1

SPIRITUALITY AND RESILIENCE ASSESSMENT PACKET

MANUAL
For Version 4.2

RESOURCES FOR RESILIENCE: BUILDING A RESILIENT WORLDVIEW THROUGH SPIRITUALITY

Behavioral Health Education Initiative Jared D. Kass, Ph.D., LMHC Lynn Kass, M.A., M.A.T., LMHC Co-Directors

Greenhouse, Inc. 46 Pearl Street Cambridge, Massachusetts 02139 617-492-0050 2000, 1996, 1990, 1989 Jared D. Kass

TABLE OF CONTENTS

I.

Introduction A. B. Purpose of SRA Description

5 5 5 10 12 12 17 18 19 20 20 21 23 23 23 25 27 27 29 30 31 32 33 35 35 37 38

II.

History of SRA

III. Conceptual Foundations A. Measuring a Resilient Worldview: The IPPA 1. Control Dimension: Self Confidence During Stress 2. Meaning Dimension: Life Purpose and Satisfaction 3. Unifying Concept: Confidence in Life and Self B. Measuring Internalized Spirituality: The INSPIRIT 1. Religion and Spirituality as Overlapping Concepts 2. Characteristics of Internalized Spirituality IV. Summary of Research A. Inventory of Positive Psychological Attitudes 1. Confirmation of Multidimensional Structure 2. Reliability 3. Construct Validity a. Correspondence with comparable scales b. Discrimination between populations 4. Outcome Research a. Improvements in psychological symptoms and chronic pain b. Improvements in psychological and medical symptoms c. Associations with lower levels of health-risk behaviors

B. Index of Core Spiritual Experiences 1. Confirmation of Unidimensional Structure 2. Reliability 3. Construct Validity

3 a. Correspondence with comparable scales b. Discrimination between population sub-groups 4. Outcome Research a. The formation of a resilient worldview b. Reductions in health-risk behaviors c. Reductions in stress-related medical symptoms V. Normative Data A. Conceptual Approach B. Data for the IPPA 1. Placing the Raw Score in an Interpretive Context 2. Normative Scores C. Data for the INSPIRIT 1. Placing the Raw Score in an Interpretive Context 2. Normative Scores VI. Guidelines for Administration of the SRA A. Conceptual Approach: Building Collaborative Dialogue B. Competency Requirements for Professionals 1. Basic Counseling Skills 2. Training in Multicultural Competencies C. Practical Steps for Preparation 1. Step One: Take the Test Yourself 2. Step Two: Be Thoroughly Familiar with the Concepts 3. Step Three: Anticipate Challenging Issues a. Language to denote God b. Defining spirituality 4. Formal and Informal Applications VII. Scoring and Interpretation of the SRA TABLES 1.1 1.2 2.1 2.2 Multidimensional Factor Structure of the IPPA-30 81 Construct Validity of the IPPA 82 INSPIRIT Factor Structure 83 Experiences of the Spiritual Core and Length of Time Meditating 84 2.3 Relationships Between Internalized Spirituality, Resilience, and Stress-Related Medical Symptoms Among Outpatients 85 2.4 Relationships of INSPIRIT to Confidence in Life and 38 39 41 42 49 53 55 55 57 57 57 59 59 60 64 64 65 65 65 66 66 66 67 67 71 78 80

4 Self (CLS) and Hostility 2.5 Predictive Model for Cigarette Smoking REFERENCES APPENDIX 86 87 88 94

I. Introduction

5 A. Purpose The Spirituality and Resilience Assessment Packet provides clergy, human service professionals, and educators with a structured vehicle through which they can engage clients in the development of internal resources that contribute to successful coping during stressful conditions. This packet enables individuals to examine the strength of their own psychological resilience, the depth of internalization of their own spirituality, and the degree to which their spirituality contributes to their psychological resilience. B. Description of the Instrument The Spirituality and Resilience Assessment Packet (SRA) is a multidimensional self-report instrument. The assessment packet includes two questionnaires. The Inventory of Positive Psychological Attitudes measures attitudes that characterize a resilient worldview. The Index of Core Spiritual Experiences measures perceptions and behaviors that reflect a high degree of internalized spirituality. These questionnaires can be used separately and together. The Inventory of Positive Psychological Attitudes can be used, by itself, to assess areas of an individuals worldview that need to become more resilient. The Index of Core Spiritual Experiences can be used, by itself, to assess areas of an individuals spirituality that may benefit from further examination and internalization. These questionnaires are used together to assess the degree to which internalized spirituality is contributing to a resilient worldview. The questionnaires are sensitive to cultural differences related to religious background, gender, race, and ethnicity among United States citizens.

6 The SRA was developed for use with adults and adolescents with a 6th grade reading level. It can be administered in written and oral form. Initial administration and scoring of the SRA requires between 30 and 60 minutes, depending on the reading proficiency of the individual and the depth of dialogue that evolves between the individual and the professional administering the assessment process. Subsequent administration of the SRA, to measure an individuals growth and development, will require 20-30 minutes. The questionnaires that comprise the SRA were developed in two formats, a research format and a self-test format. In the research format, the items in each questionnaire are presented in a randomized pattern. In addition, a randomly selected sub-group of response sets has been assigned reverse ordering of positive directionality on their Likert scales. The purpose of these randomization procedures is to minimize socially desirable responses (or perceived socially desirable responses). This format also maximizes the likelihood that respondents will answer each item carefully, because the directionality of the positive answer varies. This format is scored and interpreted by the professional who is administering the assessment process. These benefits are particularly important when conducting research. The self-test format is more ideal, however, during psychoeducational applications of this assessment packet in which the purpose is to engage individuals in a personal examination of their own resilience and spirituality. In this situation, individuals often desire, and may require, a maximum degree of privacy and autonomy during the assessment process. For this reason, the self-test versions of these

7 questionnaires are structured to enable individuals to score their own tests and to develop an initial interpretation of their results. In this format, items from each sub-scale are grouped together for ease of comprehension and interpretation. There is no reverse ordering of positive dimensions on the instruments Likert scales. Instructions for scoring and initial interpretation are provided to the individual. The first questionnaire, The Inventory of Positive Psychological Attitudes (IPPA) measures a resilient worldview, Confidence in Life and Self (CLS). CLS has been shown to buffer stress and to facilitate the prevention of stress-related psychological and physical disorders. The IPPA is composed of two related, but distinct, sub-scales. The first sub-scale, containing 15 items, measures Self-Confidence During Stress (SCDS). The second sub-scale, containing 17 items, measures Life Purpose and Satisfaction (LPS). Using a Likert scale ranging from 1-7, individuals report their degree of agreement with 32 different statements. The second questionnaire, The Index of Core Spiritual Experiences (INSPIRIT), measures two elements of spirituality that contribute to the formation of a resilient worldview. The first element is experiential. It is comprised of personally meaningful experiences that have convinced an individual that God exists (using the individuals own images and definition of the sacred aspect of life). The second element is relational. It is comprised of attitudes and behaviors that reflect the perception of a deeply felt relationship between the individual and the sacred aspect of life. Within this relational domain, God can be experienced by the individual as close and as an indwelling spiritual core.

8 The two aspects of spirituality measured by the INSPIRIT scale can best be described as experiences of the spiritual core or core spiritual experiences. Kass suggests experiences of the spiritual core to be the operant conditions of internalized spirituality (Kass, 1991a; Kass, 1991b; Kass et al., 2000a). The INSPIRIT is composed of 7 items. Each item uses a Likert scale ranging from 1-4. Questions 1-6 contain individual items. Question 7 is a checklist list of 12 spiritual experiences that many people have reported. Likert scales are used in Question 7 to designate whether or not the individual has had any of these spiritual experiences, and the impact they have had on the persons cognitive appraisal regarding the existence of the sacred aspect of life. It is important to note that the INSPIRIT scale is not a measure of spiritual wellbeing. Spiritual well being is a multidimensional and somewhat elusive concept. Further, it is likely that each major religious tradition would define this construct somewhat differently. Thus, to suggest that the INSPIRIT taps all dimensions of spiritual well being would not be accurate. Rather, as an operant measure of internalized spirituality, the INSPIRIT scale taps an important dimension of spiritual well being. Scholarship within the field of Comparative Religions suggests that experiences of the spiritual core are recognized and valued by each of these traditions (Schuon, 1984). In addition, Fowlers research in the Psychology of Religion suggests that a construct like internalized spirituality is related to a mature stage of faith development (Fowler, 1981). Thus, the INSPIRIT appears to measure an aspect of mature faith development and an important element of spiritual well being that is shared by our

9 major religious traditions. In summary, the INSPIRIT scale is best designated as a measure of internalized spirituality, or as a measure of an aspect of spiritual well-being, rather than as a comprehensive measure of spiritual well-being.

10 II. History of the SRA Copyrights for the Spirituality and Resilience Assessment Packet, the Inventory of Positive Psychological Attitudes, and the Index of Core Spiritual Experience are held by Jared D. Kass, Ph.D. The conceptual foundations of the IPPA and INSPIRIT, and their original item pools, were developed by Kass in 1985-1986. Support for this project was provided by Lesley College through a faculty development grant for research in health psychology and the psychology of religion. Validation of the IPPA and the INSPIRIT (factor analytic refinement of the item pools, measurement of internal reliability, measurement of construct validity, and preliminary clinical testing) were conducted by Kass from 1987-1990 in collaboration with Richard Friedman, Ph.D., Jane Leserman, Ph.D., Margaret Caudill, M.D., Ph.D., Patricia Zuttermeister, M.A., and Herbert Benson, M.D., at the Division of Behavioral Medicine, Department of Medicine, New England Deaconess Hospital, Mind/Body Medical Institute, Harvard Medical School, Boston, MA. Results from these validation studies were reported in Behavioral Medicine (Kass et al., 1991a) and Journal for the Scientific Study of Religion (Kass, Friedman, Leserman, Zuttermeister, & Benson, 1991b). Support for this project was provided by Mr. Laurance S. Rockefeller, the Fetzer Institute, and the United States Public Health Service (HL-27227). Subsequent to their initial validation studies, the IPPA and the INSPIRIT have been further refined and tested. The initial format of the IPPA contained 30 items (IPPA-30). At that time, the SCDS sub-scale contained 13 questions. To further

11 strengthen the construct validity of the SCDS sub-scale, Kass added two questions to this scale. In addition, the wording of 5 other SCDS questions was clarified (IPPA-32R). The factor structure and reliability of the revised instrument were tested and are consistent with the factor structure of the IPPA-30 (Kass, 1998b). In addition, the psychometric properties of the INSPIRIT scale (factor structure, reliability, and construct validity) received independent verification in a study by VandeCreek (VandeCreek, Ayres, & Bassham, 1995). Further testing of the factor structure and reliability of the INSPIRIT have been conducted by Kass and are reported in this manual. The IPPA and INSPIRIT scales were combined by Kass in 1997 into the Spirituality and Resilience Assessment Packet, Self-Test Format. The research versions of the IPPA and the INSPIRIT have been translated into Spanish. A complete Spanish language version of the SRA will be developed in 2001.

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III. Conceptual Foundations

A. Measuring a Resilient Worldview: The IPPA

Psychological assessment has tended to focus on the identification of attitudes that contribute to, and are symptomatic of, mental and physical disorders. This focus is most useful when clinicians and researchers seek to identify the degree to which individuals are impaired or at-risk. This focus becomes less useful, however, when we seek to identify the nature and strength of attitudes that contribute to resilience and primary prevention (Antonovsky, 1979). Since 1975, increased attention has been placed on explaining how resilient psychological attitudes may contribute to health. This research has focused on the stress-buffering effects of positive attitudes. Considerable evidence has demonstrated that frequent activation of the stress response produces chronic hyperarousal through dysregulation of neurotransmitter functions related to the sympathetic nervous systemadrenal medulla axis and the hypothalamic-pituitary-adrenal cortex axis of the endocrine system (Gatchel & Baum, 1983; Rose, 1980). As sequelae to dysregulation of these systems, individuals develop a range of mental and physical disorders (Gatchel & Blanchard, 1993). Psychological disorders related to hyperarousal are characterized by elevated levels of hostility, depression, and/or anxiety (Gold, Goodwin, & Chrousos, 1988a; Gold, Goodwin, & Chrousos, 1988b; Krystal et al., 1989; Van Der Kolk, 1988). Physical disorders related to hyperarousal are characterized by pathology of the

13 cardiovascular, gastrointestinal, immunologic, and neuromuscular systems (Andersen, Kiecolt-Glaser, & Glaser, 1994; Blascovich & Katkin, 1993; Dorian & Garfinkel, 1987; Taylor, 1986). In addition, individuals experiencing hyperarousal regularly develop a range of health-risk behaviors. These behaviors, which may be attempts to regulate the stress response through forms of self-medication, are leading causes of premature morbidity and mortality in the United States. They include cigarette smoking, excessive consumption of high-fat foods, and dependence on alcohol and drugs (Brannon & Feist, 1997; Grunberg & Baum, 1985; Sunderwirth, 1985). It may be useful to note, of course, that some degree of stress can produce benefits to individuals by contributing to performance, productivity, the development of new coping skills, and creativity. In conditions of chronic hyperarousal, however, these benefits are quickly lost. External stress is universally recognized as an inevitable aspect of life. The stress response, however, is an internal response to external stress. Thus, the strength and frequency of an individuals stress response are not inevitable. Research has begun to suggest that resilience can function as an intervening variable buffering or preventing the stress response (Hafen, Frandsen, Karren, & Hooker, 1992; Lazarus & Folkman, 1984). By contributing to a positive worldview, resilient attitudes help individuals to be less reactive to, and to cope more successfully with, stressful circumstances and events. Thus, by helping to regulate autonomic functions, positive attitudes can help to prevent psychological illnesses, medical illnesses, and health-risk behaviors.

14 Two major constellations of positive attitudinal constructs have been hypothesized to contribute to resilience and health. The first constellation concerns locus of control. Using Rotters model of internalized versus externalized locus of control (Rotter, 1966), Langer and Rodin demonstrated that internal locus of control contributes to health (Langer & Rodin, 1976). Similarly, Seligman has shown that learned helplessness leads to diminished coping and adaptation (Seligman, 1975). Wortman and Brehm refined this model by showing that expectations of internal locus of control counter helplessness (Wortman & Brehm, 1975). The second constellation concerns perceived meaning. Using Crumbaugh and Maholicks operational definition (Crumbaugh, 1968; Crumbaugh & Maholick, 1969; Crumbaugh & Maholick, 1964), Stevens, Pfost, and Wessel demonstrated that purpose in life contributes to improved coping (Stevens, Pfost, & Wessels, 1987). Using a somewhat different operational definition, Reker has shown that life purpose leads to improved psychological functioning (Reker, Peacock, & Wong, 1987). Additionally, Abby and Andrews found satisfaction with life to be associated with diminished levels of depression (Abby & Andrews, 1985). Initially, investigations regarding the efficacy of these two positive constellations remained separate. To some extent, the two constellations may have been seen as competing explanatory hypotheses. Eventually, researchers began to conceptualize these constellations as complementary, and to measure them within multidimensional instruments. For example, Kobasa and Maddi developed the concept of stresshardiness and conceived it as having both control and meaning dimensions (Kobasa,

15 Maddi, & Kahn, 1982). Similarly, Antonovsky developed the concept of sense of coherence (Antonovsky, 1987). This construct was also conceived as containing both control and meaning dimensions. However, it has become apparent that both the first-generation unidimensional scales and the second-generation multidimensional scales contain limitations in the ways that they have conceptualized the control and the meaning dimensions. These limitations have been articulated from two related perspectives: 1) a multicultural perspective, and, 2) an existential-religious perspective. 1. Multicultural perspective: Assessment instruments tend to define psychological health as the attitudes and behaviors that reflect the sanctioned worldview of the dominant cultural group within our society (Suzuki, Meller, & Ponterotto, 1996). This worldview considers individuals as isolates and values individualism. Thus, these assessment tools are not responsive to resilient attitudes among persons from cultural groups that do not share the dominant worldview. In addition, they are not responsive to the psychological effects on identity formation of the devaluation experienced by those who are not part of the dominant cultural group. Many women and many subordinated cultural groups hold a different worldview in which individuals experience themselves, not as isolates, but as in-connection. Miller and her colleagues point out that women experience themselves in relational contexts. It is from these relational contexts that they derive an empowered sense of self (Miller, 1976) (Jordan, Kaplan, Miller, Stiver, & Surrey, 1991). Sue emphasizes that, for cultures whose behavior and attitudes are guided by a worldview of connectedness, there are beneficial forms of

16 external locus of control (e.g. family, community, and the sacred aspect of life) whose effects are not measured in typical locus of control scales (Sue, 1978; Sue & Sue, 1981). Both Miller and Sue, among others, further point out that a primary source of diminished self-confidence for women and individuals from subordinated cultural groups is socially sanctioned devaluation. 2. Existential-religious perspective: Existential philosophy has tended to support an aspect of our societys dominant worldview by suggesting that humans are essentially alone (May & Yalom, 1989; Yalom, 1981). Proponents of an existentialreligious perspective, however, have argued that, while individuals must take full responsibility for their actions and lives, they can derive meaning from the experience of relationship with lifes spiritual core. Tillich and Frankl suggest that a primary cause of an individuals most fundamental experience of anxiety is the perception that life lacks intrinsic meaning (Frankl, 1959; Frankl, 1969; Tillich, 1952). In addition, they have suggested that a primary source of psychological strength can be found in a relationship with the transcendent reality (Frankl, 1966; Tillich, 1952). Thus, meaning in life can be experienced, not simply as a functional derivative of ones personal goals or work, but as an ontological attribute of life itself. In this worldview, individuals are fundamentally not alone. Though they are personally responsible for determining the meaning in their lives, such meaning is discovered through relationship with the sacred aspect of life. These critical perspectives suggest that operational definitions of the control and meaning dimensions are inadequate if they exclude attitudes that can emerge from an individuals sense of connection with other people or a transcendent reality. They are

17 inadequate because they are not responsive to a full range of positive attitudinal coping styles. Whether individuals perceive themselves as connected to members of their family, their community, God, or a mixture of these three factors, receiving help from such trustworthy sources can buffer activation of the stress response in substantial ways. As a third-generation positive attitudinal scale, the IPPA was developed to address these limitations in the conceptualization of the control- and meaningdimensions. 1. Control Dimension: Self-Confidence During Stress (SCDS) The IPPA is built upon the hypothesis that the stress-buffering aspects of control derive from the perception that stressful events are under control, rather than from the perception that the individual is in control. Perceptions that events are under control exist on a continuum. The range of this continuum includes perceived internal locus of control, positive forms of external locus of control, and habitually calm responses reflective of perceptions of ontological security. Thus, the Self-Confidence During Stress sub-scale of the IPPA includes 3 types of attitude. The first type measures perceived internal locus of control during stressful situations. Examples are: When I need to stand up for myself, I can do it quite easily, I feel adequate when I am in difficult situations, I react to problems and difficulties with no frustration. The second type measures positive forms of external locus of control. Examples are: In a difficult situation, I am confident that I will receive the help that I need, During times of stress, I do not feel isolated and alone. The third type measures habitually calm responses

18 reflective of perceptions of ontological security. Examples are: During stressful circumstances, I am never fearful, When there is a great deal of pressure being placed on me, I remain calm. Although these three types of attitude differ from each other, factor analyses suggest that they are related. Thus, the continuum of attitudes measured by the Self-Confidence During Stress sub-scale appears to have structural integrity. 2. Meaning Dimension: Life Purpose and Satisfaction (LPS) The second dimension of the IPPA is based on the hypothesis that meaningbased attitudinal resources also exist on a continuum. The range of this continuum includes generalized perceptions of life satisfaction, personally constructed forms of meaning, and ontologically derived forms of meaning. Thus, the Life Purpose and Satisfaction (LPS) scale also contains three types of items. The first type measures generalized life satisfaction. Examples are: My daily activities are a source of satisfaction, During most of the day, my energy level is very high. The second type measures personally constructed forms of meaning. Examples are: I feel that the work I am doing is of great value, At this time, I have clearly defined goals in my life, I feel that my life so far has been productive. The third type measures the ontological dimension of meaning. Examples are: When I think deeply about life, I feel there is a purpose to it, When sad things happen to me or other people, I continue to feel positive about life, Deep inside myself, I feel loved, I do not feel trapped by the circumstances of my life. Although these three types of attitude are different from each other, factor analyses once again suggest their relatedness. Thus, the continuum of

19 attitudes measured by the Life Purpose and Satisfaction sub-scale appears to have structural integrity. 3. Unifying Concept: Confidence in Life and Self (CLS) While the IPPA was designed to be a multidimensional instrument, the subscales within the IPPA were conceptualized as complementary aspects of a unified positive worldview, Confidence in Life and Self (CLS). Thus, while both SCDS and LPS are hypothesized to contain independent stress-buffering effects, and while an individuals scores on the two sub-scales can be different, an optimally positive worldview is hypothesized to include strength in both dimensions. The psychometric properties of the IPPA demonstrate a mixture of convergence and divergence between the two sub-scales that this conceptual model anticipates. Factor analyses distinguish between the two sub-scales. At the same time, the reliability of the unified scale, as well as inter-scale correlation, have been high. In addition, research data suggest that high scores on the total IPPA are often more strongly associated with positive outcomes than high scores on the individual sub-scales. Thus, there is an aggregate, or complementary, effect between the two sub-scales. These data lend support to the validity of the hypothesized construct, Confidence in Life and Self, as a reflection of a unified positive worldview.

B. Measuring Internalized Spirituality: The INSPIRIT

20 The value of religiosity or spirituality in individual and social health has been a matter of debate (Wulff, 1996). Aspects of religiosity have been associated with neurosis (Dittes, 1969; Pruyser, 1991), intolerance of ambiguity (Budner, 1959), suggestibility (Fisher, 1964), dogmatic authoritarianism (Rokeach, 1960), racial prejudice (Allport, 1966), and sexism (Spretnak, 1982). Nonetheless, evidence suggesting that religious factors may have a broad range of beneficial effects continues to grow (Miller & Thoreson, 1999). Some of the most pronounced effects have been observed in the area of mental health (Bergin, Masters, & Richards, 1987; Gartner, Larson, & Allen, 1991; Hood, Hall, Watson, & Biderman, 1979; Larson et al., 1992; Poloma & Gallup, 1991). In addition, a growing body of research suggests benefits within the area of physical health (Kass et al., 1991b; Koenig, 1997; Levin, 1994). Further, there has been considerable documentation of these positive effects in the area of substance abuse (Gorsuch, 1995; Marlatt & Kristeller, 1999). 1. Religion and Spirituality as Overlapping Concepts Although spirituality and religiosity are overlapping concepts, it has been useful to distinguish between them when developing an operational definition for empirical research (Kass et al., 1991b). Religiosity generally refers to participation in an organized religion. Spirituality, on the other hand, refers to the quality of the relationship that an individual experiences with the sacred aspect of life. This distinction emerges from Allports seminal differentiation between intrinsic and extrinsic religiosity, in which intrinsic religiosity (internalization of religious values and experience) provided greater protective effects against racial prejudice than extrinsic religiosity (religious participation

21 for utilitarian benefits like social support and status) (Allport & Ross, 1967). Subsequent to Allports research, the term spirituality has become somewhat synonymous with his term intrinsic religiosity. However, because the term spirituality sometimes connotes a superficial approach to religious development, Kass employs the term internalized spirituality to connote a deeply experienced, internalized relationship with the sacred aspect of life. Thus, internalized spirituality may be a more precise indicator of the health benefits of religiosity than a more extrinsically oriented construct. 2. Characteristics of Internalized Spirituality Kass has suggested two primary characteristics of internalized spirituality: 1) subjectively meaningful experiences that have demonstrated to an individual that the sacred aspect of life (God or Higher Power) exists, 2) perceptions of closeness with the sacred aspect of life, in which God is experienced as a core aspect of the individuals self. These experiences of the spiritual core (whose association with health-related variables will be reviewed in the following section of this manual) can serve as a healthpromoting resource by providing individuals and communities with an ontological foundation for the formation of the resilient worldview, Confidence in Life and Self. It should be noted, of course, that positive outcomes related to internalized spirituality can not be construed as objective proof of the existence of the sacred aspect of life. Internalized spirituality is a subjective phenomenon. However, social psychology has demonstrated that subjective attitudinal constructs can affect health outcomes. As a consequence, while not verifying Gods existence, the scientific study of internalized spirituality can demonstrate the stress-buffering effects of this subjectively experienced

22 phenomenon. The mechanism for this effect appears to be cognitive re-structuring in which internalized spirituality promotes internal locus of evaluation and a stressbuffering worldview (Kass, 1998a). Thus, internalized spirituality may provide individuals with inner strength that can mediate the effects of external stress.

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IV. Summary of Research A. Inventory of Positive Psychological Attitudes (IPPA-32R) 1. Confirmation of Multidimensional Structure Confirmation of the hypothesized multidimensional structure of the IPPA was obtained using principal components and common factor analyses. In these procedures, an item pool is differentiated mathematically into factors based on shared patterns of response sets. When these mathematically derived factors match hypothesized theoretical constructs, the conceptual structure of the questionnaire can be considered sound. Using a sample of 368 adults (172 outpatients in behavioral medicine treatment, 88 undergraduate students, 108 graduate students), principal components analysis with varimax rotation differentiated items on the IPPA-30 into 2 factors corresponding to the hypothesized theoretical factors SCDS and LPS (Kass et al., 1991a). Factor 1 (eigenvalue, 10.32; variance explained, 34.38%) contained the hypothesized 17 items of the LPS scale. Item loadings ranged from .45 to .76. Factor 2 (eigenvalue, 2.29; variance explained, 7.62%) contained the hypothesized 13 items of the SCDS scale. Item loadings ranged from .46 to .68. Despite well-differentiated loading patterns, convergence between the factors could also be observed. One LPS item loaded above .40 on the SCDS scale. Similarly,

24 2 SCDS items loaded above .40 on the LPS scale. This degree of convergence was considered acceptable because these factors are hypothesized to be complementary aspects of an underlying positive worldview. Table 1.1 reports factor loadings of the IPPA from a second, confirmatory study with a larger sample. This study was conducted by Kass and colleagues with 1,029 adult employees at a large corporation (472 females, 554 males, 90.7% Caucasian). The initial analysis of this data, without factor analytic procedures, was reported by Zuttermeister, Kass, Geiss, and Friedman (Zuttermeister, Kass, Geiss, & Friedman, 1992). In this study, common factor analysis with varimax rotation was employed. Using an initial pool of 54 items (chosen from the original item pool through which the IPPA was developed), an exploratory factor analysis retained 17 items as factor 1. These items belonged to the hypothesized LPS scale. Additionally, 13 items were retained as factor 2. These items belonged to the hypothesized SCDS scale. A confirmatory common factor analysis was then conducted using only the 30 items. Loadings for the LPS factor ranged from .403 to .739. Loadings for the SCDS factor ranged from .391 to .648. Once again, despite substantial divergence, there was some convergence. Two LPS items loaded above .40 on the SCDS scale. One SCDS item loaded over .40 on the LPS scale. This degree of convergence was again considered acceptable given the hypothesized complementary nature of the two scales (Kass, 1998b). Subsequently, the factor structure of the IPPA-32R was also tested. Kass performed common factor analyses with varimax rotation on data from a sample of 309

25 adults (55% female, 45% male, 90% White). An exploratory analysis with an unspecified number of factors differentiated 2 factors, corresponding to the LPS scale and the SCDS scale. The first factor (eigenvalue, 8.89; 27.8% variance explained) included the 17 items of the LPS scale. Factor loadings ranged from .432 to .815. The second factor (eigenvalue, 6.85; 21.4% variance explained) included the 15 items of the SCDS scale. Factor loadings ranged from .391 to .759. Once again, despite clear factor differentiation, a degree of convergence was found. One item from the LPS scale loaded above .4 on the SCDS scale. Four items on the SCDS scale loaded above .4 on the LPS scale. These results suggest that the factor structure of the IPPA-32R is highly analogous to the factor structure of the IPPA-30 (Kass, 1998b). In summary, factor analyses have consistently supported the theorized multidimensional structure of the IPPA. The LPS and SCDS scales are different from each other. At the same time, these analyses show that the two sub-scales are not fully orthogonal. This convergence suggests that they are complementary aspects of an underlying positive worldview. The degree to which Confidence in Life and Self can be considered a structural unit was then assessed through tests of reliability. 2. Reliability To evaluate the reliability of the IPPA, the internal consistency of the scales (i.e. consistency in the patterns of responses) was determined. This criterion of reliability, also called homogeneity, was measured using Cronbachs alpha coefficient of reliability.

26 In the sample of 368 adults, Kass and his colleagues found Cronbachs alpha coefficients to be consistently high for each IPPA-30 scale, both for the sample as a whole and for each sub-group within the sample. For the entire sample, Cronbachs alpha coefficients were: SCDS, .86; LPS, .91; Total IPPA (CLS), .93. These reliability coefficients were similar for each sub-group (behavioral medicine outpatients, undergraduate students, and graduate students). The range of alpha coefficients was: SCDS, .80 - .86; LPS, .87 - .92; Total IPPA (CLS), .88 - .94 (Kass et al., 1991a). In the sample of 1,029 corporate employees, Kass and his colleagues found Cronbachs alpha coefficients to be consistently high for each IPPA-30 scale, both within the whole sample and within sub-groups sorted by gender. For the SCDS subscale, the alpha coefficients were: total group, .855; females, .842; males, .858. For the LPS sub-scale, the alpha coefficients were: total group, .912; females, .908; males, . 914. For the total IPPA (CLS), the alpha coefficients were: total group, .930; females, . 926; males, .934 (Zuttermeister et al., 1992). In the sample of 309 adults, Kass also found Cronbachs alpha coefficients to be high for each IPPA-32 scale. For SCDS, the alpha was .917. For LPS, the alpha was . 942. For CLS (total IPPA), the alpha was .957. As anticipated, the revisions in the SCDS scale strengthened its reliability. In addition, these revisions strengthened the reliability of the total IPPA (Kass, 1998b). In summary, these data help to confirm the psychometric structure and reliability of the IPPA scales. Both the SCDS and LPS sub-scales have a high degree of internal consistency. They are different from each other (as shown in the factor analyses), and

27 they each display a high degree of homogeneity. At the same time, the CLS scale (total IPPA) also shows a high degree of internal consistency. These findings suggest that Confidence in Life and Self is a unified construct containing complementary aspects. 3. Construct Validity Tests of construct validity determine whether a scale actually measures its hypothesized conceptual domains. Construct validity of the IPPA was evaluated through two lines of inquiry. First, correspondences between the new scale and other scales that are recognized to measure related domains were measured. Second, the ability of the IPPA to differentiate between population samples was examined, using populations where these attitudinal domains are safely assumed to be different. a. Correspondence with comparable scales Using a sample of 368 adults, Kass and his colleagues compared the IPPA to several other scales measuring constructs related to emotional well being. The first scale was McNairs Bi-Polar Profile of Mood States (McNair, Lorr, & Droppleman, 1981). This scale measures 6 mood constructs related to emotional well being: Composed/Anxious, Agreeable/Hostile, Elated/Depressed, Confident/Unsure, Energetic/Tired, Clearheaded/Confused. The second scale was Bradburns Affect Balance Scale, a measure of life satisfaction (Bradburn, 1969). The third scale was Rosenbergs Self-Esteem Scale (Rosenberg, 1965). The fourth scale was The UCLA Loneliness Scale (Russell, Peplau, & Ferguson, 1978). Table 1.2 presents findings from this study. As anticipated, there were positive correlations between the IPPA

28 scales and positive moods, life satisfaction, and self-esteem (Table 1.3). There was a negative correlation between the IPPA and loneliness. The strength of the positive and negative correlations ranged from .38 to .79, with most falling in the .50 to .65 vicinity. All correlations were significant at p <.0001 (Kass et al., 1991a). Using a sample of 1,029 corporate employees, Kass and colleagues compared the IPPA to Derogatis Symptom Checklist-90R (SCL-90R). This measure of psychiatric symptoms contains 9 sub-scales: Hostility, Depression, Anxiety, Phobic Anxiety, Paranoid Ideation, Psychoticism, Obsessive-Compulsivity, Interpersonal Sensitivity, and Somatization. In addition, a Global Severity Index can be derived (Derogatis, 1983). Significant negative correlations, ranging from r = -.21 to r = -.64 (p <.0001), were found between the IPPA and all SCL-90R scales (Zuttermeister et al., 1992). Thus, Confidence in Life and Self (CLS) was negatively related to hostility, depression, anxiety, and Global Severity (Table 1.3). The data from these studies suggest two conclusions. First, there is a reasonable degree of correspondence between the IPPA and the related attitudinal scales. In the social sciences, correlations ranging from r =.500 to r =.600 are considered to reflect a high degree of similarity. It is reasonable to conclude, then, that the IPPA scales measure positive attitudinal domains related to these other scales. However, it is important to note that if there were complete correspondence between the IPPA and the other attitudinal scales, they would be synonymous. In that event, the IPPA scales could not be considered unique attitudinal constructs. This logic leads to the second, and somewhat converse, conclusion. There are sufficiently reasonable

29 divergences between the IPPA scales and the other scales. Correlations ranging from r =.500 to r =.600 reflect a shared variance (r-squared) of 25%-36%. Thus, the scales also perform with a reasonable amount of difference, and cannot be considered synonymous. In conclusion, the IPPA scales tap positive attitudinal domains (SelfConfidence During Stress, Life Purpose and Satisfaction, and Confidence in Life and Self) that are similar to, but distinct from, those tapped by other scales. b. Discrimination between populations To test the discriminative validity of the IPPA, Kass and his colleagues utilized their sample of 368 adults, composed of three different sub-groups. It was hypothesized that healthy graduate students with defined and attainable career goals would have the highest levels of positive attitudes; that outpatients facing uncertain medical prognoses would have the lowest levels of positive attitudes; and that healthy undergraduates with somewhat less defined career goals would score in between. Scores were compared using an analysis of covariance (ANCOVA) with sex, age, race, and education as covariates. Post hoc comparisons were obtained using NewmanKeuls tests. The results confirmed the hypotheses, with one exception. The graduate and undergraduate students scored significantly higher than the medical outpatients on all 3 IPPA scales. The graduate students scored significantly higher than the undergraduate students on the LPS and CLS scales. The graduates, however, did not score higher than the undergraduates on SCDS. Although this latter finding did not support the original hypothesis, the differences between the medical outpatients and the student groups suggested that the discriminative powers of the SCDS scale were

30 sufficient. Thus, all 3 IPPA scales demonstrated a substantial ability to discriminate between differing populations (Kass et al., 1991a). In conclusion, the data from these studies lend strong support for the construct validity of the IPPA scales.

4. Outcome Research
As described in concept section III-A, stress can contribute to psychological and physical illnesses through two pathways: autonomic hyperarousal and the elicitation of health-risk behaviors. Thus, health-promoting effects of resilient attitudes should be observable in three ways: 1) reductions in psychological symptoms related to hyperarousal; 2) reductions in stress-related medical symptoms; 3) reductions in health-risk behaviors. Ideally, investigations of the utility of the IPPA should include prospective, long-term research seeking evidence that Confidence in Life and Self helps individuals maintain low levels of psychological symptoms, stress-related medical illnesses, and health-risk behaviors. To date, long-term prospective research has not been conducted with the IPPA. However, short-term research studies with chronic pain patients, behavioral medicine outpatients, and healthy adults offer evidence that the positive attitudes measured by the IPPA are related to reductions in these areas.

31 a. Improvements in psychological symptoms and chronic pain In a sample of 228 outpatients being treated for chronic pain within a 10-week behavioral medicine program, Kass and his colleagues found the IPPA associated with reductions in psychological symptoms and stress-related medical symptoms (Kass et al., 1991a). Psychological symptoms were measured by the Global Severity Index (GSI) of the SCL-90R (Derogatis, 1983). Stress-related medical symptoms were measured by the four scales of the Multidimensional Pain Inventory (Kerns, Turk, & Rudy, 1985) and the McGill Pain Questionnaire (Melzack, 1975). Data was gathered pre- and post-treatment. Increases in CLS were associated with decreases in the GSI (r = -.57; p < .01). Increases in CLS were also associated with decreases in pain severity (r = -.29; p < .01; MPI-1), interference (r = -.28, p < .01; MPI-2), affective distress (r = -.36; p < .01; MPI-4), and the global pain rating index of the McGill Questionnaire (r = -.20, p < .02). In addition, increases in CLS were associated with increases in life control (r = .37, p < .01; MPI-3). These data suggest that increases in CLS contribute to decreases in psychological symptoms and chronic pain among these medical outpatients. In this study, Kass and his colleagues also sought to determine whether decreases in pain ratings were better explained by increases in positive attitudes or decreases in psychological symptoms. These opposing variables, while related, are not mirror images. Increases in positive attitudes may be a more useful predictor for decreases in pain than decreases in psychological symptoms. Multiple regression analyses were performed with the pain scales as dependent variable and the IPPA

32 (CLS) and SCL-90R (GSI) as co-independent variables. These analyses showed the IPPA to be the more effective predictor for pain severity (MPI-1) and pain interference (MPI-2). With life control (MPI-3) and affective distress (MPI-4), the most effective explanatory model was the interaction between CLS and GSI. The GSI was the more effective predictor only on the McGill PRI. Thus, in 4 of the 5 pain measures, the IPPA provided superior or necessary explanatory data. These results suggest that increases in CLS can contribute substantively to reductions in stress-related chronic pain. b. Improvements in psychological and medical symptoms In a related study, Tate found increases in CLS to be associated with decreases in psychological symptoms and decreases in combined medical-psychological symptoms (Tate, 1994). This study was conducted at a different behavioral medicine clinic, utilizing 183 adult outpatients in a 9-week program under treatment for a variety of stress-related illnesses. Pre- and post-treatment, and six-month follow-up, data were gathered using the IPPA, the SCL-90-R, and Lesermans Medical and Psychological Symptoms Checklist (Borysenko, 1989). The MPSCL measures 33 stress-related medical symptoms on 3 dimensions (frequency, degree of discomfort, and degree of interference). In addition, the MPSCL measures 13 stress-related behaviors, 14 negative thought patterns, and 15 negative affective states on one dimension (degree to which the symptoms bother the individual). A global score for these dimensions is obtained (MSP). Spearman rank order correlations were used to compare relationships between the change scores of these variables.

33 Tate found negative correlations between changes in CLS and GSI from pre- to post-treatment (r = -.504), from post-treatment to 6-month follow-up (r = -.394), and from pre-treatment to 6-month follow-up (r = -.571). Significance values were p < .001. Thus, increases in CLS were strongly associated with reductions in psychological symptoms. Tate also found negative correlations between CLS and MPS scores from pre- to post-treatment (r = -.550), from post-treatment to 6-month follow-up (r = -.468), and from pre-treatment to 6-month follow-up (r = -.625). Significance values were p < .001. The global MPS score does not differentiate between medical, behavioral, and psychoaffective symptom dimensions. However, a more detailed review of these findings suggests increases in CLS to be associated with all dimensions of the scale, including medical symptoms. c. Associations with lower levels of health-risk behaviors In a cross sectional study employing a sample of 735 healthy adults participating in a survey conducted through a health-related magazine, Kass found Confidence in Life and Self to be associated negatively with cigarette smoking and overeating (Kass, 2000b). There were 449 women (61%) and 286 men (49%). The composition of the sample was predominantly white (88%). Mean age for the group was 42.6 years (SD = 11.5 years). This study used a self-report question that asked, During the average day, how often do you eat a meal that contributes to more body weight than your doctor

34 recommends? Twenty-seven percent of the group (N = 195) reported Never. Fifty percent (N = 366) reported One time per day. Fourteen percent (N = 104) reported Twice per day. Six percent (N = 41) reported Three times per day. Two percent (N = 13) reported Four times per day. Two percent (N = 15) reported Five times per day. Relationships between these categories of eating behaviors and CLS were measured using Pearson chi-square statistics. Results showed a negative relationship between CLS and eating behaviors (Pearson chi-square = 102.09; p = .003). This study also asked, During the average day, how much do you smoke cigarettes? Eighty-five percent of the group (N = 623) reported Never. Seven percent (N = 52) reported pack. Five percent (N = 40) reported 1 pack. Two percent (N = 14) reported 1 packs. One percent (N = 5) reported 2 packs. Thus, this group smoked much less than they overate. Nevertheless, a modest negative relationship was also apparent between CLS and smoking (Pearson chi-square = 91.6; p-value = .001). In conclusion, this outcome research suggests that psychological resilience, as measured by the positive worldview Confidence in Life and Self, can serve as a protective factor helping to reduce psychological symptoms related to stress, medical symptoms related to stress, and health risk behaviors. Having examined the psychological and physical health benefits of resilience, we can now examine the role that internalized spirituality plays in the formation and maintenance of psychological resilience. B. Index of Core Spiritual Experiences (INSPIRIT-R)

35 1. Confirmation of Unidimensional Structure The unidimensional structure of the INSPIRIT was developed and confirmed using principal components analyses with varimax rotation. The initial sample was composed of outpatients in a hospital-based behavioral medicine program (N=83). The sample ranged in age from 25-72 years (mean=46.2, SD=11.2). It was predominantly female (66%) and white (94%). Religious backgrounds included Catholic (37%), Protestant (23%), and Jewish (40%). Educational background was high (mean = 16.1 years, SD = 2.5). The original item pool of the INSPIRIT contained 11 questions. Items 1-4 and 811 were questions (or modifications of questions) developed by the National Opinion Research Center (NORC) in conjunction with Greeley (Davis & Smith, 1985, Greeley, 1974 #83). Items 5, 6 and 7 were newly developed for the INSPIRIT. The principal components analysis retained items 1-7 as a single factor. Items 8-11 loaded into two additional factors. Items 1-7 contained the two key aspects of core spiritual experiences. (Items 3, 5, and 7 identify experiences leading to a conviction of Gods presence. Items 1, 2, 4, and 6 measure behaviors and attitudes that would be present among individuals experiencing closeness to God.) Consequently, items 1-7 were retained as the final version of the INSPIRIT. A confirmatory analysis was then conducted using the 7 items. Table 2.1 presents the factor loadings from this analysis (Kass Study-1). The loadings ranged from .69 to .85. The eigenvalue for this factor was 4.42, explaining 63% of the variance in the matrix (Kass et al., 1991b).

36 VandeCreek reported an independent replication of this factor structure in 1995. Data were gathered from 371 individuals. This sample was composed of 247 medical outpatients at a cancer hospital and 124 family members in a surgical waiting room (VandeCreek et al., 1995). The group was predominantly white (91%) and female (60%). Mean age for the group was 50 years, ranging from 17 to 78. An exploratory principal components analysis retained the seven items in a single factor. These loadings were substantive, but lower than in Kass original study. They ranged from . 163 to .620 (with five items loading in the .503 to .572 level). The eigenvalue for this factor was 3.46, explaining 49.4% of the variance in this matrix (Table 2.1). In a subsequent study of 735 individuals, Kass found additional confirmation for this factor structure (Kass, 2000a). This sample contained 449 women (61%) and 286 men (39%) participating in a survey conducted through a health-related magazine. Mean age was 42.59 (SD = 11.54). The sample was predominantly White (88%), with smaller numbers of African-Americans (2.7%), Asian-Americans (4.0%), Hispanics (1.6%) and Native Americans (1.8%). The religious affiliations of the sample included Protestant (41%), Catholic (23%), Jewish (2.6%), other (12.4%), and no affiliation (21%). All seven items loaded into a single factor. Factor loadings ranged from .699 to .823. The eigenvalue for this factor was 4.05, explaining 58% of the variance in this matrix (Table 2.1, Kass Study-2). In summary, principal components analyses of three separate samples have consistently supported the hypothesized unidimensional structure of the INSPIRIT. Conceptually, the INSPIRIT taps two aspects of spirituality: an experiential aspect

37 (experiences of Gods existence) and a relational aspect (God experienced as close to the person and as an in-dwelling spiritual core). Together, these complementary aspects are conceptualized as experiences of the spiritual core. The results from these principal components analyses confirm the unidimensional nature of the 7 items in the INSPIRIT and lend support to their hypothesized conceptual structure. 2. Reliability To evaluate the reliability of the INSPIRIT, Cronbachs alpha coefficient was utilized to determine the strength of the internal consistency of the scale. In their original sample of 83 behavioral medicine outpatient adults, Kass and his colleagues found Cronbach's Alpha reliability coefficient to be .90. The mean score for the INSPIRIT was 2.8 (SD=.83) (Kass et al., 1991b). In VandeCreeks study of 371 outpatients and family members, Cronbachs alpha coefficient was .81. The mean score for the INSPIRIT was 2.97 (SD = .74) (VandeCreek et al., 1995). In Kass subsequent study of 735 respondents in a health-related magazine survey, reported in this manual, Cronbachs alpha reliability coefficient was .87. The mean score for the INSPIRIT was 3.3 (SD = .62) (Kass, 2000a). The reliability score in VandeCreeks sample was somewhat lower than the two studies by Kass. These results were consistent with VandeCreeks principal component analyses where the factor loadings were also lower than in Kass studies. Nonetheless,

38 VandeCreeks findings reflected a substantial degree of homogeneity in the INSPIRIT. As a whole, the data from the three studies suggest a high degree of internal consistency among the seven items of the INSPIRIT scale. 3. Construct Validity The construct validity of the INSPIRIT was evaluated through two lines of inquiry. The first approach evaluated the instruments convergence (and appropriate divergence) with other scales that measure related domains. The second approach measured the ability of the INSPIRIT to differentiate between sub-groups within a sample population, where these sub-groups can reasonably be hypothesized to score differently on this instrument. a. Correspondence with comparable scales In the validation study of the INSPIRIT, Kass hypothesized a positive relationship between experiences of the spiritual core and intrinsic religiosity. He used the Intrinsic Religious Orientation scale from Allports Religious Orientation Inventory to test this hypothesis (Allport & Ross, 1967). Kass further hypothesized a weak negative relationship between the INSPIRIT and Allports Extrinsic Religious Orientation scale. This hypothesis was based on research by Allport and Feagin who found minimal relationships between extrinsic and intrinsic orientations (Allport, 1966, Allport, 1967, Feagin, 1964). The correlation of the INSPIRIT with the Intrinsic scale of the ROI was r=.69, (p = .0001). The correlation with the Extrinsic Religious Orientation scale was weakly

39 negative (r = -.26). Though this second finding was slightly outside an acceptable confidence level (p = .06), these results offered satisfactory substantiation that the INSPIRIT scale measured a spiritual construct that was highly intrinsic in its orientation. At the same time, there was sufficient divergence between Kass INSPIRIT and Allports Intrinsic Religious Orientation scale to suggest that the new scale was not redundant. Further evidence for this aspect of the INSPIRITs construct validity has been supplied by VandeCreek (VandeCreek et al., 1995). In his study of 371 outpatients and family members, VandeCreek examined the relationship between the INSPIRIT and Hoges Intrinsic Religious Motivation Scale (Hoge, 1972). The Pearson product moment correlation for this relationship was r = .61 (p < .05). This result reflects a substantial degree of convergence between the INSPIRIT and another validated measure of intrinsic religiosity. At the same time, this result reflects an appropriate degree of divergence between the scales to suggest unique qualities within the INSPIRIT that Hoges scale does not tap. b. Discrimination between population sub-groups Among the outpatients in the behavioral medicine program where Kass conducted his initial validation study, there were marked differences among the participants regarding knowledge about, and previous use of, meditation (Kass et al., 1991b). Meditation is a spiritual practice associated with increased frequency and intensity of spiritual experiences (Davidson, 1976; Kornfield, 1979; Walsh, 1978). Meditation is practiced by virtually all of the major spiritual traditions in the West and the East, though it is designated by different terms within these many traditions. Some

40 outpatients in this study had been meditating for several years. Others had never meditated before. Meditation research has suggested that its physiological and psychospiritual effects become apparent following approximately 1 month of regular practice. Consequently, Kass hypothesized that outpatients with a history of meditation longer than 1 month would score higher on the INSPIRIT scale than outpatients with a shorter history (0-1 month). To test this hypothesis, Kass and his colleagues performed an Analysis of Covariance (ANCOVA) comparing INSPIRIT scores among the patient sub-groups (Table 2.2). Demographic data (age, gender, and educational level) were utilized as control variables. A significant difference (p = .04) was found between outpatients who had been meditating one month or less (adjusted mean = 2.70) and those who had been meditating for more than 1 month (adjusted mean = 3.15). Interestingly, women scored significantly higher on the INSPIRIT than men in this sample. The role of gender, however, did not interact with, or confound, these results. These results demonstrated the ability of the INSPIRIT scale to differentiate between different subgroups of a population. In summary, these data reflect a substantial degree of construct validity for the INSPIRIT. The INSPIRIT scale measures intrinsic, internalized aspects of spirituality. At the same time, it measures an aspect of intrinsic religiosity that is not tapped by these other scales. In addition, these data provided reasonable justification for the use of the INSPIRIT in outcome research to determine whether or not internalized spirituality contributes to psychological and physical health.

41 4. Outcome Research As described in concept section III-B, the primary pathway through which Kass has hypothesized internalized spirituality to contribute to mental and physical health is through its role as a resource for resilience. While some investigators of the relationship between religion and health hypothesize prayer to be a healing agent ipso facto, Kass suggests that a more productive approach to the health benefits of spirituality lies in understanding the effect of internalized spirituality on an individuals coping mechanisms. Thus, while the development of internalized spirituality may sometimes serve as an ameliorative agent for pre-existing symptoms and disorders (i.e., those with a prominent stress component), the primary significance of internalized spirituality to the fields of mental and physical health is in the area of prevention. As a consequence, the first goal of research with the INSPIRIT has been to examine the relationship between internalized spirituality and the formation of a resilient worldview. The second goal of research with the INSPIRIT has been to examine the relationship between internalized spirituality and reductions in health-risk behaviors. The third goal of research with the INSPIRIT has been to examine the relationship between internalized spirituality and reductions in stress-related physical symptoms associated with medical illnesses. Ideally, investigations of internalized spirituality as a preventive resource should include prospective, long-term research. To date, the most extensive prospective study with the INSPIRIT spans a 9 month period. Thus, more extensive research using the INSPIRIT is required before internalized spirituality can be established as a life-long

42 preventive resource. However, the moderate-length and short-term research conducted to date with the INSPIRIT demonstrates robust relationships between internalized spirituality and the hypothesized health outcomes outlined above. a. The formation of a resilient worldview In the initial validation study of the INSPIRIT, Kass and his colleagues examined changes on the Inventory of Positive Psychological Attitudes among 83 adult outpatients in a 10-week hospital-based behavioral medicine program (Kass et al., 1991b). Medical diagnoses within this sample included musculoskeletal disorders, chronic pain, gastrointestinal disorders, hypertension and cancer. The patients included individuals coping with recent diagnoses of life-threatening illnesses as well as patients coping with long-term chronic disorders. Each patient had been referred to this treatment program by a physician who felt that the patient could benefit from improvements in coping skills. The patients participated in a psychoeducational program where they were taught to meditate and to examine the cognitive components of their reactions to stress. A majority of these outpatients expressed feelings of anxiety and depression as they entered this treatment program. Thus, a primary goal of this program was to help them cope more effectively with the stress related to their medical disorders. The sample ranged in age from 25-72 years (mean=46.2, SD=11.2). It was predominantly female (66%); and white (94%). Religious background within the sample was diverse (Catholic, 37%; Protestant, 23%; Jewish, 40%). The educational background of the group was high (mean = 16.1 years, SD = 2.5).

43 The results from this study showed internalized spirituality to be a significant resource in this coping process. Multiple regressions were utilized to analyze relationships between the INSPIRIT and psychological resilience. Forward stepwise regression was employed in which Kass controlled for health status at Time 1 (T1) and demographic data (gender, age, education). INSPIRIT scores were statistically related to increases in Life Purpose and Satisfaction (Table 2.3). The regression model retained LPS at T1, INSPIRIT, and age in its final model, though the effects of age were not statistically significant. The standardized Beta for the effects of internalized spirituality was B = .15. This model explained 71% of the variance in LPS over the 10week treatment program. It is useful to consider these results more fully. The mean score for the INSPIRIT was stable in this sample over the 10-week period (T1 = 2.81; T2 = 2.86). Thus, the sample did not show increases on the INSPIRIT during this treatment period. Nonetheless, as we have seen, there was variance in INSPIRIT scores (See section IVB, 3-b). Those who had been meditating longer prior to the treatment program had higher INSPIRIT scores. As a consequence, those who came to this treatment program with already established higher levels of internalized spirituality demonstrated the greatest increases in Life Purpose and Satisfaction during the treatment program. In summary, the individuals whose resilience improved most rapidly over the 10-week period were those who came with a foundation of internalized spirituality. This study was pivotal in suggesting to Kass that spirituality would best be conceptualized within the fields of mental and physical health as a preventive resource.

44 An additional outcome of this study was support for the utility of the specific INSPIRIT construct as a tool for the investigation of the relationship between spirituality and resilience. In addition to the INSPIRIT scale, the participants in this study were asked whether or not they believed in God. A comparable multiple regression analysis was conducted replacing the INSPIRIT with Belief in God. This analysis found no relationship between Belief in God and improvements in LPS. Thus, while belief in God and internalized spirituality are overlapping constructs, belief in God was less useful as a predictor of improvements in LPS. The most probable explanation for this difference is the lack of clarity in the Belief in God construct. Such a construct can include individuals with deeply internalized forms of spirituality. However, it can also include individuals with superficial, or highly intellectualized, form of spirituality. Consequently, questions regarding Belief in God are not sufficiently responsive to variations in the depth of spirituality to serve as a useful research tool. This study suggests that the INSPIRIT scale is responsive to these variations and that it fulfills the need for a research tool that distinguishes between more internalized, and more superficial, forms of spirituality. Subsequently, Kass has found further evidence that internalized spirituality can be a substantive source of psychological resilience. Kass and a group of researchers studied a sample of 126 adult students at a highly competitive ivy league university who were enrolled in Masters Degree programs in the universitys Divinity School (Kass et al., 1999; Kass et al., 2000b). This site was chosen for several reasons. First, in response to assumptions within the field of psychology equating spirituality with dysfunctional ego states, a sample of academically successful, highly religious

45 individuals provided an ideal means to bring clarity to this debate. Second, because it was possible that the depth of internalized spirituality would vary within this group of religious adults, this sample also provided a means to explore the distinction between religiosity (participation in an organized religion) and internalized spirituality. Third, because these high achieving individuals were engaged in training and careers that include substantial levels of stress, this site would yield meaningful information regarding relationships between internalized spirituality and psychological resilience. This cross sectional field study employed a voluntary, non-randomized sample. Most of these young adults were in their mid-30s (Mean = 32.2 years, SD = 9.41). They were predominantly female (Women = 86; Men = 40). They were predominantly white (Caucasian = 87%, People of Color = 13%). Their religious affiliations varied (Protestant = 39.7%, Catholic = 17.5%, Jewish = 3.2%, Muslim = 2.4%, Other = 24.6%, None = 11.9%). The "other" category in religious affiliation was composed, to a large extent, of individuals exploring feminist spirituality or Asian meditative disciplines. Most participants were not in an established relationship (single = 49%, married = 27%, committed relationship = 15%, divorced or widowed = 9%). Dysfunctional ego states were measured with Budners Intolerance of Ambiguity Scale (Budner, 1959) and the Symptom Checklist 90-R, a measure of psychiatric symptoms (Derogatis, 1983). In addition, Kass gathered demographic data related to family structure during childhood and adolescence, a potential indicator of dysfunctional ego states. Psychological resilience was measured using the Inventory of Positive Psychological Attitudes.

46 INSPIRIT scores were high in this sample, while at the same time displaying a significant degree of variance (Women: Mean = 3.30, SD = .57; Men: Mean = 3.13, SD = .58). As a consequence, this sample provided a meaningful testing ground for a relationship between INSPIRIT scores and dysfunctional ego states. No relationship was found between INSPIRIT scores and Intolerance of Ambiguity (r = -.042; p = .644). No relationships were found between INSPIRIT scores and psychiatric symptoms: Obsessive-Compulsive (r = -.032; p = .726); Psychosis (r = .039; p = .672); Paranoia (r = .007; p = .939); Phobias (r = -.044; p = .638); Somatization (r = .034; p = .715); Interpersonal Sensitivity (r = -.110; .233). In addition, no relationships were found between INSPIRIT scores and family structure during childhood: intact nuclear family (r = -.046; p = .609); death of mother ( r = -.016; p= .858); death of father (r = -.020; p = . 821); death of sibling (r = -.097; p = .279); loss of one parent through separation or divorce (r = .065; p= .471); loss of both parents through separation or divorce (r = .119; p = .183); composite loss of any members of nuclear family (r = .055; p = .544). In summary, there was no evidence that experiences of the spiritual core can be categorically associated with dysfunctional ego states. Pearson product-moment correlations between internalized spirituality and a resilient worldview, on the other hand, were substantial. Positive relationships were found between the INSPIRIT and CLS for women (r = .271, p = .013) and for men (men: r = .373, p = . 018). To clarify these relationships, multiple regression analyses were conducted using CLS as dependent

47 variable. As part of this study, Kass had identified gender-specific areas of stress that contribute to decreases in CLS. For women, stress concerning primary interpersonal relationships was associated with lower CLS. For men, stress concerning academic studies was associated with lower CLS. To control for these effects, and to examine their interactions with spirituality, Kass treated these stressors and the INSPIRIT (as well as potentially important demographic factors) as co-independent variables in the regression analysis (Table 2.4). These analyses confirmed the negative effects of these gender-specific stressors. However, INSPIRIT was retained as the primary factor contributing to increased levels in CLS for women (Standard Beta = .278, p = .011) and men (Standard Beta = .383; p = .010). INSPIRIT buffered the negative effects of these stressors and contributed to increases in CLS. These regression models, which had strong explanatory value (Women: Multiple R = .401, p = .002; Men: Multiple R = .548, p = . 00), lend considerable support to the hypothesis that internalized spirituality contributes to resilience in both women and men. An additional study by Kass adds further credence to this hypothesis. Kass conducted a cross sectional study employing a sample of 735 individuals participating in a survey conducted through a health-related magazine (Kass, 2000a). There were 449 women (61%) and 286 men (49%) in this study. The racial composition of the sample

48 was predominantly white (Caucasian = 88%, Asian = 4%, Black = 2.7%, Native American = 1.8%, Hispanic = 1.6%, Biracial = .82%, Other = 1.5%). Present religious affiliation was varied (Protestant = 41%, Catholic = 23%, None = 21%, Jewish = 2.6%, feminist and earth-based spirituality = .4%, Moslem = .3%, Eastern Orthodox = .14%, Other = 8.8%). The mean age for the group was 42.6 years (SD = 11.5 years). To test the association between the INSPIRIT and the IPPA, Pearson product moment correlations were calculated. Substantial correlations were found in the whole group with CLS (r = .443, p = .000), SC (r = .394; p = .000) and LPS (r = .443; p = .000). Similar relationships were found for women with CLS (r = .448; p = .000), SC (r = .422; p = .000), and LPS (r = .432; p = .000). Similar relationships were also found for men with CLS (r = .444; p = .000), SC (r = .357; p = .000), and LPS (r = .464; p = .000). In addition to these studies conducted by Kass, several other studies have linked internalized spirituality (as measured by the INSPIRIT) with resilience. Zinnbauer and Pargament have found internalized spirituality to be related to increases in positive sense of self and self-esteem among medical outpatients (Zinnbauer & Pargament, 1998). McBride found that internalized spirituality contributed to functional health status among adult outpatients in a family medical practice (McBride, Arthur, Brooks, & Pilkington, 1998). Finally, Easterling found internalized spirituality to contribute to constructive methods of coping among individuals suffering bereavement (Easterling, Gamino, Sewell, & Stirman, 1999). This study is particularly meaningful because Easterling also measured the effects of church attendance on coping. He found internalized spirituality, and not church attendance, to be the primary predictor of

49 positive coping. While church attendance (like belief in God) was linked to positive benefits, these benefits were present only when church attendance was linked with internalized spirituality. In summary, there is reasonable evidence that internalized spirituality is associated with, and contributes to, psychological resilience. This relationship applies fairly equally to women and to men. However, it needs to be noted that the samples reported in the studies conducted by Kass have been predominantly white. Although there is considerable qualitative literature suggesting that this relationship is relevant to many African-American communities (Billingsley, 1992; Freedman, 1993), we must show appropriate restraint in generalizing these conclusions from these studies to African-Americans and other peoples of color. b. Reductions in health-risk behaviors Kass has hypothesized that internalized spirituality, through increases in resilience, can buffer the effects of gender-specific stressors and reduce health risk behaviors. Kass has conducted studies that address three such behaviors, particularly as they affect womens health: hostility (associated with lung cancer and hypertension), cigarette smoking (associated with lung cancer and heart disease), and alcohol dependence (associated with alcoholism and kidney disease). As part of their study of divinity school students (see discussion above), Kass and his colleagues examined how internalized spirituality and a resilient worldview may affect hostility. Table 2.4 reports a multiple regression analysis with hostility as the

50 dependent variable. INSPIRIT, CLS, stress concerning physical appearance (a genderrelated factor), lack of time for fun, and age were all retained in the final model although age was not considered statistically significant. Stress concerning physical appearance and no time for fun contributed to hostility. CLS and INSPIRIT protected against it. Although CLS was the primary factor associated with lower levels of hostility (a finding consistent with Kass' model), INSPIRIT was retained in the model as a co-variable. Thus, it retained an independent effect on hostility in addition to its contributions to CLS (Kass et al., 1999; Kass et al., 2000b). In a related, but separate, study, Kass and this same group of colleagues studied cigarette smoking in first year undergraduate women (Kass et al., 2000a). Using a longitudinal research design, data was collected from 54 young women at the beginning and end of their first year of undergraduate studies in education or human services. Students enrolled in a required, 2-semester course in health and fitness were invited to participate in a study of health without knowing the specific focus of the project. Slightly more than 50% of the students volunteered. The sample was predominantly white (87%) and Catholic (48%). Other religious denominations included Jewish (17%), Protestant (11%), Other (7%), and None (15%). Income levels for the families of most students ranged from $45-60,000, indicating predominantly lower middle class backgrounds. Though we did not employ a randomization process, several characteristics of this sample suggested suitability for this study. The subjects were at an age (Mean = 18.5 years, SD = 1.4) when smoking patterns are not yet set (Geronimus, Neidert, & Bound, 1993). The proportion of smokers (25%) was representative for white women in this age group (NCHS, 1997). The career goals of

51 the subjects (education or human services) were typical of many young women in our society. In addition, two characteristics of this college campus contributed to the suitability of this sample. First, as an urban campus, the psychosocial stressors experienced by these students were typical of contemporary, young adulthood (separation from families, high level of autonomy, career and relationship uncertainties). Second, as a non-sectarian campus, religious or spiritual commitment was not a prescribed social norm. The lack of such norms is evident in the samples moderate scores on internalized spirituality. On a scale of 1 to 4 (high), mean scores were 2.72 at T1 (SD = .60) and 2.66 at T3 (SD = .62). Bivariate correlations with smoking were calculated at T1. Positive correlations were found with family income level, prevalence of family members and friends who smoke, current alcohol usage, and stress concerning physical appearance. This finding provided initial confirmation regarding the relationship between stress concerning physical appearance and smoking in young women. A theoretical model was then constructed for predicting variance in cigarette smoking at T3 (end of academic year). Variables associated with smoking at T1 were used in this model, in conjunction with internalized spirituality, self-confidence, and hostility. Multiple regression analyses were used to test this model, controlling for demographic factors and cigarette smoking at T1. Cigarette smoking at T3 served as dependent variable (Table 2.5). The final model contained two main effects: 1) cigarette smoking at T1 (the control variable); 2) an interactive variable containing the following factors:

52 stress concerning physical appearance, hostility, family members and friends who smoke, self-confidence, current alcohol usage, and internalized spirituality. This model was highly predictive (Multiple R = .903; Multiple R-SQ = .815; F-ratio = 105.97; p= .000). Table 2.5 indicates the direction of the relationships between the factors in the interactive variable and cigarette smoking. Kass and his colleagues found that family and friends who smoke, hostility, and self-confidence are risk factors for cigarette smoking. (The directions of these correlations were derived from trends observed during the initial exploratory regression analyses.) In addition, stress concerning physical appearance predicted increases in cigarette smoking. The primary factor associated with reductions in cigarette smoking was internalized spirituality. (Moderate alcohol use, associated with relaxation, was also associated with lower levels of cigarette smoking. This finding was particularly reasonable given the age of the sample cohort.) Thus, internalized spirituality buffered the effects of stress concerning physical appearance, hostility, and prevalence of friends and family who smoke, thereby serving as a significant protective factor against cigarette smoking. Finally, in an exploratory study conducted with colleagues at the Addictions Research Center, National Institute of Drug Abuse, Kass and colleagues found internalized spirituality associated with decreased intent to drink alcohol among recovering alcoholics (Arias, Douglas, Singleton, & Kass, 1994). This study of 125 recovering adult alcoholics also associated internalized spirituality with decreased dysphoria, decreased hostility, and increased levels of happiness.

53 While the studies reported in this section must be considered exploratory, they provide sound evidence that internalized spirituality can be a prevention resource by contributing to reductions in health-risk behaviors. Further, though not comprehensive, these studies lend support to Kass proposed prevention model linking spirituality with health-promoting behaviors. In this two-step model, internalized spirituality contributes to a resilient worldview. In turn, a resilient worldview contributes to reductions in health risk behaviors. c. Reductions in stress-related medical symptoms When medical symptoms are caused or aggravated by the stress response, it is reasonable to hypothesize that internalized spiritualityin conjunction with the development of stress-reducing behavioral skillscan serve as resource contributing to the reduction of these symptoms. In the study of behavioral medicine outpatients reported above, Kass and his colleagues found internalized spirituality associated with increases in Life Purpose and Satisfaction (Kass et al., 1991b). Using multiple regression analysis, they also found internalized spirituality associated with reductions in the frequency of stress related medical symptoms (Table 2.3). Changes in the average frequency of symptoms were further analyzed by dividing the outpatients into two groups: those who scored above and below the mean group score on the INSPIRIT. An analysis of co-variance adjusting for differences linked with demographic factors (age, gender, education) continued to show a significant difference (p < .0034) between the two groups. Those scoring low on the INSPIRIT showed a very slight increase in average frequency of symptoms (adjusted

54 mean change = .110), while those scoring high on the INSPIRIT showed a moderate decrease (adjusted mean change = -.786). In addition, they compared the INSPIRIT data to data from the Belief in God question. Multiple regression analyses, controlling for demographic data, found that "belief in God" was not significantly related to the average frequency of symptoms ( = -.167, p = .094). Thus, the findings regarding frequency of medical symptoms parallel those regarding Life Purpose. First, internalized spirituality served as a resource contributing to reductions in these symptoms when the patient came to this treatment program with an already developed sense of internalized spirituality. Second, though belief and God and internalized spirituality are overlapping concepts, internalized spirituality is the more efficacious predictor of health outcomes.

55

V. Normative Data A. Conceptual Approach The use of normative data has advantages and disadvantages. Quite often, the interpretation of an individuals raw score on an assessment scale is nearly impossible without a sense of comparison to groups of similar people. Respondents, themselves, often want to know how their scores compare with others. Thus, it is almost inevitable that some degree of normative data will be developed for a widely used assessment scale. Despite these necessary benefits, normative scores can be problematic. First, normative scores are often misinterpreted to mean normal scores. In many instances, however, and particularly in relationship to concepts like spirituality and resilience, what most people score may not necessarily be a healthy or a normal score. Precisely because we live in a society whose educational and medical systems do not place sufficient focus on the development of psychological resilience and emotional intelligence, it is not clear that normative data for the IPPA represents normalcy. Similarly, because we live in a society that does not teach or support the development of spiritual intelligence, it is not clear that normative scores presently available for the INSPIRIT scale represent a healthy level of internalized spirituality. For these reasons, Kass has been reluctant to replace raw score data from these questionnaires with normative scales. Rather, Kass has chosen to emphasize the use of raw score data and to provide sufficient normative information to allow the

56 respondent or professional a reasonably clear comparison with other individuals. The SRA Scoring and Interpretation Instructions provide normative mean scores for each questionnaire, as well as normative data regarding one standard deviation. Because one standard deviation on each side of the mean comprises 68% of the variance in a population sample, this data comprises a broad normative range without placing an inordinate amount of attention on the process of comparison. This degree of normative data allows individuals to place themselves into one of several broad and meaningful categories:

Average Score X Lower Middle 34% Y-1 Lowest 16% Z-1 Upper Middle 34% Y-2 Highest 16% Z-2

57

X represents the average, mean score. Y-variables represent one standard deviation to either side of the mean. Z-variables represent the absolute lowest and highest scores that an individual can achieve. Thus,

If the score is between Z-2 and Y-2 Y-2 and X X and Y-1 Y-1 and Z-1

Then the score is in the Highest 16% Upper Middle 34% Lower Middle 34% Lowest 16%

B. Data for the IPPA 1. Placing the Raw Score in an Interpretive Context The lowest possible score on the IPPA is 1.00. The highest possible score is 7.00. The mid-point of the IPPA is 4.00. A useful interpretive context is established by dividing this variance into 4 equal quartiles.

Low Medium Low

= =

1.00 2.49 2.50 4.00

58 Medium High High = = 4.01 5.50 5.51 7.00

The raw score can now be further compared to normative data. 2. Normative Scores Norms for the IPPA were developed using a sample of 1,029 adult employees at a corporate center in the western United States (Kass, 1998b, Zuttermeister, 1992 #72). The sample was composed of 554 males and 475 females. The scores for the women (Mean = 4.800; SD = .940) were quite similar to those for the men (Mean = 5.086; SD = .878). This similarity allows the use of normative data for men and women together, rather than the development of separate norms for each. The mean score for the entire group was 4.953. This number is rounded off to 4.95 for use in the self-test scoring and interpretive instructions. The standard deviation for this sample was .920. Thus, one standard deviation below the mean is 4.03. One standard deviation above the mean is 5.87. Therefore, 68% of the respondents in this sample scored between 4.03 and 5.87, with the average score being 4.95. In summary: Those who scored Above 5.87 Between 5.87 and 4.95 Between 4.95 and 4.03 Were in the Upper 16% Upper Middle 34% Lower Middle 34%

59 Below 4.03 Lower 16%

C. Data for the INSPIRIT 1. Placing the Raw Score in an Interpretive Context The INSPIRIT scale has 7 questions. Each question can be scored 1, 2, 3, or 4. The lowest possible score on the INSPIRIT is 7. The highest possible score is 28. A useful interpretive context is established by dividing this variance into 4 quartiles. Score Interpretive Minimum Score in Descriptor Range Corresponds To This Pattern Score on 7 questions: 1 Range Corresponds To This Pattern: Score on 4 questions: 1 Score on 3 questions: 11 - 17 MEDIUM LOW Score on 4 questions: 2 Score on 3 questions: 18 - 24 MEDIUM HIGH 1 Score on 4 questions: 3 2 Score on 4 questions: 2 Score on 3 questions: 3 Score on 4 questions: 3 Maximum Score in

7 10

LOW

60

Score on 3 questions: 25 28 HIGH 2 Score on 4 questions: 4 Score on 3 questions: 3

Score on 3 questions: 4 Score on 7 questions: 4

In essence, a low score can be equated with scores that are predominantly 1. A medium low score can be equated with scores that are predominantly 2. A medium high score can be equated with scores that are predominantly 3. Finally, a high score can be equated with scores that are predominantly 4. This raw score can now be further compared to normative data. 2. Normative Scores Norms for the INSPIRIT were developed through a complex analysis of five data sets. These samples were composed of 735 participants in a magazine survey (Kass & Kass, 2000), 371 medical surgery outpatients and family members (VandeCreek et al., 1995), 83 outpatients in a behavioral medicine program (Kass et al., 1991b), 126 adult students at a divinity school ( et al., 1999), and 54 first year undergraduates (Kass et al., 2000a). Five different samples provided the opportunity to analyze INSPIRIT with a diverse range of populations. However, the analysis of these scores made it clear that none of these scores can be considered fully normative. As a consequence, we

61 developed an analytic procedure to designate a putative mean score that best represented the central tendency of these population samples. Similarly, we have designated a number as the putative standard deviation that best represents the central tendency of the variance within these samples. While this procedure has not been wholly satisfactory, and while we hope to test a sample in the future that seems sufficiently normative, the logic leading to the designation of these putative scores seems reasonable. In ascending order, the mean scores for the five samples were: First-year undergraduates Behavioral Medicine Outpatients Surgical Outpatients and Family Members Divinity School Students Health Magazine Respondents 19.04 19.60 20.79 22.61 23.31

While the variance between the mean scores of these samples is not extreme, it is sufficiently large to require thoughtful designation of a putative standardized mean score. In addition, it was not reasonable simply to give these samples equal weight and to create an average among them, though this is an approximate description of the method we chose. With the lowest mean score, we considered the undergraduates a group where little exploration of spirituality has taken place. We considered their mean (19.04) to represent a minimum range of the central tendency. With the highest mean scores, we considered the divinity school students and the health magazine respondents the groups where the most spiritual exploration has taken place. We

62 averaged their scores and considered this average mean score (22.96) to represent a maximum range of the central tendency. With their scores in the middle range, we considered the two outpatient populations groups most close to the central tendency. Additionally, we considered these groups likely to include the greatest variance in spiritual exploration, ranging from individuals who have engaged in a considerable amount to individuals to individuals who have engaged in a negligible amount. This assumption was supported by the fact that these two samples contain the largest standard deviations. We averaged the mean scores of these two samples to represent the middle value in the central tendency (20.195). We then averaged the high, middle, and low values that we had generated and considered (20.73) it to best represent the central tendency of the INSPIRIT. For simplicity of presentation, we have rounded this figure off a negligible amount to 20.5 for use in the self-test interpretive guide as the average score on the INSPIRIT. The determination of the standard deviation followed a similar process. In ascending order, these figures were: Divinity students Undergraduates Magazine respondents Surgical outpatients Behavioral Medicine outpatients 4.06 4.20 4.34 5.18 5.81

It is interesting to note that the two samples with the highest mean score (Divinity students and magazine respondents) and the sample with the lowest mean score

63 (undergraduates) had the smallest internal variance, indicating greater homogeneity within these samples. This lent credence to the interpretation that many of the divinity students and magazine respondents had engaged in spiritual exploration. In addition, it supported the likelihood that the undergraduates, as a group, had not engaged in very much spiritual exploration. With the largest standard deviations, the outpatient samples appear to contain the greatest variance in internalized spirituality, with a greater mixture of those who have, and who have not, explored their own spirituality. We averaged the standard deviations of the outpatient groups (5.495) and considered them, once again, to represent the middle ground of the samples. We averaged the standard deviations of the divinity students and magazine respondents (4.2) and considered them to represent a more homogeneous high group. We used the standard deviation of the undergraduates (4.2) and considered them to represent a more homogeneous low group. We then averaged these middle, high, and low numbers (4.63) and considered this number to represent the central tendency of the standard deviations. For simplicity of presentation, we have rounded this figure off a negligible amount to 4.5 for use in the interpretive guide. Thus, the interpretive guide describes the average score on the INSPIRIT to be 20.5, with most peoples scores ranging between 16 and 25. Those who scored Above 25 Between 20.5 and 25 Between 16 and 20.5 Below 16 Were in the Upper 16% Upper Middle 34% Lower Middle 34% Lower 16%

VI. Guidelines for Administration of the SRA

64

A. Conceptual Approach: Building Collaborative Dialogue

The Spirituality and Resilience Assessment Packet can be administered to individuals or groups. It is administered in a Self-Test Format that enables an individual to score and interpret the results privately. Spirituality and psychological resilience are often experienced as very personal domains, particularly when individuals have not had experience discussing these aspects of their lives with human service professionals or peers. The Self-Test format of the SRA allows individuals to retain a strong degree of control over the information generated by this assessment packet, and provides them with the freedom to decide whether or not they wish to discuss their results with a member of the clergy or a human service professional. While this procedure might appear to minimize the likelihood that an individual will discuss these results with professionals or peers, the opposite situation appears to be the case. When this assessment process is presented to individuals as a vehicle for collaborative dialogue and self-empowerment, the control of information retained by the individual contributes to the formation of trust in the helping relationship. Similarly, while this procedure might appear to increase the likelihood that individuals would report inaccurate or socially desirable scores, the opposite situation also appears to be the case. When individuals are encouraged to begin the process of self-assessment by being honest with themselves, prior to discussion with others, the rapidity with which individuals move from a stance of self-protection or defensiveness toward accurate and honest disclosure is increased.

B. Competency Requirements for Professionals

65 1. Basic Counseling and Referral Skills For use in psychoeducational and psychospiritual interventions, the SRA is best administered by a professional who has received training in basic counseling skills. The examination of attitudes and life domains as personal as psychological resilience and spirituality can stimulate anxiety or other uncomfortable emotions. These concerns and emotions may require psychological and spiritual support. The administrator of the SRA should be able to observe signs that an individual is withdrawing, or has withdrawn, from contact with others regarding their psychospiritual difficulties. In addition, the administrator should have interpersonal skills with which to intervene directly and respectfully when an individual is showing signs of a psychospiritual crisis. If necessary, the professional must be prepared to provide spiritual and emotional counseling, or to provide referral to trained professionals for such counseling. 2. Training in Multicultural Competencies The formation of trust is a key element in the successful exploration of psychospiritual issues. Trust, however, is strongly affected by the dynamics of power (perceived and actual) within the helping relationship (Gawelek, Kass, Langley, Llera, & Roffman, 1994). In turn, the dynamics of power in the helping relationship are strongly related to differences in cultural identity (religious background, race, ethnicity, gender, sexual orientation, and physical ability) between the professional and the client. Consequently, a professionals inability to recognize the effects of cultural differences on power dynamics within the helping relationship can undermine the formation of trust.

66 As a result, professional preparation for administration of the SRA must include the acquisition of multicultural competencies.

C. Practical Steps for Preparation

1. Step One: Take the Test Yourself An individual who has not used the SRA as a tool for his or her own growth and development should not administer the SRA to others. The first step in preparation to administer this instrument is to become thoroughly familiar with the process of selfexamination created by the SRA. For the purposes of professional preparation, this self-examination process must include in-depth explorations of the professionals psychological resilience, the role that internalized spirituality plays in her or his resilience, and the formative events that have contributed to the professionals faith development. 2. Step Two: Be Thoroughly Familiar with the Concepts Introductory pages precede the two questionnaires in the SRA. These pages explain the questionnaires purpose and key concepts. These introductory pages can be used by the professional as a script for the presentation of this assessment process. It is recommended that the professional be highly familiar with these introductory pages prior to administration of the SRA. The professional should be prepared to discuss these concepts with a respondent without needing to refer to these scripted pages. The discussions in the following section may help professionals to manage some of the more difficult and challenging concepts.

67 3. Step Three: Anticipate Challenging Issues Two challenging issues arise fairly consistently during administration of the SRA. First, respondents often need to discuss the language that will be used to denote God. Second, individuals often need to discuss the meaning of the word spirituality. The administrator of the SRA should be prepared to respond to both issues. The following guidelines can help the professional to prepare for these discussions. a. Language to denote God Particularly within multifaith organizations and contexts, the use of sufficiently inclusive language to denote God is difficult. The language denoting God in the SRA has been chosen carefully to respectfully include conceptualizations of the sacred aspect of life from a wide range of cultural and religious traditions. Thus, the packet uses the word God to affirmatively include Christian, Jewish, Muslim, and Hindu respondents who often conceptualize the sacred aspect of life in a personal form. At the same time, the SRA employs the terms Higher Power, Spirit of Life, spiritual core, and the sacred aspect of life to affirmatively include respondents who conceptualize the transcendent reality in a non-personal form. Such respondents can include practitioners of Buddhism and Taoism, Native American religions, and other religious traditions of indigenous peoples. These respondents can also include practitioners of feminist and earth-based forms of spirituality (Celtic and Wiccan traditions) that provide a useful critique of gender-bias in descriptors of the sacred.

68 Clear theological differences exist between, and among, these religious traditions. The intent underlying the development of the INSPIRIT is not to overlook these substantive differences. At the same time, the intent underlying the development of the INSPIRIT is not to engage in debate regarding these differences. Rather, the INSPIRIT seeks to articulate two fundamental concepts of spirituality shared by these faith traditionsdespite their differences. These concepts are reflected in the two aspects of spirituality measured by the INSPIRIT, the experiential aspect and the relational aspect. The experiential aspect of spirituality: Each of our faith traditions recognizes the existence of a transcendent, sacred aspect of life. Whether our traditions describe God in personal language (i.e. Jesus, Jehovah, Allah) or non-personal language (i.e. the Spirit of Life, the Tao), the sacred aspect of life is understood to be the ground of all being. In addition, each of our faith traditions recognizes that the presence of the sacred aspect of life can be felt and experienced by the individual. Such an experience is more than an intellectual belief in God. It is an inner knowing, based on personal experience. The INSPIRIT seeks to find out whether the individual has had such an experience irrespective of their particular religious affiliation. The relational aspect of spirituality: Our faith traditions share the principle that a relationship exists between the individual and the sacred aspect of life. When God is pictured in personal terms,

69 this connection is conceptualized as though it were a person-to-person relationship. When God is pictured as the Spirit of Life, this connection is conceptualized as a fundamental unity in which God is the core of each person and all life. In addition, our traditions teach that the ability of an individual to live in a health-promoting and ethical manner proceeds from that individuals recognition and nurturing of this relationship. Thus, the closer that we feel to God, the more likely we are to be able to translate our experience of Gods existence into positive actions in our lives. The INSPIRIT seeks to find out how close an individual feels to God, irrespective of a persons specific God-image.

Consequently, despite substantial doctrinal differences within and between our faith traditions, the INSPIRIT taps two aspects of spirituality that are shared by our faith traditions1[1]. A respondent who has become comfortable with such differences, and who is equally comfortable recognizing the underlying similarities between our faith traditions, rarely expresses difficulty with the language denoting God in the INSPIRIT. However, a respondent who is less comfortable with such differences, and who has not yet recognized the underlying similarities among our faith traditions, is likely to have some negative reactions to the inclusive language of the INSPIRIT. It is helpful for 1 [1] Tolerance for religious differences should never be equated with tolerance for immoral or unethical activities. It should be recognized that some leaders or groups within every religious tradition have sanctioned unethical uses of power.

70 the professional to be prepared to respond to these negative reactions in a nondefensive and acceptant manner. For example, it can be anticipated that some Christians from more traditional backgrounds may not be fully comfortable with language referring to God as the sacred aspect of life. In order to complete the INSPIRIT, they may wish to cross out the impersonal terms denoting God that they find unacceptable in order to represent the nature of their own belief system. While we would hope that the use of the INSPIRIT would eventually lead individuals to more inclusive perspectives, the choice to cross out (or change) some of the language denoting God is acceptable. In a similar vein, some women who have been wounded emotionally or physically by misuses of power within patriarchal religious structures, are not comfortable with the use of the word God because it traditionally denotes a male figure. They may wish to cross out this word, or to replace it with a female-focused image like Goddess or Mother, or with a gender-free term like Great Spirit. Here, too, it is useful for the professional to support respondents in choices that allow them to define the sacred aspect of life in their own terms. Such changes will enhance the ability of the respondent to utilize the INSPIRIT. In addition, a respondents need to make such changes often creates a doorway for dialogue between the respondent and the professional. Rather than treating such negative reactions as problematic, it is useful for the professional to treat these interchanges as diagnostic of issues that could be discussed. Specifically, these interchanges can be treated as opportunities to understand more about the spiritual life

71 and history of the respondent. Thus, one of the most useful ways to respond to these critical reactions is to learn more about the factors that have led the individual to these strongly felt responses. b. Defining spirituality. As we have seen in the conceptual discussion in Section III-B, religiosity and spirituality are overlapping concepts. Religiosity generally refers to participation in an organized religion. Spirituality, on the other hand, refers to the quality of the relationship that an individual experiences with the sacred aspect of life. As a consequence, an individual with a deeply internalized sense of spirituality will often participate in an organized religion. However, the fact that an individual participates in an organized religion is not equivalent to having a deeply internalized sense of spirituality. Further, some individuals with a deeply internalized sense of spirituality have not found a personally satisfying organized faith community. Particularly during the early stages of spiritual exploration, when a person is beginning to seek an internalized form of spirituality, it is possibleand in some cases highly likely--that this person will experience a significant difference between spirituality and religiosity. Whenever an individual has experienced organized religion as an external imposition of beliefs, rather than as a vehicle for the personal development of internalized spirituality, the individuals need for such an authenticating process often draws this person away from the organized religion in which he or she was educated. Thus, we now find in our society a substantial number of individuals who state that they are spiritual but not religious. At times, it is tempting for the

72 professionals to treat such statements as superficial. However, it is useful to hear the message beneath this statement. This unstated message often indicates that a person is in the early stages of seeking an internalized form of spirituality. Rather than treating such a statement as superficial, it is more useful to treat this statement as a signal that a person is in the midst ofor in need ofa process of growth that will lead to a deepened quality of relationship with the sacred aspect of life. We often think of spirituality as a static quality that some individuals possess, whereas other individuals do not possess it. However, the differentiation that we are developing between internalized spirituality and religiosity helps to emphasize that spirituality is a dynamic, developmental process. This process includes a continuum of depth and experience. Similarly, it includes a process of learning. An emphasis on spirituality as a process of learning provides an entrance point for individuals who wish to examine this unexplored aspect of their lives. As a consequence, Kass defines spirituality, initially, in the following way: Spirituality is a developmental process through which individuals learn to enhance the quality of their relationship with the sacred aspect of life (Kass, 1998c). This statement can serve as a useful, initial working definition of spirituality. However, this definition soon needs to be expanded to include an individuals actions in the world. Each of our faith traditions teaches that internalized spirituality will and should--manifest itself in visible behavior. First, this behavior includes the courage and strength to treat the needs of others as having equal importance with ones own. Second, this behavior includes the ability to respond to the conditions of life with

73 several important qualities: loving kindness, inner peace, a sense of purpose, and an empowered self. Thus, we can expand our definition of spirituality to the following:

Spirituality is a developmental process in which individuals learn to enhance the quality of their relationships with the sacred aspect of life, and with others. In addition, spirituality is a developmental process in which individuals learn to develop skills to face the conditions of their lives with the following qualities: an empowered self, a sense of purpose, loving kindness, inner peace, and the courage to place the needs of others on an equal footing with their own (Kass, 1998c)2[2].

If we look carefully at this definition, we see that an essential feature of internalized spirituality is connection. The development of internalized spirituality produces increased connection to the sacred aspect of life, to others, and to self (Kass, 1998c). This emphasis on connection is central to an understanding of the practices and teachings of our spiritual traditions. Where mechanistic philosophies focus on an individuals existential isolation, thereby promoting behaviors and attitudes that 2[2] It is useful to note that many of these behavioral qualities are measured by the Inventory of Positive Psychological Attitudes. As noted in the interpretation guidelines of the SRA, some individuals score HIGH on the INSPIRIT and LOW on the IPPA. This indicates that they are not yet learning to integrate their experiences of the spiritual core into health-promoting and prosocial behaviors. This pattern seems to occur often among individuals who use spirituality as a form of psychological escape, as well as among authoritarian religious groups that demand an inordinate degree of social conformity. A recognition of this disjuncture between INSPIRIT and IPPA scores can contribute to an individuals spiritual maturation.

74 emphasize separateness, the worlds spiritual traditions focus on the human capacity, and need, for connective awareness (Kass, 1998c). Here, too, our spiritual traditions emphasize a developmental, learning process. On the one hand, internalized spirituality leads to connective awareness. On the other hand, connective awareness leads to internalized spirituality. Each builds upon the other, as the individualand communitiesgradually develop an increasingly deep sense of connection to the sacred aspect of life, to others, and to self. It is important to recognize, however, that the developmental path through which connective awareness is acquired is different for each individual. Nor does the development of internalized spirituality always begin with a sense of connection to God. For some people, internalized spirituality begins with a sense of connection to others. For some people, it begins with a sense of connection to the creative self. For still others, internalized spirituality begins with a sense of connection to nature. (This is not surprising. The contemplation of natures beauty is one of the most direct vehicles for experiencing the sacred aspect of life.) An understanding of these developmental pathways emphasizes that the process through which spirituality becomes internalized does not necessarily take place in a house of worship. Rather, it begins to develop within the web of a persons life (their creative activities, their relationships, their explorations of nature) as well as within more formal practices like prayer and meditation.

75 As a consequence, the SRA utilizes an inclusive perspective that values evidence of internalized spirituality in each aspect of a persons life. For this reason, the introduction to the INSPIRIT includes the following discussion:

The essence of spirituality is not whetheror how oftenyou attend religious services. Rather, the essence of spirituality is the way that you experience life. Spirituality is the experience of connection to the sacred aspect of life, the spirit of life.
For some of us, the experience of the spirit of life grows from a sense of connection to our own inner, creative core. For some, this experience grows from a sense of connection to other people. For some, this experience grows from a sense of connection to nature. For some, this experience grows from a sense of connection to a power that is greater than our selves: the ground of being, God.

Over time, an exploration of your spirituality can lead you to new experiences in each of these areas. For these experiences share a common thread: recognition of the spiritual core that creates and sustains the fabric of life.

This discussion articulates many different avenues through which individuals begin to experience and explore their own spirituality. Through such an introduction, the SRA seeks to give individuals an opportunity to recognize the seeds of their own spirituality. It is useful and important for the professional to recognize and value the many areas of life where internalized spirituality may first begin to flourish. In a similar vein, the spiritual experience checklist (Question 7) on the INSPIRIT articulates a continuum of experiences through which individuals can recognize the presence of the sacred aspect of life. While not meant to be comprehensive (an

76 individual can include a different experience of his or her own), this continuum begins with comparatively ordinary, daily experiences and gradually moves to less ordinary experiences: An experience of profound inner peace An overwhelming experience of love A feeling of unity with the earth and all living beings An experience of complete joy and ecstasy Meeting or listening to a spiritual teacher or master An experience of God's energy or presence An experience of a great spiritual figure (e.g. Jesus, Mary, Elijah, Buddha) A healing of your body or mind (or witnessed such a healing) A miraculous (or not normally occurring) event An experience of angels or guiding spirits An experience of communication with someone who has died An experience with near death or life after death

This continuum allows an individual to begin to conceptualize spirituality as a developmental process, and to emphasize the many highly ordinary, yet extremely profound moments of spirituality which individuals often experience. By helping individuals grow more connected to themselvesand by helping them become more aware of, and more responsive tothe moments of spirituality that occur throughout their lives, we enable individuals to recognize their own spiritualityand their own

77 spiritual capacities. An individuals recognition of his of her own capacity for spiritual awareness is key to helping that person embark upon this important learning process. Unfortunately, most human service professionals, educators, and clergy have not learned to utilize this developmental approach to spirituality. The recognition of the significant role that internalized spirituality can play in human maturation is still minimal within the fields psychology, medicine, and education. At the same time, training curricula for clergy often do not help to correct this imbalance. Quite ironically, such training often places minimal emphasis on clergys role as facilitators of developmental learning leading to internalized spirituality. This minimization separates our traditional religious practiceslike prayerfrom the dynamic developmental process to which they should be connected, severely reducing the likelihood that individuals and communities will develop internalized forms of spirituality. As a consequence, our society has not learned to utilize this unique resource for human maturation that is particularly vital to the well being of young adults and youth, as well to adults in the midst of crisis or stress (Kass, 1995; Kass & Douglas, 2000). It should be evident that this discussion of spirituality as a developmental process is not an argument leading away from traditional religious practices. Our research on internalized spirituality suggests that the outcome of this developmental process is an integration of religious practices into individual and family life. Thus, in their most developed forms, spirituality and religiosity once again become synonymous. 4. Formal and Informal Applications of the SRA

78 The preceding discussion on the meaning of spirituality suggests two different ways to administer and use the SRA. On the one hand, the professional can utilize the SRA as a formal assessment tool. On the other hand, the professional can utilize the SRA informally to generate discussion and exploration. When administered formally, the professional will introduce the purpose of the SRA and ask the respondent to complete the questionnaire. While questions and limited dialogue are appropriate, these would be kept to a minimum. When the respondent has completed the scoring and interpretive process, the professional (or the respondent) can initiate dialogue regarding the respondents results, or any issues generated by completion of the SRA. When administered informally, the SRA can be used as a vehicle for a structured conversation between the professional and the respondent. For example, the professional and the respondent might read through the SRA together and discuss each item. In other instances, the professional might use the SRA as a guideline for dialogue without actually giving the assessment packet to the client. Such a dialogic approach, of course, can lead to substantive issues regarding the respondents emotional and spiritual life. Thus, a less formal, dialogic approach will require a greater commitment of time. Structured conversations using the SRA generally require between 1 and 2 hours. Although this informal approach will appeal to many professionals, it should be noted that this dialogic approach may be too revealing of personal issues for individuals

79 who are not prepared for emotional disclosure at this level of depth. In many cases, it is prudent to begin use of the SRA with an individual in a manner that provides them with the greatest amount of privacy and control over this very personal information. With either approach, it is helpful to emphasize to the respondent that the purpose of this assessment packet is not to give information to the professional that will be used on the client. Rather, the purpose of this assessment packet is to generate information that the professional and the respondent can use together collaboratively to enable the respondent to develop internal resources to handle stress and crisis more constructively.

80

VII. Scoring and Interpretation of the SRA Instructions for scoring the SRA are provided in the assessment packet and do not require further explanation in this manual. The professional can refer to Section V (Normative Data) to further understand the conceptual development and the meaning of a respondents scores. Similarly, basic guidelines for the interpretation of a respondents scores are provided in the assessment packet. These interpretive guidelines will be self-evident to clergy, human service professionals, or educators and can provide the basis for more extensive discussions between the professional and the respondent.

81

Table 1.1

Multidimensional Factor Structure of the IPPA-30 Common Factor Analysis with Varimax Rotation1

LPS Scale
Energy level is high Life seems vibrant Daily activities satisfy Every day is new and different Purpose to life My life has been productive My work is valuable I do not wish I were different Clearly defined goals Continue to feel positive about life when sad My life feels worthwhile Present life satisfies me Feel joy in my heart Do not feel trapped by my life circumstances No regrets regarding my past Feel loved Hopeful about solving my problems SCDS Calm during pressure React to problems with no frustration No anxiety during stress Can like myself after a mistake No catastrophic worries during stress situations Can concentrate during stress

Factor 1

Factor 2

.403 .724 .608 .617 .459 .607 .588 .506 .479 .423 .700 .739 .612 .619 .451 .507 .561 .137 .225 .160 .286 .140 .153

.229 .161 .135 .136 .188 .182 .119 .4022 .245 .5022 .292 .259 .222 .315 .335 .311 .331 .537 .648 .545 .464 .555 .528

82 No fear during stressful circumstances Can stand up for myself when I need Feel adequate during difficult situations Able to respond positively during difficulties Can relax during times of stress Remain calm in frightening situations Worry about the future during stress Eigenvalues Total Variance Explained
1

.159 .239 .368 .4132 .369 .099 .286 6.430 21.43%

.575 .431 .520 .492 .391 .529 .461 4.770 15.90%

Confirmatory analysis using the 30 items of the IPPA. No restrictions on number of factors.
2

Loading above .4 on both factors.

83

Table 1.2

Construct Validity of the IPPA

Correlations between IPPA Scales and Other Attitudinal Measures

Inventory of Positive Psychological Attitudes p-value SCDS LPS CLS-Total McNair Bi-Polar Profile of Mood States (POMS)1 Composed/Anxious Agreeable/Hostile Elated/Depressed Confident/Unsure Energetic/Tired Clearheaded/Confused Rosenberg Self-Esteem Scale1 Bradburn Affect Balance Scale1 UCLA Loneliness Scale1 Derogatis Psychiatric Symptom Checklist (SCL- 90-R)2 Hostility Depression Anxiety Global Severity Index
1

.60 .37 .55 .65 .38 .51 .67 .55 -.50

.56 .47 .65 .67 .49 .56 .76 .65 -.64

.63 .46 .66 .72 .48 .58 .79 .66 -.63

<.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001 <.0001

-.41 -.57 -.54 -.57

-.35 -.60 -.40 -.52

-.41 -.64 -.50 -.59

<.0001 <.0001 <.0001 <.0001

(Kass et al., 1991a)

84
2

(Zuttermeister et al., 1992)

85

Table 2.1

INSPIRIT Factor Structure

Kass Study 1(1) N = 83 .809 .816 .848 .688

VandeCreek(2) N = 347 .620 .572 .163 .541

Kass Study 2(3) N = 735 Strongly spiritual or religious .799 Time spent on spiritual practices .774 Close to a powerful spiritual force .715 .823 Close to God Experience of Gods existence

.793 .836 .765 4.42 63.20

.548 .510 .503 3.46 49.40

.788 Agree that God dwells within you .715 .699 4.05 57.81 Spiritual experience(s) leading to conviction of Gods existence Eigenvalues Variance Explained (Percent)

86

Table 2.2

Experiences of the Spiritual Core and Length of Time Meditating

Analysis of Covariance Controlling for Demographic Data: Age, Gender, and Educational Level

Source

df

SS

MSS

Between Subjects 70 49.9166

Covariates

0.1281

0.0640

0.098

0.9076

Age

0.0194

0.0194

0.030

0.8640

Education

0.1087

0.1087

0.166

0.6850

Time Medit

2.9669

2.9669

4.532

0.0371

Gender

4.0930

4.0930

6.252

0.0149

87 Time X Gend 1 0.1761 0.1761 0.269 0.6057

Subj w Groups

65

42.5525

0.6547

Factors

Adjusted Means

Combined

71

2.8244

Time Medit

<1 month

51

2.6963

>1 month

20

3.1513

Gender

Male

24

2.4480

Female

47

3.0167

88

Table 2.3

Relationships between Internalized Spirituality, Resilience, and StressRelated Medical Symptoms among Outpatients

Multiple Regression Analyses with Controls for Demographic Data and Health Status at Time 1 Dependent Variable Life Purpose and Satisfaction (T2) Independent Variables Life Purpose (T1) INSPIRIT AGE Beta p-Value Adjusted R-Square .83 .15 .10 .0000 .0235 .1303

.715 Frequency of Stress-Related Medical Symptoms (T2) Frequency (T1) INSPIRIT Gender Education .66 -.31 .17 .11 .0000 .0005 .1068 .3128 .469

89

Table 2.4

Relationship of INSPIRIT to Confidence in Life and Self (CLS) and Hostility

Multiple Regression Analyses

Divinity School Students (Female and Male)

DEP VAR

IND VAR

STD BETA COEF .278 -.274 .383 -.377

PVAR

MULTR

MULTR SQ

FRATIO

PMODEL

CLS

Women Men

INSPIRIT Mate INSPIRIT School

.011 .013 .401 .010 .012 .548 .301 7.521 .002 .161 7.005 .002

Hostility

Women

CLS INSPIRIT Appear No Fun Age

-.321 -.200 .267 .207 -.157

.003 .054 .008 .040 .113 .600 .360 7.889 .000

90

Table 2.5

Predictive Model for Cigarette Smoking:

Multiple Regression Analysis with Cigarette Smoking at T3 as Dependent Variable1

CO-IND VAR

Std Beta Coef .625 .329

pvar .000 .001

Mult-R

Mult-R Sq

Fratio

pmodel

Variable 1 (Control Variable): Cigarette smoking at T1 Variable 2 (Interactive Factors): Stress concerning physical appearance (+ correlation2) * Hostility (+ correlation2) * Family and friends who smoke (+ correlation2) * Self-confidence (SC) (+ correlation2) * Current alcohol usage (- correlation2) * Internalized spirituality

91

(- correlation2) .903
1

.815

105.974 .000

Interactive stepwise multiple regression, controlling for cigarette smoking at T1.

2 Direction of regression coefficients for interactive factors, when considered as co-independent variables.

92

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98 Pruyser, P. (1991). The seamy side of current religious belief. In N. Malony, Spilka, B. (Ed.), Religion in psychodynamic perspective: The contributions of Paul W. Pruyser . New York: Oxford University Press. Reker, G. T., Peacock, E. J., & Wong, P. T. (1987). Meaning and purpose in life and well being: A life-span perspective. Journal of Gerontology, 42(1), 44-49. Rokeach, M. (1960). The open and closed mind: Investigations into the nature of belief systems and personality systems. New York: Basic Books. Rose, R. M. (1980). Endocrine responses to stressful psychological events. Psychiatric Clinics of North America, 3(2), 251-276. Rosenberg, M. (1965). Society and the adolescent self-image. Princeton, NJ: Princeton University Press. Rotter, J. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, 80(601). Russell, D. L., Peplau, L., & Ferguson, M. (1978). Developing a measure of loneliness. Journal of Personality Assessment, 42(3), 290-294. Schuon, F. (1984). The transcendent unity of religions. Wheaton, Illinois: Theosophical Publishing House. Seligman, M. (1975). Helplessness: On depression, development, and death. San Francisco: W. H. Freeman. Spretnak, C. (Ed.). (1982). The politics of women's spirituality. New York: Anchor Books. Stevens, M. J., Pfost, K. S., & Wessels, A. B. (1987). The relationship of purpose in life to coping strategies and time since the death of a significant other. Journal of Counseling and Development, 65, 424-426. Sue, D. W. (1978). Eliminating cultural oppression in counseling: Toward a general theory. Journal of Counseling Psychology, 25, 419-428. Sue, D. W., & Sue, D. (1981). Counseling the culturally different: Theory and practice. New York: John Wiley. Sunderwirth, S. G. (1985). Biological mechanisms: Neurotransmission and addiction. In H. B. S. Milkman, H. J. (Ed.), The addictions . Lexington, MA: Lexington Books.

99 Suzuki, L. A., Meller, P. J., & Ponterotto, J. G. (Eds.). (1996). Handbook of multicultural assessment: Clinical, psychological, and educational applications. San Francisco: Jossey-Bass. Tate, D. (1994). Mindfulness meditation group training: Effects on medical and psychological symptoms and positive psychological characteristics. Unpublished Doctoral Dissertation, unpublished, Brigham Young University. Taylor, S. (1986). Health psychology. New York: Random House. Tillich, P. (1952). The courage to be. New Haven: Yale University Press. Van Der Kolk, B. A. (1988). The trauma spectrum: The interaction of biological and social events in the genesis of the trauma response. Journal of Traumatic Stress, 1(3), 273-290. VandeCreek, L., Ayres, S., & Bassham, M. (1995). Using INSPIRIT to conduct spiritual assessments. Journal of Pastoral Care, 49(1), 83-89. Walsh, R. (1978). Initial meditative experiences: Part two. Journal of Transpersonal Psychology, 10(1), 1-28. Wortman, C. B., & Brehm, J. W. (1975). Responses to uncontrollable outcomes: An integration of reactance theory and the learned helplessness model. In L. Berkowitz (Ed.), Advances in experimental social psychology . New York: Academic Press. Wulff, D. M. (1996). The psychology of religion: An overview. In E. P. Shafranske (Ed.), Religion and the clinical practice of psychology (pp. 43-70). Washington, D.C: American Psychological Association. Yalom, I. (1981). Existential psychotherapy. New York: Basic Books. Zinnbauer, B. J., & Pargament, K. I. (1998). Spiritual conversion: A study of religious change among college students. Journal for the Scientific Study of Religion, 37(1), 161-180. Zuttermeister, P., Kass, J., Geiss, S., & Friedman, R. (1992). Further validation of the inventory of positive psychological attitudes. Paper presented at the 13th Annual Scientific Sessions of the Society for Behavioral Medicine, New York, New York.

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APPENDIX

THE SPIRITUALITY AND RESILIENCE ASSESSMENT PACKET

101

==RESOURCES FOR RESILIENCE==

BUILDING A RESILIENT WORLDVIEW THROUGH

SPIRITUALITY

Spirituality and Resilience Assessment Packet

Version 4.2

Behavioral Health Education Initiative

Jared D. Kass, Ph.D., LMHC Lynn Kass, M.A., M.A.T., LMHC

Co-Directors

102

Greenhouse, Inc. 46 Pearl St. Cambridge, Massachusetts 02139 617-492-0050

2000, 1996, 1990, 1989 Jared D. Kass

103

Part I: A Resilient Worldview

Difficulties, serious problems, and crises are an inescapable part of life.

The purpose of this packet is to help you strengthen important inner resources that will enable you to face a crisis or serious problem more effectivelyeither now or in the future.

Whether the difficulty you face is medical, emotional, or circumstantialwhether it confronts you or someone you lovewhether it is taking place in your personal life, your family life, or your work life...your own inner resources strongly affect your ability to face a serious problem.

The most significant inner resource that you have is your own worldview-your attitudes about life. If your worldview is resilient, you can respond to a crisis constructively.

A resilient worldview is characterized by feelings of Confidence in Life and Self. This means that, in times of crisis or stress, you feel confidentand connected to a sense of purpose in your life.

A resilient worldview is empowering. It helps you to:

104 Mobilize your energies when you need to act.

Relax your body and mind when you need to rest.

Think for yourself when others do not know what is best for you.

Trust in others, and in life itself, when you have done all that you can.

The first questionnaire in this packet will help you determine how resilient your worldview is. You will probably learn that you already have many resilient attitudes. You will also learn, most likely, that some of your attitudes are not as resilient as they might be. By reviewing these results on your own, and with those who provide you with support, you can begin to build new strengths where they are lacking.

The first questionnaire is called The Inventory of Positive Psychological Attitudes (IPPA). After you complete it, follow the simple scoring instructions to interpret the results.

105

INVENTORY OF POSITIVE PSYCHOLOGICAL ATTITUDES

SELF TEST VERSION (IPPA-32R)

The following questions contain statements and their opposites. Notice that the statements extend from one extreme to the other. Where would you place yourself on this scale? Place a circle on the number that is most true for you at this time. Do not put your circles between numbers. LIFE PURPOSE AND SATISFACTION:

very low

very high

2. As a whole, my life seems

dull

vibrant

3. My daily activities are

not a source of

a source of

106 satisfaction satisfaction

4. I have come to expect that every day will be

exactly the same 1

new and different

5. When I think deeply about life

I do not feel there is any purpose to it

I feel there is

a purpose to it

6. I feel that my life so far has

not been productive

been productive

7. I feel that the work* I am doing

is of no value 1

is of great value

*The definition of work is not limited to income-producing jobs. housework, studies, and volunteer services.

It includes childcare,

8. I wish I were different than who I am.

107 agree strongly 1 2 3 4 5 6 7 disagree strongly

9. At this time, I have

no clearly defined goals for my life

clearly defined goals for my life

10. When sad things happen to me or other people

I cannot feel

I continue to feel positive about life

positive about life

11. When I think about what I have done with my life, I feel

worthless

worthwhile

12. My present life

does not satisfy me

satisfies me

13. I feel joy in my heart

never

all the time

108

14. I feel trapped by the circumstances of my life.

agree strongly

disagree strongly

15. When I think about my past

I feel many regrets

I feel no regrets

16. Deep inside myself

I do not feel loved

I feel loved

17. When I think about the problems that I have

I do not feel hopeful about solving them

I feel very hopeful about solving them

SELF CONFIDENCE DURING STRESS:

1. When there is a great deal of pressure being placed on me

109 I get tense 1 2 3 4 5 6 7 I remain calm

2. I react to problems and difficulties

with a great deal 1 of frustration

with no frustration

3. In a difficult situation, I am confident that I will receive the help that I need.

disagree strongly

agree strongly

4. During stressful circumstances, I experience anxiety

all the time

never

110

5. When I have made a mistake during a stressful situation

I feel extreme dislike for myself

I continue to like myself

6. When a situation becomes difficult, I find myself worrying that something bad is going to happen to me or those I love

all the time

never

7. In a stressful situation,

I cannot concentrate easily

I can concentrate easily

8. During stressful circumstances, I am fearful

all the time

never

9. When I need to stand up for myself

111 I cannot do it 1 2 3 4 5 6 7 I can do it quite easily

10. I feel less than adequate when I am in difficult situations.

agree strongly 1

disagree strongly

11. During times of stress, I feel isolated and alone.

agree strongly 1

disagree strongly

12. In really difficult situations

I feel unable to 1 respond in positive ways

I feel able to respond in positiveways

13. When I need to relax during stressful times

I experience no peace-only thoughts and worries

I experience peacefulness

free of thoughts and worries

14. When I am in a frightening situation

I panic

I remain calm

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15. During stressful times in my life, I worry about the future

all the time

never

113

SCORING INSTRUCTIONS FOR IPPA

You can calculate 3 scores for the IPPA: Section 1: Section 2: Total: Life Purpose and Satisfaction (LPS) Self Confidence During Stress (SCDS) Confidence in Life and Self (CLS)

1. For each individual question, the number that you circled is your score. 2. Add your scores for the questions in each section. 3. Add your two section scores to make a total score. 4. Divide each sum by the number of questions in that section (use a calculator):

Life Purpose and Satisfaction: (Sum of scores) ______ 17 = _____.___

Self-Confidence During Stress: (Sum of scores) ______ 15 = _____.___

TOTAL: Confidence in Life and Self: (Sum of scores) ______ 32 = _____.___

Note:

Each score should range between 1.00 and 7.00.

114 Scores may include decimals (example: 5.15).

INTERPRETATION

High Medium High Medium Low Low = =

5.51 7.00 4.01 5.50 2.50 4.00

= 1.00 2.49

Most adults from test sites in the USA score between 4.03 and 5.87. The average score is 4.95.

Your score on each scale reflects how strongly you feel these resilient attitudes. Do these scores make sense to youas you reflect on your life?

Review the individual questions. Each answer shows you particular attitudes and areas of your life where your worldview isor is notresilient. Do you notice any patterns? If there is a large difference between your LPS and SCDS scores, one part of your worldview is more resilient than the other part. This difference identifies the part of your worldview that you most need to strengthen. If your combined score on both scales is low (or even medium low), dont hide this fact from yourself or others. Seek support. Talk with a minister, counselor, or friend about how you are feeling about yourself and your life.

115

Part II: Building Confidence in Life and Self Through Spirituality

One of the most valuable inner resources that you can develop is your own spirituality. Spirituality is a particularly effective way to build a resilient worldview. Spirituality, of course, is not the only way to develop resilient attitudes. However, for countless generations and in countless cultures, spirituality has been a primary source of resilience for individuals, families, and communities. The next questionnaire will help you to clarify the degree to which spirituality is a central aspect of your life. If it is not central, this questionnaire may help you to think about spirituality in some new waysand your results on this questionnaire may surprise you. The essence of spirituality is not whetheror how oftenyou attend religious services. Rather, the essence of spirituality is the way that you experience life. Spirituality is the experience of connection to the sacred aspect of life, the spirit of life. For some of us, the experience of the spirit of life grows from a sense of connection to our own inner, creative core. For some, this experience grows from a sense of connection to other people. For some, this experience grows from a sense of connection to nature. For some, this experience grows from a sense of connection to a power that is greater than our selves: the ground of being, God. Over time, an exploration of your spirituality can lead you to new experiences in each of these areas. For these experiences share a common thread: recognition of the spiritual core that creates and sustains the fabric of life. As your sense of connection to the spirit of life grows, you may also find yourself developing important new skills. You may find yourself able to respond to crises and difficulties in a new way: with a sense of empowerment and life purpose. As you develop a sense of connection to the spirit of life, you may discover yourself becoming a more resilient person who can respond to stress with confidence in life and self. This questionnaire will help you to measure the degree to which you have already begun to develop a sense of connection with the spiritual core of life. It is called the Index of Core Spiritual Experiences (INSPIRIT). If your score is low, this questionnaire may spur you to an exploration of your spiritualityin a way that is meaningful and appropriate for you. If your score is high, this questionnaire will confirm your sense of connection to the spirit of life. In each case, you can use

116 the results from this questionnaire to determine how much your spirituality now contributes to a resilient worldview.

117

INDEX OF CORE SPIRITUAL EXPERIENCES

SELF TEST VERSION (INSPIRIT-R)

The following questions concern your spiritual or religious beliefs and experiences. There are no right or wrong answers. For each question, circle the number of the answer that is most true for you.

1. How strongly religious (or spiritually-oriented) do you consider yourself to be? 1. Not at all 2. Not very strong 3. Somewhat strong 4. Strong

2. About how often do you spend time on religious or spiritual practices? 1. Once per year or less 2. Once per month to several times per year 3. Once per week to several times per month 4. Several times per day to several times per week

3. How often have you felt as though you were very close to a powerful spiritual force? 1. Never

118 2. Once or twice 3. Several times 4. Often

PEOPLE HAVE MANY DIFFERENT IMAGES AND DEFINITIONS OF THE HIGHER POWER THAT WE OFTEN CALL GOD. USE YOUR IMAGE AND YOUR DEFINITION OF GOD WHEN ANSWERING THE FOLLOWING QUESTIONS.

4. How close do you feel to God? 1. I don't believe in God 2. Not very close 3. Somewhat close 4. Extremely close

5. Have you ever had an experience that has convinced you that God exists? 1. No 2. I don't know 3. Maybe 4. Yes

6. Indicate whether you agree or disagree with this statement: "God dwells within you." 1. Definitely disagree 2. Tend to disagree 3. Tend to agree

119 4. Definitely agree

7. The following list describes spiritual experiences that some people have had. Indicate if you have had any of these experiences and the extent to which each of them has affected your belief in God.

NEVER HAD EXPERIENCE THIS EXPERIENCE Did not

HAD THIS AND IT:

Convinced me of God's

strengthen Strengthened belief in God existence belief in God

SPIRITUAL EXPERIENCES:

A. An experience of profound inner peace 1 2 3 4

B. An overwhelming experience of love 1 2 3 4

120 C. A feeling of unity with the earth and all living beings 1 2 3 4

D. An experience of complete joy and ecstasy 1 2 3 4

E. Meeting or listening to a spiritual teacher or master 4 1 2 3

F. An experience of God's energy or presence 4 1 2 3

G. An experience of a great spiritual figure (e.g. Jesus, Mary, Elijah, Buddha) 1 2 3 4

H. A healing of your body or mind (or witnessed such a healing) 1 2 3 4

I. A miraculous (or not normally occurring) event 1 2 3 4

121 J. An experience of angels or guiding spirits 1 2 3 4

K. An experience of communication with someone who has died 1 2 3 4

L. An experience with near death or life after death 1 2 3 4

M. Other (specify)________________ 4

122

SCORING INSTRUCTIONS FOR INSPIRIT

Questions 1 through 6: The number you checked is your score for that question. Add these scores together. Your sum should range from 6 to 24.

Question 7 (items A-M): The highest number you checked for any of these items is your score for this question. Your score for Question 7 should be 1, 2, 3, or 4.

Sum of Questions 1-6: ___ + Question 7 (highest item) ___ = INSPIRIT Score ____

INTERPRETATION High Medium High Medium Low Low = = = 25 28 18 24 11 17 = 7 10

Most adults from test sites in the USA score between 16 and 25. The average score is 20 .

Does your score make sense to you? If not, this test may measure concepts that have not been central to your spirituality. Review each questionand consider whether the INSPIRIT may be suggesting new areas of experience for you to explore. Some questions focus on experiences that convince you of Gods existence. Others concern the strength of your relationship with the spirit of lifeand the degree to which you experience God as the ground of your own being. If your score does make sense to you, consider these interpretive guidelines:

HIGH: You often experience a close and intimate connection with the spirit of life. You know, with deep conviction, that the spirit of life is the core of your being.

123

MEDIUM HIGH: You experience a close and intimate connection with the spirit of life. However, this experience may not take place on a regular basis. If your score is 2224, you may have begun to realize, with a growing sense of conviction, that the spirit of life is the core of your being. If your score is 18-21, you may be testing this possibility.

MEDIUM LOW: You have had some experiences concerning the spirit of life, though they have not convinced you that God exists. If your score is 15-17, these experiences have deepened your awareness of lifes spiritual core. If your score is 11-14, these experiences have had little effect on you.

LOW: You have had few experiences concerning the spirit of life. If you believe that the spirit of life is the core of your being, this belief has, most likely, not grown out of your personal experience. NOTE: A low score may also mean that you have not acknowledged spiritual experiences that you have had. Perhaps these experiences seemed insignificant or coincidental. Perhaps it seemed embarrassing, or prideful, to admit having them. Keep in mind that experiences of the sacred are part of a human beings natural capacities--and a vital way to discover your link with God. Allow yourself to acknowledge moments of spiritual connection as they occur in your daily life.

124

Part III: Does Your Spirituality Contribute to a Resilient Worldview?

SUMMARY OF SCORES

DATE___/___/___ NAME (OPTIONAL)__________________________________

RESILIENT WORLDVIEW (IPPA)

My TOTAL Confidence in Life and Self (CLS) score is: My Life Purpose and Satisfaction (LPS) score is: My Self-Confidence During Stress (SCDS) score is:

________ ________ ________

EXPERIENCES OF THE SPIRITUAL CORE (INSPIRIT): A SENSE OF CONNECTION WITH THE SPIRIT OF LIFE

My INSPIRIT score is:

________

LIST YOUR SCORES IN THE APPROPRIATE BOXES:

125
CLS HIGH LPS SCDS INSPIRIT HIGH

Score: 5.51 7.00 Score: 25 28 MEDIUM HIGH 4.95* MEDIUM HIGH ** 20

Score: 4.01 5.50 MEDIUM LOW

Score: 18 24 MEDIUM LOW

Score: 2.50 4.00

LOW

Score: 11 17

LOW

Score: 1.00 2.49 Score: 7 10

* 4.95 = Average adult score on IPPA. Most adults from test sites in the USA score between 4.03 and 5.87.

** 20 = Average adult score on INSPIRIT. Most adults from test sites in the USA score between 16 and 25.

126

INTERPRETIVE GUIDE

This guide can help you determine whether your spirituality contributes to a resilient worldview. Note: This guide refers to HIGH and LOW scores on the IPPA and INSPIRIT scales. MEDIUM HIGH scores fit into the HIGH interpretationbut less strongly. Similarly, MEDIUM LOW scores fit into the LOW interpretationbut less strongly.

IPPA scores are HIGH; INSPIRIT score is HIGH: You have a resilient worldview with a strong sense of confidence in life and self. It is likely that your connection to the spirit of life is a primary source of your empowering worldview. Reflect on the events that have contributed to your spirituality and resilience. How can you continue to develop these health-promoting aspects of your life?

IPPA scores are LOW; INSPIRIT score is HIGH: While you experience your connection to the spirit of life deeply, these experiences may not be translating into resilient attitudes in your life. This is a common occurrence. Absorbed in their spiritual experiences, people may not realize that these experiences are not contributing to positive changes in daily life. Recognizing this disparity is a useful way to bring your spiritual development back into focus. Examine the positive attitudes that need strengthening in your life. Do your spiritual activities and experiences contribute directly to the strengthening of these attitudes? If not, seek to develop a focus to your spirituality that will help you to develop confidence in life and self more effectively.

IPPA scores are HIGH; INSPIRIT score is LOW: It is likely that spirituality is not the primary source of your resilient attitudes. This is true for many people. It is important to remember that spirituality is not the only source of a resilient worldview. At the same time, a high degree of confidence in life and self often indicates a sense of harmony with the world and a sense of connection with others that are integral parts of a spiritual worldview. Is it possible that you have not acknowledged a spiritual element in your life? If so, examine where this lack of acknowledgment of your own spirituality comes

127 from. Such an examination often provides useful insights into the events that have shaped your personal development.

IPPA scores are LOW; INSPIRIT score is LOW: If you are a person whose life experiences and personal relationships have not enabled or taught you to develop confidence in life and self, this may be a moment to recognize that spirituality can be an important source of personal resilience. As you learn to experience the spirit of life as the core of your own being, your self-esteem will begin to rise. Then, you can learn to tap the power and strength of your own inner self. As your inner self grows more empowered, you will become able to discover meaning and purpose in your life that you may not have known how to recognize. As a result, you can develop the courage to act in more confident and creative ways. If your low INSPIRIT score represents a lack of spiritual grounding, seek help from others to develop spirituality into a source of empowerment and resilience.

128

Personal Notes: