This study sought to examine the effect of a spiritual/religious intervention, designed especially for Iranian Muslim women with breast cancer, on their psychological well-being and S/R coping. Results indicated that the intervention may be a way to increase positive S/R coping and reduce negative S/R coping among women with breast cancer. This suggests that this S/R intervention may change the way these patients deal with religious/spiritual matters. However, the S/R intervention did not affect participants’ psychological well-being compared to the control group.
The S/R interventions helped patients to understand their S/R challenges and needs, and in this way helped them to engage in positive coping when facing their illness and related S/R concerns. Interventions such as the present one have sought to increases patients' awareness of spirituality, its domains and values, and help them to recognize and evaluate their spiritual needs . In the face of cancer, patients experience spiritual struggles, including existential worries, frustrations, conflicting beliefs, anger at God, and feelings of abandonment by God [21, 4]. Because of this, S/R care interventions are needed to address these issues [22, 23]. In this intervention, patient’s S/R problems (such as S/R reasons for their cancer, inability to answer the question of justice, and the ineffectiveness of their past actions) were discussed. In addition to greater awareness and recognition of their emotions, patients acquired new knowledge and attitudes that help them to accept their illness based on their holy scriptures. In this way, patients developed more comprehensive answers to these S/R questions and concerns. This intervention model is consistent with those used to solve problems through which the patient manages a challenging situation through behavioral and cognitive changes . Following the intervention, patients were more able to find practical solutions and specific answers to questions that weaken their faith and adversely affected their intimacy with God.
Belief systems and culture are essential aspects of S/R interventions and ways of caring for these patients. This intervention approach is consistent with the culture and beliefs of Iranian Muslims and uses schemas and narratives that are familiar to them and thus more effective. Positive S/R coping through faith in God may generate positive thoughts that help patients to deal more effectively with stressful experiences especially when dealing with life threatening diseases such as cancer .
According to sacred Islamic texts, painful experience of having disease such as cancer is considered part of divine order and wisdom, leading the patient into a closer and more intimate relationship with God . While confirming and acknowledging the patient’s previous good deeds (important in Islam), this program helps to redefine religious duties and makes conducting such duties a goal.
Participants in this program talked about how to pray and how prayers are answered according to the sacred texts of Islam and their cultural beliefs. This S/R intervention encourages patients to actively participate in the program, and may help to enhance positive forms of coping and reduce negative spiritual that may adversely affect their mental and possibly even physical health [4, 26].
The Qur’an emphasizes that humans are often shortsighted and may not be able to see the divine wisdom in life’s difficulties, particularly physical illnesses. When breast cancer strikes, this may cause women to re-evaluate their belief systems as they confront the illness, seeing it as a test of how strong their faith is and learning humility from it, relying entirely on God. Helping patients understand that, as this intervention sought to do, may enable them to find meaning in their illness and learn important lessons that Muslims believe God is trying to teach them. This may help breast cancer patients to accept their illness, and perhaps even help them to realize that this experience of having breast cancer may be one of the best things that ever happened to them (Qur’an 2:155–157; 6:42; 21:35) .
Religion is still considered one of the most important ways that individuals cope when dealing with adversities such as cancer . According to stress and coping theory, religion as a source of support is effective in reducing stress, to the extent that positive religious coping can shape transcendent relationships and meaning in life . As noted above, this intervention emphasized the need to reflect on religious beliefs and use them in a healthy manner. They were encouraged to engage in their faith as a valued resource despite hesitation and doubt, thereby strengthening their S/R beliefs and practices that led to greater spiritual support.
The cognitive, behavioral, and spiritual experiences are the focus of this intervention. The cognitive element is represented by helping the individual find meaning in their illness. The behavioral component includes worship and other S/R activities. The spiritual element involves helping the person experience more hope, love, and acceptance of their illness. Worship and prayer have been found effective for relieving distress in many studies . Addressing misconceptions about the cause of illness, meditating on religious texts, and discussing the importance of worship and doing good deeds may help to support and preserve patients’ S/R beliefs and values. Trusting and seeking understanding of divine wisdom, and being patient are important coping strategies when dealing with an illness such as breast cancer.
Repairing the emotional connection with God while empathizing and recognizing these conflicting feelings about this relationship, may help to increase closeness to and trust in God. The Qur'an describes the believers as: "Those who entrust their work to Allah, Allah is aware of His servants” (25: 58). Accepting the will and wisdom of God enhances the connection with God in a way that will help them to cope better with the suffering that comes from their illness . This may help to reduce threats, fears, and stress and bring them closer to God . According to religious teachings, hope for divine mercy and belief in healing reduces the feeling of emptiness and despair and helps patients view process of treatment and recovery more positively [31, 4].
One of the components used in the present S/R intervention is that patients pay attention to feelings of remorse for the sin that they believe caused their cancer. The patient is encouraged to ask for forgiveness for such perceived transgressions. This has been done with good results in previous studies  and in helping them to reach a state of peace with their illness .
According to Pargament, positive S/R coping in disease conditions is not necessarily generalizable to other stressful situations. How individuals cope and adapt to stressors varies depending on their psychological characteristics and complexity (Pargament et al., 2004). In the present study, while the religious coping of individuals increased, the intervention did not affect their psychological well-being. Although previous research suggests that S/R is associated with positive psychological functioning  and may increase well-being , there is little consensus among these studies partly due to differences in the measurement of S/R. These differences in measurement may help to explain a lack of consistency in the findings [35, 36].
The exact role that S/R plays in psychological well-being or distress has been elusive . Research on the relationship between psychological well-being and S/R may depend on the stage of disease and length of time that has elapsed since diagnosis. In addition, the terms mental health, well-being, and quality of life are often used interchangeably. The concept of well-being includes happiness, life satisfaction, and self-esteem, in addition to Ryff’s conceptualization of well-being. Not all previous studies have used Ryff’s scales as indices of well-being. In many studies, the relationship between psychological well-being and S/R coping, general religiosity, and belief in God have been positive [13, 38], and positive images of God have been related to greater hope and optimism . However, the relationship between the image of God and psychological well-being in women receiving spiritual care was not significant in Schreiber’s (2011) study . Also, Gall et al. (2009) reported that among women with breast cancer, those who pleaded for God's help and intercession experienced more distress after surgery . Gall also found that women who challenged their religious beliefs experienced lower emotional well-being and more emotional pain. However, women who used religious activities to distract attention from the disease had less emotional distress six months after surgery .
Consistent with previous research, improvement and positive change in the illness condition can also influence the effect of S/R interventions. Negative religious coping has been found to be more common in patients just after receiving the diagnosis, whereas this declined and psychological well-being increased following treatment and recovery [10, 39, 16]. Ellington, et al. (2017) acknowledged that spiritual challenges could result in an increase in psychological well-being over time . In contrast, those with S/R doubts may have a chaotic or negative relationship with God or experience negative social and interpersonal interactions in religious settings, resulting in a worsening of S/R struggles and increasing psychological distress. Of note here is that some variables such as personality may mediate or moderate the effectiveness of S/R interventions in increasing patient well-being .