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Chapter 3 Coping Behavior, Religiosity and Suicide

Definitions of Coping
Coping is defined as constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person to a stressful situation. It is the effort to manage and overcome these demands and critical events that pose a challenge, threat, harm, loss, or benefit to a person (Lazarus and Folkman, 1984; Seiffge-Krenke, 1995) Coping is also defined as a process by which an individual manages the ever-changing environment. Coping may be seen as actions taken by persons directed at confronting demands, solving problems, and/or altering and managing stressors. Coping behavior is generally influenced by maturation and cognitive development such as problem-solving ability, and

understanding peers and adults (Lewis & Brown, 2002). Koch & Shepperd, (2004); Schlozman et al., (2004); Morling et al., (2006) further stated that coping is perhaps best defined as a problem-solving behavior that is intended to bring about relief, reward, quiescence, and equilibrium. Nothing in this definition promises permanent resolution of problems. It does imply a combination of knowing what the problems are and how to go about reaching a correct direction that will help resolution.

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Yet most approaches in coping research follow Folkman and Lazarus (1980), who define coping as `the cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and conflicts among them.'

The Stress Theory

Two concepts are central to any psychological stress theory: appraisal, i.e., individuals' evaluation of the significance of what is happening for their well-being, and coping, i.e., individuals' efforts in thought and action to manage specific demands (Lazarus, 1993). Lazarus (1966) illustrated two basic forms of appraisal, primary and secondary appraisal; these forms rely on different sources of information. Primary appraisal concerns whether something of relevance to the individual's well being occurs, whereas secondary appraisal concerns coping options. Within primary appraisal, three components are distinguished: goal relevance describes the extent to which an encounter refers to issues about which the person cares. Goal congruence defines the extent to which an episode proceeds in accordance with personal goals. Type of egoinvolvement designates aspects of personal commitment such as selfesteem, moral values, ego-ideal, or ego-identity. Likewise, three secondary appraisal components are distinguished: blame or credit results from an individual's appraisal of who is responsible for a certain event. By coping potential Lazarus means a person's evaluation of

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the prospects for generating certain behavioral or cognitive operations that will positively influence a personally relevant encounter. Future expectations refer to the appraisal of the further course of an encounter with respect to goal congruence or incongruence. Unlike approaches discussed so far, resource theories of stress are not primarily concerned with factors that create stress, but with resources that preserve well being in the face of stressful encounters. Several social and personal constructs have been proposed, such as social support (Schwarzer and Leppin 1991), sense of coherence (Antonovsky 1979), hardiness (Kobasa 1979), self-efficacy (Bandura 1977), or optimism (Scheier and Carver 1992). Whereas self-efficacy and optimism are single protective factors, hardiness and sense of coherence represent tripartite approaches. Hardiness is an amalgam of three components: internal control, commitment, and a sense of challenge as opposed to threat. Similarly, sense of coherence consists of believing that the world is meaningful, predictable, and basically benevolent. Within the social support field, several types have been investigated, such as instrumental, informational, appraisal, and emotional support The recently offered conservation of resources (COR) theory (Hobfoll 1989, Hobfoll et al., 1996) assumes that stress occurs in any of three contexts: when people experience loss of resources, when resources are threatened, or when people invest their resources without subsequent gain. Four categories of resources are proposed: object resources (i.e., physical objects such as home, clothing, or access to transportation), condition resources (e.g., employment, personal relationships), personal resources

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(e.g., skills or self-efficacy), and energy resources (means that facilitate the attainment of other resources, for example, money, credit, or knowledge).

The Concept of Coping

Early conceptualizations of coping centered around the Transactional Model for Stress Management, put first by Lazarus and colleagues in the late 1960s (Lazarus, 1966), this conceptualization stressed the extent of coping to which patients interact with their environment as a means of attempting to manage the stress of illness. These interactions involve appraisals of the current medical condition, with psychological and cultural overlay that varies from patient to patient (Stern et al., 2008). In the late 1970s a major new development in coping theory and research occurred (Lazarus, 1993); in which the hierarchical view of coping with its trait or style emphasis was abandoned in the favor of treating coping as a process. The term coping is used whether the process is adaptive or non adaptive, successful or non successful, consolidated or fluid and unstable. Lazarus (1993) stated that the process of coping employed for the different threats produced by cancer, or any other complex source of psychological stress, whether disease-based or not, varies with the diverse adaptational significance and requirements of these threats. Therefore, when studying how the patient copes with this illness, it is necessary to specify the particular threats of immediate concern to the patient and to treat them separately rather than broadening the focus of attention to the overall illness. Coping also changes from one time to another in any given stressful encounter; this is an empirical statement of what means to talk about coping

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as process. When stressful conditions are viewed by a person as refractory to change, emotion focused coping predominates; while when they are appraised as controllable by action, problem focused coping predominates (Folkman and Lazarus 1980; Lazarus and Folkman1987). The coping process approach assumes that coping is flexible, involves active planning, and is responsive to environmental demands and personal preferences. Thus coping should be conceptualized as a dynamic and constantly changing process as stated by Ayers et al.,(1996) who further added that both cognitions (e.g., the individuals appraisal of the situation) and behaviors (e.g., what a person actually does) from a situation-specific perspective should be considered. The Lazarus (Lazarus 1991; Lazarus and Folkman 1984; Lazarus and Launier, 1978) model outlined above represents a specific type of coping theory. These theories may be classified according to two independent parameters: (a) trait-oriented versus state -oriented. (b) microanalytic versus macroanalytic approaches (Krohne, 1996). Trait-oriented and state-oriented research strategies have different objectives: The trait-oriented (or dispositional) strategy aims at early identification of individuals whose coping resources and tendencies are inadequate for the demands of a specific stressful encounter. An early identification of these persons will offer the opportunity for establishing a selection (or placement) procedure or a successful primary prevention program. Research that is stateoriented, i.e., which centers around actual coping, has a more general objective.

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Microanalytic approaches focus on a large number of specific coping strategies, whereas macroanalytic analysis operates at a higher level of abstraction, thus concentrating on more fundamental constructs. The distinction of the two basic functions of emotion-focused and problemfocused coping proposed by Lazarus and Folkman (1984) represents a macroanalytic state approach. While S. Freud's (1926) classic defense mechanisms conception is an example of a state-oriented, macroanalytic approach. Although Freud distinguished a multitude of defense mechanisms, in the end, he related these mechanisms to two basic forms: repression and intellectualization (Freud 1936). The trait-oriented correspondence of these basic defenses is the personality dimension repressionsensitization (Byrne 1964; Eriksen, 1966).

Classification and Types of Coping Behavior

An overview of the perspectives of coping theorists shows that they have generally categorized coping strategies under three groups: a) strategies focused on resolving the problem; b) strategies used to alleviate the emotions triggered by the situation; and c) strategies involving social support (Snyder, 1999). Folkman and Lazarus (1980); Taylor et al. (1998) went on to make an important and now widely accepted distinction between two types of coping. In one, problem focused; the person attempts to address directly the problems that he is facing. In the second, emotion focused; the person tries to dampen or minimize the emotional state itself, without addressing the problem that elicited the state. Coping efforts may focus on altering ones environment or emotions , the majority of individuals utilize both types of

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strategies and adapt these strategies to fit specific stressful situations and achieve successful resolutions (Aldwin & Brustrom, 1997) Weiten and Lloyd (2006) added the appraisal-focused strategies to the above 2 strategies: Appraisal-focused strategies occur when the person modifies the way they think, for example: employing denial, or distancing oneself from the problem. People may alter the way they think about a problem by altering their goals and values, such as by seeing the humour in a situation. Problem-focused strategies are used by people who try to deal with the cause of their problem. They do this by finding out information on the problem and learning new skills to manage the problem. Emotion-focused strategies involve releasing pent-up emotions, distracting one-self, managing hostile feelings, turning to religion, meditating, using systematic relaxation procedures, etc. Moos and Schaefer (1984) helped better understanding of the previous three coping categories each with three skills; 1. Appraisal-Focused Coping: These skills involve how we understand

the stressful situation a) Logical analysis and mental preparation Breaking down an overwhelming problem down into manageable parts, taking advantage of past similar experiences, evaluating and rehearsing plausible "whatif" scenarios

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b) Cognitive redefinition Restructuring or re-framing the situation to find something favorable c) Cognitive avoidance or denial Denying or minimizing the severity of the situation 2. Problem-focused Coping: These skills involve doing something about

the problem itself a) Seeking information and support Getting information about the situation and evaluating any possible courses of action b) Taking problem-solving actions Taking deliberate action to deal directly with the situation c) Identifying alternative rewards Trying to replace any losses or setbacks with new sources of satisfaction 3. Emotion-focused Coping: These skills involves what we do with our

reactions to the situation a) Affective regulation Working to maintain hope and to control emotions b) Emotional discharge Expressing feelings and using humor to help reduce strain c) Resigned acceptance Accepting the situation for what it is, realizing the circumstances cannot be altered and submitting to fate. Typically, people use a mixture of all three types of coping, and coping skills will usually change over time. All these methods can prove useful, but

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some claim that those using problem-focused coping strategies will adjust better to life (Taylor, 2006) Apart from these three categories, theorists such as Billings and Moos (1981), along with Pearlin and Schooler (1978), have constructed alternative models by classifying the coping strategies in accordance with the approach-avoidance dichotomy. At a more practical level, Frydenberg and Lewis' (1993, 1996) model offers an assessment of coping strategies by separating them into productive, nonproductive (Zeidner and Endler , 1996) Endler and Parker (1990) additionally suggest avoidance-focused coping as a category, which entails person-oriented or task-oriented strategies to distract away from the stressor at hand. Others have described religious faith and spiritual beliefs as a means of coping (Dervic et al., 2006; Walker and Bishop, 2005; Hovey, 1999). Folkman and lazarus (1985) used the 2 general dimensions of problem focused and emotion focused coping as a conceptual guide to develop the ways of coping checklist which include; Wishful thinking, detachement, self blame, tension reduction, keeping to self emphasizing the positive, problem focused and seeking social support, Parker & Endler (1996) added that both types of coping are important, and, if used properly, can have extraordinarily beneficial consequences for physical and mental health. Matud(2004)

found that men often prefer problem-focused coping, whereas women can often tend towards an emotion-focused response. Problem-focused coping mechanisms may allow an individual greater perceived control over their problem, while emotion-focused coping may more often lead to a reduction

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in perceived control. Certain individuals therefore feel that problem-focused mechanisms represent a more effective means of coping. An additional distinction is often made in the coping literature between active and avoidant coping strategies (Holahan & Moos, 1997). 1- Active coping strategies: Are either behavioral or psychological responses designed to change the nature of the stressor itself or how one thinks about it. 2- Avoidant coping strategies: Lead people into activities (such as alcohol use) or mental states (such as withdrawal) that keep them from directly addressing stressful events. Avoidance-oriented coping has been conceptualized as involving person-oriented and/or taskoriented responses (Endler & Parker, 1992). Strategies associated with this approach include seeking out other people (social diversion) or engaging in a substitute task (distraction) (Sandler et al., 1997). Frazier (2002) gives another illustration to the different types of coping: 1. Active Coping (e.g., I take additional action to try to get rid of the problem; I consult others who have had similar problems about what they did) 2. Emotional Regulation (e.g., I talk to someone about how I feel; I learn to accept and live with it; I get upset and let my emotions out) 3. Distancing (I seek Gods help; I refuse to believe it has happened; I turn to other activities to take my mind off things). Gupta & Derevensky (2000) stated that positive coping processes include the utilization of multiple problem and solution-focused

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strategies that allow the individual to consider multiple options in dealing with difficult problems. Generally speaking, active coping strategies, whether behavioral or emotional, are thought to be better ways to deal with stressful events, and avoidant coping strategies appear to be a psychological risk factor or marker for adverse responses to stressful life events. Carver et al. (1989) found among ways which people respond to stress behavioral disengagement; which is reducing one's effort to deal with the stressor, even. Giving up the attempt to attain goals with which the stressor is interfering. In theory, behavioral disengagement is most likely to occur when people expect poor coping outcome. Mental disengagement is a variation on behavioral disengagement, postulated to occur when conditions prevent behavioral disengagement (Carver et al., 1983), which include using activities to take one's mind off a problem (e.g. day dreaming, escaping through sleep, watching T.V.). Rumination or self-focused attention may be defined as a stable, emotionfocused coping style that involves responding to problems by directing attention internally toward negative feelings and thoughts. Ruminating about problems includes both cognitive (self-focused cognitions) and affective (increased emotional reactivity) elements (Broderick & Korteland, 2002) While faulty coping processes may include the use of a high number of emotion-focused responses to stressful situations that usually involve avoidance, rumination, and negatively centered affective strategies (Gupta & Derevensky, 2001). It is important to note that, although women are more likely to ruminate than men, rumination is not an exclusively female

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behavior. Similarly, avoiding or distracting oneself from problems is not a coping strategy unique to males (Tavris, 1999).

Function of Coping
Lazarus (1999); Lazarus (1983) documented the unsuspected benefits of the coping process. He demonstrated experimentally that patients who engage in forms of denial (for example, refusing to believe that a serious medical problem exists or to accept that the problem is as severe as it, in fact, is) recover better and more quickly than patients who do not engage in such denial. Lazarus thus came to believe, contrary to orthodox wisdom, that under certain conditions, false beliefs can have very beneficial consequences to one's health and well-being. The study on the benefits of denial has now been replicated by others, and its findings are taken into consideration in health psychology and psychosomatic medicine. Pearlin and Schooler (l978) stated that coping is seen as having three main (protective) functions: Management of the problem causing the distress through elimination or modification of the conditions giving rise to it, alteration of (perceptually controlling) the meaning of the experience so as to neutralize its problematic character and, regulation of the emotional distress produced by the problem. These functions have been supported and are widely recognized by others (Mechanic, 1977; Kahn et al., 1964; Folkman and Lazarus, 1980). Hamburg et al. (1967) stated that the goals of Effective Coping Behavior are: To keep distress within manageable limits, to maintain a sense of personal worth, to restore relations with significant other people, to increase

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the likelihood of working out a personally valued and socially acceptable situation. Folkman and Lazarus(1988) assessed subjects' emotional state at the beginning and end of a number of stressful encounters, focusing on amount and direction of change as a function of the coping strategy reported. Some coping strategies, such as planful problem solving and positive reappraisal were associated with changes in emotion from negative to less negative or positive while other coping strategies such as confrontive coping and distancing, correlated with emotional changes in the opposite direction that is toward more distress (Haan, 1969). Individuals vary in the extent to which they use humor to cope with stressful situations. Those with greater tendencies to cope with humor report greater daily positive mood (Dillon et al., 19851986; Lefcourt, 2001). Consequently, in response to stress, those with greater propensities to cope with humor show increases in levels of immunoglobulin A (S-IgA), a vital immune system protein.

Ineffective Coping
Ineffective coping is an inability to for a valid appraisal of stressors, inadequate choices of practiced responses, and/or inability to use available resources (Gordon, 2002) House (2009) stated that coping responses may be ineffective. There are few rules about what makes effective coping. In general, a broad and flexible repertoire is desirable, with a strong element of active problem focused techniques. However not all illnesses, nor all aspects of a particular illness,

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are likely to be amenable to problem-focused coping. Probably the most effective coping is matched to the situation. That is, the coping matches the demands, so that heavy reliance is not placed on problem-focused coping when little in the situation can change, nor excessive use made of emotionfocused coping when active involvement in illness management is needed. Sharpe and Curran (2006) stated that demands of the situation may be overwhelming. The news that one has a terminal illness takes time to assimilate-to understand all its meanings, grasp all the threats and losses involved. While that process of appraisal is going on, it is difficult to marshal resources and use them effectively. This explains, in part, why mood disorder is more commonly associated with acute than chronic illness. Also, resources may be inadequate or missing. One problem associated with physical illness is that it may impair personal resources as a primary effect of the disease process-most importantly when the illness has effects on the central nervous system by virtue of the direct involvement of the brain or through the neurological effects of systemic disturbance. A common problem of failure to match coping to the situation is found in patients with chronic illness, who are responding to their circumstances as if they none the less have an acute illness. In acute illness, problem-focused coping often involves seeking reversal or even cure of the illness process, while emotion focused coping involves dealing with the anxiety of uncertainty, or grieving if the prognosis is clearly poor. On the other hand, in chronic illness, problem-focused coping involves symptom management and maximizing function, while emotion-focused coping requires a degree of acceptance. (House, 1988)

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Mental Illness and Coping

Schomerus and Angermeyer (2008) stated that many people suffering from serious mental illness do not seek appropriate medical help. The stigma of mental illness has often been considered a potential cause for reluctance in seeking help; intervention studies show that destigmatisation may lead to increased readiness to seek professional help and thus a better coping. Recent research conducted by Wu et al.(2010) has found that people with psychiatric disabilities tended to utilize passive and emotional-focused strategies to cope with their illness ; analysis of survey data found the sense of helplessness and the overall illness adaptation significantly impact negative emotion coping utilization. Those who felt highly impact by the illness, more sense of helplessness, less actively managing their illness, and more social support availability were more likely to use positive emotion as a coping strategy. Broderick & Korteland (2002) stated that ruminative strategies including isolating oneself to think out a problem, writing in a diary about how sad one feels, or talking repetitively about a negative experience with the purpose of gaining increased personal insight; may actually make the depression worse. Broderick & Korteland (2002) have found that the use of distraction, that is, the deliberate focusing on neutral or pleasant thoughts or engaging in activities that divert attention in more positive directions, can attenuate depressive episodes

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Both depressed suicide attempters and depressed individuals without a suicide attempt displayed higher levels of hopelessness and poorer problem solving ability in a study conducted by Roskar et al. (2007) Kolla et al. (2008) found that borderline personality disorder as a chronic psychiatric condition is characterized by a pervasive pattern of instability in affect regulation and impulse control. These maladaptive coping strategies predispose these individuals to suicidal behavior. A recent study was conducted by Cukrowicz et al. (2008) the purpose of this study was to examine coping styles and thought suppression as predictors of a suicide risk in a sample of depressed older adults with cooccurring personality disorders. Based on the extant literature, it was hypothesized that maladaptive coping (i.e. emotional and avoidance coping) and chronic thought suppression would significantly predict suicide risk. The results of this study indicated that elevated emotional coping and thought suppression were associated with increased suicide risk. Contrary to hypotheses, lower avoidance coping was associated with increased risk. Coping style of suppression was significantly and positively related to suicide risk, as were several other coping styles (Josepho and Plutchik ,1994).Thus, treatments that focus on decreasing emotional coping and chronic thought suppression may result in decreased suicidal ideation and hopelessness for older adults with depression and Axis II pathology (Cukrowicz et al., 2008) Also there is consistent evidence that dimensions of active coping that include problem-solving in a stressful situation is related to lower mental health and substance use problems (Sandler et al., 1997). Also individuals

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with substance abuse problems demonstrate an avoidance-oriented coping style that often focuses on strategies such as daydreaming, helplessness, distraction, and diversion (Winters & Anderson, 2000). The robust and isolated representation of suicidal ideas and attempts associated with maladaptive coping strategies with younger age confirms the specificity of coping qualities, and also confirms the association of depression with dysfunctional attitudes and with maladaptive coping distinctly, but risky problem solving, maladaptive coping and dysfunctional attitudes seem to characterize different groups of depressive syndromes with only a moderate overlap (Csorba et al., 2007). Roskar et al. (2007) stated that next to feelings of hopelessness, certain cognitive features such as problem solving deficiency, attentional bias and reduced future positive thinking are involved in the development and maintenance of suicidal behavior. Horesh et al. (2007) added that suicidal patients were significantly less likely to use the coping styles of minimization and mapping. They were unable to de-emphasize the importance of a perceived problem or source of stress. They also lacked the ability to obtain new information required to resolve stressful life events. Four coping styles correlated negatively with the suicide risk (minimization, replacement, mapping and reversal), while another three (suppression, blame and substitution) correlated positively, also female who used emotion-focused coping were more likely to experience suicidal ideations (Edwards and Holden, 2001) In a study conducted by Gould et al. (2004); Dinya et al. (2009) to identify youths' attitudes about coping and help-seeking strategies for

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suicidal ideation and behavior; it was found that they use maladaptive coping strategies in response to depression and suicidal thoughts and behaviors such as avoidance and approach coping responses respectively. Dinya et al. (2009) further added that future research is needed to identify possible variation in the coping strategies among different adolescent suicidal patients. Gonzalez et al. (2009) stated that drinking to cope was a significant intervening variable in the relationships between suicidal ideation and alcohol consumption, heavy episodic drinking, and alcohol problems, even while controlling for depression. These results suggest that the relationship between suicidal ideation and alcohol outcomes may be due to individuals using alcohol to regulate or escape the distress associated with suicidal ideation. Further research studies on the psychological processes underlying suicidal behavior have highlighted deficits in social problem-solving ability, and suggest that suicide attempters may, in addition, be passive problem-solvers (Pollock and Williams, 2004) Orbach et al. (1990) compared qualitative aspects of problem solving among suicide attempters, suicide ideators, and nonsuicidal patients.Problem solving was analyzed along eight qualitative categories: versatility of the various solutions, reliance on self versus others, activity versus passivity, confrontation versus avoidance, relevance of the solution to the problem, positive versus negative affect, reference to the future, and extremity of the solution. The solutions of suicidal patients showed less versatility, more avoidance, less relevance, more negative affect, and less reference to the

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future than the solutions of the non suicidal patients. The suicide attempters and non suicidal patients offered more active solutions than did the suicide ideators. Several researchers have reported the importance of avoidancefocused and emotion-focused coping as predictors of suicidal ideations. In HIV positive patients, suicidal ideations were more likely to be experienced by individuals who cope through avoidance and escape

strategies. (Kalichman et al.,2000) , the relationship between greater reliance on avoidance coping and suicidal ideations has also been demonstrated among psychiatric inpatients (Orbach et al.,1990; DZurilla et al.,1998) Overall, reported avoidance-focused and to be less effective emotion-focused coping strategies, are often these

primarily because

approaches do not address the direct management of the problem at hand. This exacerbates the stressful experience, and in turn can lead to suicidal behaviors as a means to escape (Edwards and Holden, 2001) Alexander et al.(2009)conducted a study examined how individuals with serious mental illness and a history of suicidal behavior cope with suicidal thoughts; the respondents in the study wrote up to five strategies they use to deal with suicidal thoughts; included spirituality, talking to someone, positive thinking, using the mental health system, considering consequences of suicide to family and friends, using peer supports, and doing something pleasurable. In a present study of adult survivors of suicide to examine their natural coping efforts; results indicated that participants experienced high levels of

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psychological distress since the suicide, including elevated symptoms of depression, guilt, anxiety, and trauma, they also experienced substantial difficulties in the social arena (e.g., talking with others about the suicide) ,they also reported higher levels of psychological distress, social isolation, and barriers to seeking help, also depression and a lack of information about where to find help served as barriers to help-seeking behaviors. Future research is needed to build on these preliminary findings and to provide a solid foundation for evidenced-based interventions with survivors

(McMenamy et al., 2008) DeAngelis (2001) stated that suicide experts are beginning to recognize common emotional threads that may underlie some suicides. Prominent among these, they say, are a perceived sense of isolation, a lack of personal attachments and a dearth of coping skills. Healthy coping, according to crisis theory, involves four dimensions: involvement in daily activities, a supportive community, physical well-being and good quality of life; suicide attempts, on the other hand, can be seen as maladaptive efforts to cope. Since feelings of hopelessness decreases over time and problem solving ability nevertheless remains stable it is important that treatment not only focuses on mood improvement of depressed suicidal and depressed nonsuicidal individuals but also on teaching problem solving techniques. (Roskar et al., 2007) These findings may have important implications for therapists and primary prevention workers, and might pave the way towards recognition of the role played by coping styles in predicting suicide and its use for cognitive intervention in high-risk patients (Horesh et al., 2007)

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Religiosity and Psychiatry

The relationship between religion and mental health has been debated for centuries, since Freud and other famous mental health scholars have put forth their postulations concerning the neurotic influences of religion in mental health, many of the 20th century mental health professionals have been influenced to hold skeptical and even hostile attitudes toward religion. However, the past two decades have increasingly found more empirical evidence supporting the beneficial effects of religiousness on mental health that apparently contrasts with the postulations of Freud (Yeung & Chan, 2007) The definition and meaning of spirituality and religion remains a grey area, they are often regarded as 2 sides of the same coin. However in both the psychological and religious arenas spirituality is distinct from the traditional concepts of religion (Emmons and paloutzian, 2003) spirituality refers to matters concerning god and the human need to find a higher meaning and the relationship with the metaphysical such as soul, spirit, after-life and angels (Elkins, et al., 1988; Emmons and paloutzian, 2003). While religion refers to organized and institutionalized beliefs and system of faith which serves as a means of spiritual expression and includes: Islam, Christianity, Buddhism, Judaism, and Hinduism (Piedmont et al., 2001; Piedmont et al., 2003; Emmons and paloutzian, 2003) Evidence suggests that the religious and spiritual dimensions, while sometimes overlapping, often correlate differentially to psychosocial outcomes thereby yielding more robust information (Hill & Pargament, 2003; Piedmont, et al., 2003).

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Definition of Religion
Paloutzian& Santrock (2002) stated that religion is defined as the institutional, the organizational, the ritual, and the ideological, whereas spirituality is defined as the personal, the affective, the experiential, and the thoughtful. This contrast includes the idea that an individual can be spiritual without being religious or religious without being spiritual. A second contrast between religion and spirituality involves reserving the term spiritual for the loftier side of life with spiritualitythe search for meaning, for unity, or connectedness, for transcendence, and for the highest level of human potential. While the term religion is correspondingly reserved for institutionalized activity and formalized beliefs, things that can be seen as peripheral to spiritual tasks (Paloutzian& Santrock, 2002) The trend in defining religion is moving away from a broad conceptualization of the institutional and the individual toward a more narrow definition in terms of the institutional side of life. The trend in defining spirituality is to describe it in terms of individual expression that speaks to a persons highest level of human functioning (Emmons, 1999). Despite such trends, there is still a great deal of controversy about how to define religion and spirituality.

Religion and Mental Health

Paloutzian& Santrock (2002) stated that a common stereotype is that religion is a crutch for weak people and that unconscious feelings of guilt are the reasons that people become religious. Just because some religious individuals show signs of a mental disorder does not mean that their religious beliefs caused the disorder or that they adopted their beliefs as an

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escape. Similarly, just because individuals with a severe mental disorder, such as schizophrenia, use the word God or have a vision that they are Jesus or another charismatic religious leader does not mean that religion caused their severe mental disorder or that they became religious to try to cure themselves. All that such illustrations do is inform us that aspects of religion and mental disorder co-occur in a small number of individuals. They tell us nothing about religion causing mental disorders or mental disorders causing religiousness.

Role of Religious Coping in Mental Health

Some psychologists have categorized prayer and religious commitment as defensive coping strategies, arguing that they are less effective in helping individuals cope than are life-skill, problem-solving strategies (Paloutzian& Santrock, 2002) However, recently researchers have found that some styles of religious coping are associated with high levels of personal initiative and competence, and that even when defensive religious strategies are initially adopted, they sometimes set the stage for the later appearance of more-active religious coping (Pargament & Park, 1995). In one recent study, depression decreased during times of high stress when there was an increase in collaborative coping (in which people see themselves as active partners with God in solving problems) (Brickel et al., 1998). Also, in general, an intrinsic religious orientation tends to be associated with a sense of competence and control, freedom from worry and guilt, and an absence of illness, whereas an extrinsic orientation tends to be associated with the opposite characteristics (Ventis, 1995).

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Instead of disintegrating during times of high stress, religious coping behaviors appear to function quite well in these periods (Koenig, 1998). In one study, individuals were divided into those who were experiencing high stress and those with low stress (Manton, 1989). In the high-stress group, spiritual support was significantly related to personal adjustment(indicated by low depression and high self-esteem). No such links were found in the low-stress group. In the research on religious coping, growing body of literature documents beneficial outcomes of religious coping (Ahrens et al., 2009; Yeung &Chan , 2007), and as a result of their efforts in the past two decades, social scientists have gradually come a consistent view on the positive relationship between religiousness and mental health. Turning to religion is an important way of coping; data collected by (McCrae and Costa, 1986) suggest that such a coping tactic may be important to many people. One might turn to religion when under stress widely varying reasons, religion might serve as a source of emotional support , as a vehicle for positive reinterpretation and growth, or as a tactic of a coping with a stressor. Koenig et al. (2001) have recently completed a systematic review of studies on religion and mental health. They identified 850 relevant studies conducted in the 20th century addressing the relationship between religious involvement and mental health. Although they used a broad term to define mental health and well-being, which include psychologically perceived wellbeing, life satisfaction, hope, optimism, purpose and meaning in life,

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depression, anxiety, and suicidal ideation, most of the studies reported the positive role of religious involvement in maintaining mental health. George et al. (2002) stated that the social and psychological factors that have been hypothesized to explain the mental health promoting effects of religious involvement are health practices, social support, psychosocial resources such as self-esteem and self-efficacy, and belief structures such as sense of coherence. Similarly, Jones (2004) also proposed a set of mediators through which religiousness could enhance mental and physical outcomes. They are the increase in relaxation response to stress, decrease in unhealthy behaviors, increase in social support, more compliance with physicians treatment, a sense of coherence, more positive self-concept (e.g. higher self-esteem and less anxiety), and the positive interaction between mental and physical wellbeing (a potentiating interaction effect). Yeung &Chan (2007) (as shown in figure E) stated that religiousness can promote various resources, including spiritual, cognitive, psychological and social resources. Not only do these resources have unique positive effects on mental health, they also interact and mutually reinforce each other. Spiritual resources could be something particular to religious involvement. They may be hope, ultimate concern, eternal life after death, spiritual support, and assistance from an omnipotent GOD. These spiritual resources could be helpful and beneficial enough to change ones worldview and cognition from an apathetic, competitive and meaningless worldview to a world with hope, warmth, and meaningfulness (Yeung &Chan, 2007).

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Figure (E):

Mediational channels of the positive effects of religious

involvement on mental health (Yeung &Chan, 2007) Research pointed out that many people who were not religious previously might turn to religion for comfort (Koenig, 2001; Koenig & Larson, 2001). This often involves in beliefs in a living and caring God, private religious activities, reading religious scriptures for direction and encouragement, or looking for support from pastors or members of faith community. In fact, many studies commonly reported that religiousness was powerful resources of hope, meaning and purpose in life. These protective and beneficial effects are particularly strong in people with illness and disability (Ehman et al., 1999; King, 2000; Koenig et al., 1998; Koenig et al., 2004; Mueller et al., 2001). George et al.(2002); Mueller et al.( 2001) stated seven dimensions of religious involvement: public affiliation religious participation in (e.g. a church religious

attendance), religious

(e.g. involvement

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organization/ denomination), private religious practices (e.g. prayer and reading religious materials), and religious coping (turn to his/her religion/belief system for assistance), daily religion-related spiritual experiences (e.g. ones subjective perception of the transcendent in daily life), religious commitment (times and resources involved in religious activities and beliefs), and self-rated overall salience of religion (importance of religion in ones life). Pargament (2001) stated that in the eyes of many mental health professionals comfort, solace and relief are the basic functions of religion; similarly some coping researchers described religion as a form of emotion focused coping. He further added that religious beliefs and experiences act as immediate coping devices for current problems, but also as spurs to further psychological and emotional growth. Lewis et al. (2005) found that there are presently two dominant research perspectives within the psychology of religion and well-being literature. The first dominant construct within contemporary psychology of religion relates to religious orientation. Individuals described as having an intrinsic orientation toward religion are described as wholly committed to their religious beliefs, and the influence of religion is evident in every aspect of their life (Allport, 1966). On the other hand, those who demonstrate an extrinsic orientation toward religion have been describe as using religion to provide protection, consolation, and social status (Allport & Ross, 1967), in other words Intrinsic religious orientation involves religious motives that lie within the person; the person lives the religion. By contrast, extrinsic religious orientation involves personal motives that lie outside the religion itself; using the religion for some nonreligious ends (Hill &Hood, 1999).

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However, due to a number of studies investigating the extrinsic orientation toward religion (Gorsuch & McPherson, 1989; Gorsuch &Venable, 1983; King & Hunt, 1969; Leong & Zachar, 1990; Maltby, 1999), there is the strong suggestion that the extrinsic orientation towards religion comprises two dimensions, extrinsic-personal (protection, consolation) and extrinsicsocial (religious participation, social status). Religious coping has been conceptualized as a mediator, accounting for the relationship between religiousness and mental health in times of stress, and as a moderator, altering the relationship between stressors and mental health. 2 forms of religious coping were described: Collaborative religious coping which is active, refers to sharing the responsibility for problem solving with God. The deferring approach is more passive and is characterized by giving the responsibility for problem solving to God (Fabricatore et al.,2004) Pargament et al. (1988) also described three problem solving styles in religious coping: self-directing, deferring, collaborative. A self-directing style stresses personal agency and involves lower levels of traditional religious involvement. Deferring problem-solving implies awaiting solutions from God, and shows lower levels of coping competence. The collaborative style of problem-solving involves active personal exchange with God, internalized commitment and higher levels of personal competence. Religious coping appears to decrease the risk of suicidal ideations. Among depressed adults with a history of child abuse, an inverse

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relationship was demonstrated between the severity of suicidal ideations and religious beliefs. (Dervic et al., 2006) Religious coping decreased the risk of suicidal ideation among African American and White college students(Walker and

Bishop,2005)and Latin American immigrants. Hovey (1999) added that religion may protect against suicidal thoughts by providing meaning in peoples lives, as well as by fostering a sense of hope for the future. It needs to point out that religiousness does not necessarily bring about positive mental health outcomes in patients. A two-year longitudinal study indicated that use of negative religious coping, such as viewing God or a higher power as punitive, would have hazardous effect on patients psychological and physical health (Pargament et al., 2004). On the other hand, patients who adopted positive religious coping to deal with their illness, such as seeking spiritual support and religiously benevolent reappraisal of their situations, showed concrete improvements in mental and psychical health two years later. The relationships between positive religious coping and better mental and physical health outcomes was significant. Religion and spirituality have been linked, positively and negatively, to a host of outcomes across multiple domains of physical and mental health (Baumeister, 2002; Pargament, 1997). As religious attendance, did not predict subjective well being, replicating previous research in the area of positive psychology and spirituality (Ciarrocchi & Deneke, 2005). Negative religious coping, commonly referred to now as spiritual struggles(Murray-Swank, et al., 2005) on the other hand, can be viewed as having a less secure relationship with God, with a greater struggle with meaning and belief in God, with a more disconnected congregational

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relationship, and more spiritual discontent (Pargament et al., 1998; Zinnbauar & Pargament,1998). Depressive patients may derive consolation as well as struggle from their religion, Braam et al. (2010) found that the more or less universal finding about 'feeling abandoned by God' may suggest how depression represents an existential void, irrespective of the religious background.

Negative religious coping strategies had several positive associations with depressive symptoms, sub-threshold depression, and major depressive disorder: the most robust association was found for the item 'wondered whether God has abandoned me'. Other significant associations were found for interpreting situations as punishment by God, questioning whether God exists, and expressing anger to God (Braam et al., 2010).

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Summing Up
Coping is also defined as a process by which an individual manages the ever-changing environment. Coping may be seen as actions taken by persons directed at confronting demands, solving problems, and/or altering and managing stressors. Coping behavior is generally influenced by maturation and cognitive development such as problem-solving ability, and understanding peers and adults. Two concepts are central to any psychological stress theory: appraisal, i.e., individuals' evaluation of the significance of what is happening for their well-being, and coping, i.e., individuals' efforts in thought and action to manage specific demands. There are two basic forms of appraisal, primary and secondary appraisal. Resource theories of stress are not primarily concerned with factors that create stress, but with resources that preserve well being in the face of stressful encounters. Several social and personal constructs have been proposed, such as social support, sense of coherence, hardiness, selfefficacy, or optimism. An overview of the perspectives of coping theorists shows that they have generally categorized coping strategies under three groups: a) strategies focused on resolving the problem; b) strategies used to alleviate the emotions triggered by the situation; and c) strategies involving social support. Lazarus went on to make an important and now widely accepted distinction between two types of coping. In one, problem focused; the person attempts to address directly the problems that he is facing. In the second, emotion

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focused; the person tries to dampen or minimize the emotional state itself, without addressing the problem that elicited the state. Coping has three main (protective) functions: Management of the problem causing the distress through elimination or modification of the conditions giving rise to it, alteration of (perceptually controlling) the meaning of the experience so as to neutralize its problematic character and, regulation of the emotional distress produced by the problem. Ineffective coping is an inability to for a valid appraisal of stressors, inadequate choices of practiced responses, and/or inability to use available resources. Recent research conducted has found that people with psychiatric disabilities tended to utilize passive and emotional-focused strategies to cope with their illness. Next to feelings of hopelessness, certain cognitive features such as problem solving deficiency, attentional bias and reduced future positive thinking are involved in the development and maintenance of suicidal behavior. Suicide experts are beginning to recognize common emotional threads that may underlie some suicides. Prominent among these are a perceived sense of isolation, a lack of personal attachments and a dearth of coping skills. Healthy coping, according to crisis theory, involves four dimensions: involvement in daily activities, a supportive community, physical well-being and good quality of life; suicide attempts, on the other hand, can be seen as maladaptive efforts to cope. These findings may have important implications for therapists and primary prevention workers, and might pave the way towards recognition of the role played by coping styles in predicting suicide and its use for cognitive intervention in high-risk patients.

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Turning to religion is an important way of coping; data collected by suggest that such a coping tactic may be important to many people. One might turn to religion when under stress widely varying reasons, religion might serve as a source of emotional support , as a vehicle for positive reinterpretation and growth, or as a tactic of a coping with a stressor. The definition and meaning of spirituality and religion remains a grey area, they are often regarded as 2 sides of the same coin. However in both the psychological and religious arenas spirituality is distinct from the traditional concepts of religion. Spirituality refers to matters concerning god and the human need to find a higher meaning and the relationship with the metaphysical such as soul, spirit, after-life and angels. While religion refers to organized and institutionalized beliefs and system of faith which serves as a means of spiritual expression and includes: Islam, Christianity, Buddhism, Judaism, and Hinduism.