Introduction

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Religious faith addresses the existential questions of life and death. Death of a close relative or companion is an extremely distressing experience, and grieving can take a long time. But little research on whether spiritual or religious beliefs alter the process of grief has been carried out. Studies of families coping with the death of a child ^{1 2} and research into the adaptation of older people to widowhood³ suggest that religious belief affects the outcome of bereavement. Research is often retrospective, however, and causal connections are difficult to establish.¹ Furthermore, research has been hampered by a lack of standardised measures.

The development of valid and reliable measures of spiritual beliefs⁴ and of the process of bereavement⁵ has enabled us to study the relation between spiritual beliefs and grieving.

	Method

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All close relatives or friends of patients admitted between January 1997 and August 1998 to a Marie Curie centre for specialist palliative care in London were eligible to take part. Patients are admitted from the local area, irrespective of their religious affiliation, and there is no manifest religious imagery or culture in the building. We sought informed consent from the relative or friend thought to be closest to the patient.

We used five standardised measures to assess strength of spiritual belief and bereavement outcome: the Royal Free interview for religious and spiritual beliefs, the core bereavement items scale, the hospital anxiety and depression scale, the close persons questionnaire, and the locus of control behaviour scale.^4-8 We aimed to test the null hypothesis that spiritual belief has no effect on the grieving process. We also hypothesised that age, sex, emotional status, cognitive style, and social networks could be associated with spiritual beliefs and bereavement outcome, thereby acting as confounders in the putative relation between them.

Although many people return to near normal four to six months after the death of a loved one,⁹ resolving a bereavement may take longer in others. Thus, we followed up participants at 1, 9, and 14 months after the death of their relative or friend.

Data analysis
We used Student's t test for normally distributed data and the ² statistic for categorical data. On an a priori basis, we divided the sample into three groups on the basis of their beliefs: no spiritual belief, low strength of belief, and high strength of belief. The latter two groups were divided on the mean score of the spiritual scale. We compared the three groups by using analysis of variance and the Pearson ² statistic. We analysed our principal outcomes at 1, 9, and 14 months by using multivariate, repeated measures analyses (see bmj.com).

	Results

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Response rates
We approached 216 people, 135 (90 women and 45 men) of whom took part in the baseline interviews. In all, 129 patients (96%) died within the time available for follow up and thus the relatives and friends of these 129 comprised the study cohort. Ninety five (74%) of these completed all follow up assessments. (See bmj.com for a flow chart of the study.)

Baseline characteristics
Fifty one participants (40%) were the spouse or partner of the dying patient and 52 (40%) were their adult children. The remaining 26 (20%) were made up of 9 (7%) friends and 17 (13%) other relatives. Fifty two (40%) named the dying patient as the person they had felt closest to over the previous 12 months, with a further 13 (10%) naming the dying patient as the second closest person to them.

A total of 21/129 people (16%) reported no religious or spiritual belief; 53 (41% of all participants) reported spiritual beliefs of low intensity and 55 (43%) reported strongly held beliefs (table 1). Marital status and ethnic origin were significantly related to spiritual belief: people with partners had stronger beliefs, and almost everyone in the low belief group was white.

Spiritual belief and outcome of bereavement
The main result of this study arose from the analysis of the 95 participants (74%) who completed all follow up assessments (table 2). Participants with strongly held spiritual beliefs recovered from their bereavement in a linear fashion (figure), whereas those with low strength of belief showed little change by nine months but recovered rapidly thereafter. Participants with no spiritual beliefs showed a temporary gain at nine months but their symptoms of grief had intensified again by the final assessment.

View larger version (15K): [in this window] [in a new window]   Strength of spiritual belief and outcome of bereavement

We used a multivariate analysis to explore the potential effect of confounders on the main outcomes and found a borderline significant effect (P=0.058) for the interaction between strength of belief and time (figure).

When we entered the demographic variables of sex and age into the model, the effect of strength of belief remained significant. Although sex of the participant was important (men had higher grief scores than women initially but not by nine months), it did not remove the effect of strength of belief on the course of grieving. Age was not a significant covariate in initial grief or recovery with time. We then examined the effects of psychological status and locus of control. Mean scores on the hospital anxiety and depression scale before the death were significantly associated with initial levels of grief. Higher depression scores at baseline also predicted higher scores on the core bereavement items scale at all follow ups. However, scores on the hospital anxiety and depression scale or mean locus of control scale failed to have a major impact on the effect of strength of belief (P=0.063) or the interaction between sex and time. Adding social isolation and emotional closeness of the participant to the deceased reduced the effect of strength of belief. Closeness to the dying patient predicted higher grief scores at all follow ups.

The final model included strength of belief, sex, and closeness to the deceased as between subject factors and hospital anxiety and depression scale score at baseline as a covariate. Strength of spiritual belief retained its borderline significance. At 14 months the difference between the group with no beliefs and the combined low and high belief groups was 7.30 (95% confidence interval 0.86 to 13.73) points on the core bereavement items scale. Adjusting for confounders in the final model reduced this difference to 4.64 (1.04 to 10.32) points.

	Discussion

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Our main finding is that strength of spiritual belief is an important predictor of bereavement outcome. People with low strength of belief resolved their grief more slowly during the first nine months but by 14 months had caught up with people with strong beliefs.

Limitations of the study
One limitation of our study is sample size, which restricts the number of potential confounders we can explore. Set against that is the difficulty of recruiting a large sample of people before the death of their loved one and following them for a considerable time afterwards. Another limitation is a lack of qualitative detail to help in our interpretation of the results. It would also have been useful to know more about participants' experiences of palliative care and counselling before the death. However, to avoid overburdening the participants, we restricted ourselves to data that were germane to our hypothesis. Furthermore, not all participants completed all follow ups.

Great sensitivity was required in approaching participants, and it was inevitable that a proportion would refuse to participate. We cannot know whether some dropped out because of unresolved bereavement issues or dissatisfaction with the circumstances of the death.

Strengths of the study
The strengths of our study are that it was prospective over a long follow up period and that we recruited participants in a secular palliative care unit that has no religious affiliation. A further strength is that we recruited participants before they were bereaved. Most participants, however, appreciated that their loved one was very sick and that their death was imminent.

Spiritual belief
Spiritual beliefs may provide an existential framework in which grief is resolved more readily. Most spiritual beliefs, whether or not associated with religious practice, contain tenets about the course of human life and existence beyond it. Strong beliefs may be a proxy for better adjustment and less psychological distress. But our analysis suggests that strength of belief affected the course of bereavement, independently of psychological status. Relating to a person with terminal illness may sharpen our focus on spiritual or existential matters. Participants in this cohort, however, held beliefs that were similar in character and strength to those of other populations in which this standardised measure of spiritual and religious beliefs has been used. ^{10 11}

Concluding remarks
If our results were replicated, this would show that the absence of spiritual belief is a risk factor for delayed or complicated grief. Most palliative care units try to involve family members and friends who are important and close to the person dying. Attention to spiritual matters may be a component in this work that is often overlooked or avoided by secular services. We are not suggesting that an intervention concerning spiritual matters is appropriate for people with no professed beliefs. Rather, our finding might help in identifying people who are having difficulty in readjusting to life after their loss.