure variables described earlier)
may be related to religious coping styles in adulthood, the samples were compared on their partici-
pants' age at first trauma, first mental health symptoms, and first substance use. Independent samples
t tests indicate that ages at first abuse were comparable across the samples. Significant differences
between the samples were apparent, though, between the age at first mental health problems and the
substance use variables. Specifically, Stockton women were younger than DC women when their first
emotional or mental health problem began (mean = 12.3 and 15.6 years old, respectively; P < .001).
And, in terms of substance use, Stockton women were significantly younger than DC women when
they first used alcohol to intoxication (mean = 14.5 and 17.1 years old, respectively; P < .001 ) and
illegal drugs (mean = 14.0 and 16.7 years old, respectively; P < .001). Pearson correlations were run
to ascertain whether these "age at first..." variables, upon which sample differences existed, related
to religious coping. DC women who drank alcohol to intoxication earlier were likely to use more
negative coping styles (P < .05) and those who were older when they first experienced a mental
health problem were likely to use more positive coping styles (P < .05); such relationships were not
found in the Stockton sample. Age at first illegal drug use was not related to religious coping styles
in either Stockton or DC.

Religious Coping and Trauma FALLOT,HECKMAN 223

 Discussion
This study's findings support the importance of increased attention to spirituality for women
trauma survivors with co-occurring disorders. For example, levels of religious coping, both positive
and negative, axe high in these samples when compared to those in women in the general population.
These findings are consistent with studies reporting that spiritual coping is a common way of dealing
with extreme stressors 7,9 and that traumatic experiences may increase religious or spiritual activities?
A compelling, potential explanation for such high levels of spiritual coping is that trauma, especially
interpersonal violence, challenges fundamental assumptions about the self and the world, including
issues related to benevolence and justice. 21 Because trauma raises such ultimate questions, spirituality
or religion may offer an important source of correspondingly ultimate responses, framed in terms
of the positive or negative role of the divine or sacred in relation to such painful events. In addition,
as Pargament has argued, religious coping may be particularly salient for people with less access
to mainstream economic and social resources, offering them significant solutions to life problems. 7
From these perspectives, it is not surprising that economically disadvantaged trauma survivors with
co-occurring mental health and substance use disorders would rely heavily on spiritual coping.
Also importantly, among these women, levels of positive religious coping are much higher than
negative coping, suggesting that women survivors experience spiritual ways of dealing with stress
more often as positive resources or supports than as struggles or conflicts. The large preponderance
of women whose positive religious coping score exceeded their negative score confirms that, at the
individual level, women are more likely to draw on spirituality as a supportive, strengthening, or
collaborative force than in a way that reflects divine punishment or abandonment. Both the direction
of this difference and its magnitude are consistent with those of women in general.
These results also confirm previous reports of significant relationships between childhood abuse,
particularly that of a sexualized nature, and negative aspects of spirituality in adulthood. These
findings suggest a relationship between frequency of childhood abuse and negative religious coping
and, in the DC sample, an inverse relationship between childhood abuse frequency and positive
religious coping. Furthermore, women who experienced sexual abuse in childhood (forced sex and,
to a less consistent degree, forced sexual touch) had higher levels of negative religious coping than
those whose first experience of sexual abuse occurred in adulthood. This same pattern did not apply to
emotional or physical abuse. These findings offer an important refinement to previous studies that have
examined group differences on the basis of the presence or absence of a reported abuse history. Even
among women with very extensive and severe histories of traumatic violence, there is an especially
negative association between spirituality and both frequency of childhood abuse and childhood sexual
abuse; that is, earlier and more sexualized violence is related to more negative spiritual coping.
Finally, religious coping styles in this population are significantly related to both post-traumatic
symptoms and to symptoms of distress more generally. Here, the current results are consistent
with the body of findings connecting styles of spirituality with mental health. As Pargament has
cogently argued, spiritual coping may be connected in a helpful or harmful way to psychosocial
well-being. 9 In this study, severity of post-traumatic symptoms and other mental health symptoms
were significantly related to negative spiritual coping. Those women who understood the stressors
in their lives as reflecting divine punishment or abandonment or who said they dealt with stress
without assistance from God also reported more extensive symptoms. And, to a less consistent
degree (ie, in the DC sample and among African American women in Stockton), positive spiritual
coping was related to fewer mental health symptoms. The stronger association of positive religious
coping style with fewer symptoms among African American women suggests an important role for
culture in the relationship between spiritual coping and well-being. Although longitudinal studies
are needed to examine the sequencing and causality in these relationships, some of the spiritual
understandings reflected in negative religious coping might plausibly be expected to exacerbate
mental health problems. Interpreting traumatic and violent events as a sign of God's punishment

224 The Journal of Behavioral Health Services & Research 32:2 April~June 2005
or abandonment may deepen distress, adding the perception of divine retribution or absence to an
already painful personal and interpersonal reality. Conversely, understandings that draw on images of
divine sustenance may buffer the impact of negative events and lead to less severe symptom patterns.
Given the fairly consistent relationships between trauma-related and mental health symptoms
and negative religious coping, further research, especially with longitudinal designs, is needed to
understand the notable lack of relationships between religious coping and current substance use,
as measured by the composite scores. The absence of significant correlations is consistent in some
ways, with prospective studies indicating that spirituality is only a weak indicator of substance
abuse recovery.22 Spirituality may nonetheless play a significant moderating role in recovery by, for
example, facilitating engagement in other interventions. 2~

Implications for Behavioral Health

From the research perspective, this collection of findings reinforces the importance of moving
beyond the more general questions relating spirituality and abuse (Does abuse negatively affect spir-
itual or religious aspects of an individual's life? Are symptoms related in a consistent way to religious
coping?) to more specific ones: What characteristics of abuse or violence (eg, type, frequency, age at
event, severity) are related to what aspects of spiritual or religious life? At what point in the recovery
process? What mental health symptoms or substance abuse patterns are related to specific religious
or spiritual variables? At what time? Do specific ethnic or racial differences moderate these rela-
tionships? In what ways? The importance of longitudinal data examining the possible relationships
between spiritual or religious dimensions and various recovery indicators is an essential next step.
From the services perspective, these findings support the numerous clinically based calls for
inclusion of attention to spirituality in behavioral health services for trauma survivors. 2'4'5'23 When
providing services for women who have experienced severe abuse and violence and who also have
other complicating problems with substance use and mental health, it is vital to draw on all available
personal and contextual resources. The prevalence of positive religious coping suggests that this
potential source of support is worthy of clinicians' attention. On the other hand, negative religious
coping is clearly and consistently related to more severe symptoms. Even though women in this
population use this coping style less frequently, its association with poorer self-reported functioning
makes it clinically significant as a potentially complicating factor in recovery.
Because religious coping styles can be connected to trauma-related and other mental health symp-
toms in both positive and negative ways, mental health assessment and service or recovery plans need
to take this domain more fully into account. Conducting assessments that explore the.function of spiri-
tual coping (eg, as a resource or an obstacle) is one avenue by which mental health and substance abuse
service programs may address the importance of spirituality in recovery. This study's findings suggest
that such assessments may be especially important for clinicians working with women who have his-
tories of childhood sexual abuse. Clinicians may need to be especially sensitive in mobilizing spiritual
resources in this subgroup of women because of their higher rates of negative religious coping.
Increasingly, mental health programs are offering formal avenues, through both individual and
group therapy, for consumers to explore spirituality in relation to their recovery. 24,25 For example,
in the DC study described earlier, Fallot et al developed and implemented an 11-session manualized
"Spirituality and Trauma Recovery" group that includes such key issues as the meaning of being spir-
itual; spiritual coping strategies; spirituality and difficult trauma-related emotions and experiences;
and spirituality, hope, and healing. 26 These emerging group models are sensitive to the concerns of
many mental health service providers who are wary of interventions that promulgate a particular
religious or faith-based program, These groups take seriously the potential for positive and negative
roles of spirituality; offer a context for exploring how spirituality has functioned in consumers' lives;
and facilitate consumers' deciding if and how spirituality may have a place in their recovery plans.

Religious Coping and Trauma FALLOT,HECKMAN 225

 In multiple ways, then, behavioral health services may helpfully incorporate increased sensitivity
to the importance of spirituality to many consumer-survivors and may facilitate the exploration of
its roles in relation to recovery. Awareness of the importance of spiritual coping styles is one key
element in this spiritually informed approach.

Acknowledgments
This work was conducted as part of the Women, Co-occurring Disorders, and Violence Study
funded by grants from the Federal Substance Abuse and Mental Health Services Administration
(grant no. 2UD 1 TI11400-05 to Community Connections and grant no. 5UD 1 TIl1396-05 to
ETR Associates). The authors also thank Sue Thiemann, MS, and Gregory McHugo, PhD, for their
statistical consultation and the many interviewers who were involved in data collection.

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226 The Journal of Behavioral Health Services & Research 32:2 April~June 2005