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An exploratory study of the role of religion and religious involvement among Latinos with schizophrenia and family caregivers

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An exploratory study of the role of religion and religious involvement among Latinos with schizophrenia and family caregivers

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An Exploratory Study of the Role of Religion and Religious Involvement among
Latinos with Schizophrenia and Family Caregivers

by

Lizbeth Gaona

_________________________________________________________

A Dissertation Presented to the FACULTY OF THE USC GRADUATE SCHOOL
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

May 2019
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION ii
Abstract
Schizophrenia is a debilitating mental illness associated with numerous individual and societal
costs. It is important to examine resources for Latinos diagnosed with schizophrenia, often
identified as a vulnerable population, more likely to experience stressors associated with issues
such as acculturation, low socioeconomic status, low education, and multiple barriers to
accessing care, yet are also an understudied population. Family caregivers, many living with the
family member, may experience heavy caregiving burden and psychological distress. Although
many Latinos diagnosed with schizophrenia and their family caregivers identify religion as a
helpful resource, there is little research that examines this in-depth. This qualitative secondary
data analysis study explored the role of religion and religious involvement from the perspectives
of 14 Latinos diagnosed with schizophrenia and 20 family caregivers. Transcripts of 34
interviews were analyzed using thematic analysis and a constant comparative method. Findings
generally aligned with Pargament’s theory which asserts that religion may be experienced as a
part of the coping process, as contributing to the coping process and as a result of the coping
process. The role of religion was prominent for many participants, appearing to help them cope
with mental illness by increasing hope, offering guidance and increasing motivation. There were
only slight differences in the types of religious activities in which consumers and family
caregivers were actively engaged. After the onset of schizophrenia there appeared to be a change
in some participants’ religious beliefs and involvement; participants described both decreases
and increases. Despite study limitations based on secondary data analysis, these findings offer
insight into the complexity of religion as a coping resource for Latinos diagnosed with
schizophrenia and their family caregivers. Future studies with larger, more diverse Latino
subgroups are needed to determine the robustness of these results.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION iii
Dedication
This dissertation is dedicated to my mother Paula Gaona, madresita linda, siempre seras mi héroe
y mi mejor amiga. Este doctorado es tuyo. My grandfather Merced Gaona, abuelito, papi,
gracias por tu gran amor. To my dear husband Matthew, honey, we did it! -We are one (Genesis
2:24) and what is mine is yours. You are equally deserving of this doctorate for the
immeasurable love and support that you have given me. I could not imagine accomplishing it
without you. Thank you for believing in me and for your patience and unwavering love and
support. To my twin sister Lizett, thank you for being my greatest supporter. You have never
doubted in me. Your constant encouragement, wisdom and fervent prayers have been
instrumental through this entire journey. You are by far one of the strongest women in my life.
You are selfless beyond words, thank you for all that you do and give- I admire you so much.
And lastly, to my Lord and Savior Jesus Christ- apart from Him, I can do nothing, John 15:5.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION iv
Acknowledgements
First, thank you to Drs. Concepcion Barrio and Mercedes Hernandez for allowing me to
collaborate with them. I am privileged to have been able to carry out this qualitative secondary
data analysis study and look forward to future work together. I will be forever indebted to my
mentor Dr. Concepcion Barrio who has been instrumental in my ability to complete this degree
successfully. As a Latina and pioneer in the area of research for Latinos with a serious mental
illness and their families, she has served as an excellent role model for me. Her work will
continue to motivate me to break barriers and achieve greatness for years to come. I am also
thankful for the support and mentorship of Dr. Ann Marie Yamada who has served as a constant
source of guidance. Her role modeling in the areas of teaching and mentoring inspires me. I also
thank Dr. Lourdes Baezconde-Garbanati. I stand in awe of her accomplishments and am very
fortunate to have had her as a professor and as a member of my qualifying exam and dissertation
committees. I am also thankful to Dr. Maria Aranda who served as my mentor during my first
year in the program. I have great admiration for her and am privileged for the opportunity to
have been mentored by her. I would like to thank my colleagues Drs. Paula Helu-Brown,
Mercedes Hernandez and Caroline Lim, as they paved the way, opened doors and have
generously given so much to me. I would also like to thank Drs. Lynn McFarr and Lisa Bolden
and Ulises Ramirez, LCSW. As professional mentors whom I highly esteem, they have each
believed in me and stood by my side for the past 11 years. I would also like to thank Dr. Elyn
Saks for allowing me to be a part of the wonderful Saks Institute for Mental Health Law, Policy
and Ethics and Dr. Duy Nguyen, Director of the Council on Social Work Education Minority
Fellowship Program, whose mentorship has been invaluable over the past year. Words cannot
express how much being a part of the MFP program has meant to me.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION v
Table of Contents
List of Tables vii
List of Figures viii
CHAPTER I: INTRODUCTION 9
Latino Consumers 10
Religion and Religious Involvement 10
Latino Family Caregivers 11
Religion and Religious Involvement 11
Study Aims 12
Significance of the Study 12
CHAPTER II: LITERATURE REVIEW 14
Role of Religion and Mental Health 14
Consumers with Schizophrenia 15
Religious Involvement 16
Intrinsic and Extrinsic Religion 16
Religion and Latinos 17
Family Caregivers: Stigma, Biopsychosocial Factors and Gender 18
Latino Family Caregiver Values 19
Providers 20
Conceptual Framework 21
Summary 22
CHAPTER III: METHODS 23
Parent Study 23
Sample and Data Collection 24
Data Analysis 25
CHAPTER IV: RESULTS 28
The Prominent Role of Religion 28
Thematic Results Guided by Pargament’s Conceptual Framework 29
Religion as Part of the Coping Process 29
Intrinsic religious involvement 29
Extrinsic religious involvement 29
Religion Contributes to the Coping Process 30
Religion helps to cope with the mental illness 30
Credit, thankfulness and praise towards God 31
Religion as a Result of the Coping Process 32
Religious Freedom 34
Discussing Religion with Providers 35
CHAPTER V: DISCUSSION 37
The Prominent Role of Religion 37
Thematic Results Guided by Pargament’s Conceptual Framework 38
Religion as a Part of the Coping Process 38
Religion Contributes to the Coping Process 39
Religion helps to cope with the mental illness 39
Credit, thankfulness and praise towards God 40
Religion as a Result of the Coping Process 42
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION vi
Religious Freedom 42
Discussing Religion with Providers 44
Implications and Future Directions 45
Limitations 45
Conclusion 46
References 48
APPENDIX: Interview Guide Questions 68
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION vii

List of Tables
Table 1: Demographic Profile of Study Sample 61
Table 2: Thematic Results Guided by Pargament’s Conceptual Framework 62
Table 3: Religion as Part of the Coping Process 63
Table 4: Religion Contributes to the Coping Process 64
Table 5: Religion as a Result of the Coping Process 65
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION viii
List of Figures

Figure 1: Flow Chart of Parent and Current Study Sample 66
Figure 2:
Latino Family Caregiver Praise Towards God Model

67

AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 9
CHAPTER I: INTRODUCTION
Schizophrenia is a highly debilitating mental illness associated with significant
impairments in functioning (Kessler & Lev-Ran, 2019; Ko et al., 2018). Individuals diagnosed
with schizophrenia have higher risks of substance use disorders and suicide (Kessler & Lev-Ran,
2019; Ko et al., 2018; Kooyman, Dean, Harvey, & Walsh, 2007; Lehman & Dixon, 2016;
Nesvåg et al., 2015). Social costs are also numerous and include high risks of victimization,
unemployment and homelessness (Kooyman et al., 2007). Moreover, it has been documented
that Latinos, tend to experience higher levels of depression, lower levels of household income
and more problems meeting basic needs relative to other ethnic groups such as European
Americans (Plant & Sachs-Ericsson, 2004). Further, a study based on the National
Epidemiological Survey on Alcohol and Related Conditions found Latinos have higher exposure
to psychological stress relative to European Americans (Hasin & Grant 2015). The study reports
that factors such as acculturation were associated with an increased risk for a mental health
disorder (Hasin & Grant).
It is important to examine culturally relevant ways of coping for Latinos diagnosed with
schizophrenia, as there is little research regarding mental health care for this population (Lopez,
Barrio, Kopelowicz, & Vega, 2012). There is a need to examine culturally relevant ways of
coping for this understudied and vulnerable population.
It is also essential to examine culturally relevant coping tools for family members of
Latino adults diagnosed with schizophrenia. Latinos diagnosed with schizophrenia are more
likely to reside with family members than to live independently or in supportive housing;
therefore the caregiving role often falls on one or more family members (Barrio et al., 2003;
Guarnaccia & Parra, 1996; Jenkins & Schumacher, 1999). As a result, Latino family caregivers
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 10
of adults diagnosed with schizophrenia have an increased risk of experiencing higher burden and
developing depression symptoms compared to Latinos in the general population (Magaña,
Ramirez Garcia, Hernandez, & Cortez, 2007).
Noteworthy is that Latinos have identified religion (Comas-Diaz, 2006; Guarnaccia,
Parra, Deschamps, Milstein, & Argiles, 1992; Hernandez & Barrio, 2015; Yamada et al., 2009)
and religious involvement as coping resources (Coon et al., 2004). Although the use of religion
has been identified as salient for family members coping with a loved one’s serious mental
illness (Organista & Muñoz, 1996; Weisman, Gomes & López, 2003), and the importance of
incorporating religion in treatment has been emphasized (Weisman, Rosales, Kymalainen &
Armesto, 2005) research in this area is sparse.
Religion has been defined as set beliefs or ideological commitments and spirituality has
often been described as an individual’s personal, subjective religious experience (Hill &
Pargament, 2008). For the purposes of this study religion will be referred to as a general term
that encompasses both concepts related to religion and spirituality.
Latino Consumers
Religion and Religious Involvement
Religion and religious involvement have been found to be associated with positive mental
health outcomes for persons diagnosed with schizophrenia (Abdel Gawad et al., 2019; Bonelli &
Koenig, 2013). They have been associated with less suicidal ideation and fewer suicide attempts
(Abdel Gawad et al., 2019). In a recent study of Latinos diagnosed with schizophrenia, religious
involvement was associated with higher quality of life (Gaona, Hernandez, Lim, Helu-Brown &
Barrio, 2019). In another study, Latinos diagnosed with schizophrenia and other serious mental
illnesses who endorsed religious involvement were found to have greater positive mental health
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 11
outcomes over time (Tepper, Rogers, Coleman & Malony, 2001). Nevertheless, few studies
have indicated the unique perspectives of the role that religion plays in the lives of Latino
consumers, nor what types of specific religious activities they undertake.
Latino Family Caregivers
Caregiving for a relative diagnosed with a serious mental illness may take a high toll on
the family. Latino family caregivers of a relative diagnosed with schizophrenia may be at risk
for an increase in burden (Magana, Ramirez Garcia, Hernandez & Cortez, 2007). Further, they
may experience distress and lower psychosocial well being associated with their relative’s
symptomology (Hegde, Chakrabarti & Grover, 2019; Mitsonis et al., 2012; Mueser, Webb,
Pfeiffer, Gladis & Levinson, 1996; Reinares et al., 2006; Rofail, Regnault, le Scouiller, Lambert
& Zarit, 2016). The consumer’s symptomology and lower levels of caregiver education have
been associated with depression for Latino family caregivers (Magana et al., 2007). In one
study, Mexican American family caregivers reported significantly higher rates of depression
relative to European American, African American and Japanese American caregivers (Adams,
Aranda, Kemp & Takagi, 2002). In another study, when compared to European American
caregivers, Latino family caregivers were found to have significantly higher objective and
subjective caregiver burden, poorer health, and emotional problems (Arevalo-Flechaz et al.,
2014).
Religion and Religious Involvement
Latino family caregivers have identified their faith as a source of courage to help them
manage with their relatives’ illness (Rivera-Segarra, Fernández, Camacho-Acevedo, Ortiz &
López-Robledo, 2016). It has been recognized that Latino family caregivers have relied on their
religion to overcome challenges (Gelman, 2010). For example, organized religious involvement,
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 12
such as church attendance, was found to be associated with a decrease in burden for Latino
family caregivers of a relative diagnosed with schizophrenia (Gaona et al¸ 2019). Latino family
caregivers of a relative diagnosed with schizophrenia have reported experiencing comfort and a
greater ability to cope with their loved one’s illness as a result of religious involvement
(Weisman, Gomes & Lopez, 2003; Weisman, 2005). Although these findings are promising,
there is still a dearth of literature regarding the role of religion and religious involvement for
Latino family caregivers of adults with schizophrenia. There is a lack of understanding of the
role of religion and religious involved from the unique perspectives of Latino family caregivers.
Further, the literature has not identified the specific types of religious activities that they endorse.
Study Aims
The first aim of this qualitative secondary data analysis study was to examine the
perceptions of the role of religion and religious involvement among Latinos diagnosed with
schizophrenia. The second aim was to examine the role of religion and religious involvement
among family caregivers.
Significance of the Study
Although research has examined the relationship between religion and mental illness
(Bonelli & Koenig, 2013), there is a dearth of literature that examines the role of religion and
religious involvement from the perspectives of Latinos diagnosed with schizophrenia. It is
particularly crucial to understand their expressions and gain an understanding of the perspectives
of Latinos with schizophrenia, as this population has been vastly understudied (Lopez et al.,
2012) and may be at risk of being over diagnosed with schizophrenia (Schwartz & Blankenship,
2014). In a review on the racial disparities in psychotic disorder, Schwartz and Blankenship
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 13
(2014) found that on average Latinos were disproportionately diagnosed with psychotic disorders
three times higher compared to European American consumers.
This underscores the importance of examining culturally relevant coping tools which may
help support culturally relevant interventions in treatment delivery for specific cultural groups; as
culturally adapted interventions have been found to be four times more effective than
interventions provided to groups consisting of clients from a variety of cultural backgrounds
(Griner & Smith, 2006). A recent meta-analysis of extant studies concluded that culturally
adapted treatments are consistently more significant and predict more positive outcomes relative
to standard treatments (Soto, Smith, Griner, Domenech Rodríguez & Bernal, 2018).
Yet, practitioners may feel hesitant to explore culturally relevant coping tools such as
religion with consumers. Clinicians may shy away from discussing the role of religion and
religious involvement for this population due to the fear of the client experiencing symptoms
such as religious delusions, religious compulsions or obsessions (Singh, Beniwal, Bhatia, &
Deshpande, 2019). Still, it is unreasonable to ignore that Latinos with schizophrenia and their
caregivers have identified that religion plays an important role in coping with schizophrenia
(Hernandez et al., 2019).
To this end, this study will conduct an in depth qualitative secondary data analysis of the
role of religion and religious involvement from the perspective of Latino consumers and their
family caregivers. This exploratory study will build on findings from a recent quantitative study
by allowing for a deeper investigation of the role of religion in that it will help identify specific
types of religious involvement (Gaona et al¸ 2019). This exploratory study will serve as a
foundation and important catalyst for future studies in this understudied area of research.

AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 14
CHAPTER II: LITERATURE REVIEW
Role of Religion and Mental Health
A recent systematic evidence based literature review found that a total of 43 studies
statistically examined the relationship between religion and specific mental health disorders
between 1990-2010 (Bonelli & Koenig, 2013). Over half of the studies (72%) showed that an
increase in religious involvement was associated with less mental health disorder. Almost
twenty percent (18.6%) of the studies found mixed results and two studies found that religious
involvement was associated with more mental disorders. Despite over half of the studies finding
that religion may have a positive association with mental illness, still some studies found
otherwise.
There has been some evidence of a U-shaped relationship between religious involvement
and mental health (King et al., 2007; Taylor, Chatters & Nguyen, 2013). Taylor, Chatters and
Nguyen (2013) found that persons who attended religious services a few times a year or less, a
few times a month and nearly every day had higher likelihood of having lifetime major
depressive disorder compared to persons who attended religious services at least once a week.
Similarly, King et al. (2007) found that persons who reported moderate levels of religious
involvement in the form of church attendance were less likely to be depressed relative to those
who endorsed high or low levels of church attendance. Still, this same study found that persons
who endorsed high levels of religious involvement in the form of prayer, were less depressed.
Another recent study indicated that persons with high religiosity scores also had significantly
more psychotic symptoms (Abdel Gawad et al., 2018). Importantly, despite the high psychotic
symptoms, they also had significantly lower levels of suicidal ideation and suicide attempts than
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 15
those with lower religiosity. It appears as though religiosity may have served as a protective
factor against such behaviors.
These findings illustrate the complex relationship between religion and mental health.
Study results may vary by numerous factors such as type of mental health disorder (Bonelli &
Koenig, 2013), type of religious involvement (Aranda, 2008; King et al., 2007) as well as ethnic
group (Mui & Lee, 2014). As such, it is important to avoid generalizations regarding the
relationship between religion and mental health, but rather to advocate for research focused on
specific subgroups that hones in on unique characteristics relevant to that population.
Consumers with Schizophrenia
Schizophrenia focused studies have shown that religion has been associated with positive
outcomes to a greater extent and with negative outcomes to a lesser extent. For example, in one
study, with a sample of 115 outpatients, Mohr et al. (2006) found that the majority, 71% of
consumers associated religion with hope, purpose and meaning, however14% of the consumers
associated religion with despair. Moreover, 54% of the consumers believed that religion helped
to decrease their psychotic symptoms, yet 10% believed that religion was associated with an
increase in their symptoms. Another study found that consumers who endorsed being “religious
but non-collectively practicing” had higher non-compliance treatment rates relative to those who
were “spiritual and collectively practicing” and the “non religious” groups (Borras et al., 2007).
In a different study, Linden, Harris, Whitaker and Healy (2010) found that intensive religious
experiences were associated with an increase in transient psychotic disorders.
Although mental health outcomes have been mixed, overall a majority of the studies
pertaining to persons diagnosed with schizophrenia report that religion serves as a positive
source of coping for this population (Borras et al., 2007; Mohr et al., 2006; Nolan et al., 2012).
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 16
Nolan et al. found that 64% of consumers diagnosed with schizophrenia rated the importance of
being connected to a religious community as “very much” to “much importance”. Borras et al.
(2007) found that out of 103 outpatient consumers, two thirds endorsed religion as being “very
important” or “essential in their every life”. In another study, consumers diagnosed with
schizophrenia and their family caregivers shared that their hope for the future was related and
sustained by their faith (Hernandez et al., 2018). There is evidence that the various findings and
attributions towards religion may be related to the type of religious involvement that participants
engage in. That is, there may be differences in outcomes based on intrinsic religion (private non-
organized religious involvement) or extrinsic religion (public organized religious involvement).
Religious Involvement
Intrinsic and Extrinsic Religion
Although religious involvement can be defined in a number of ways, in this paper we will
distinguish between the two general forms of religious involvement as intrinsic religion and
extrinsic religion according to psychologist Gordon Allport (1950). Intrinsic religion will refer
to non-organized, private religious practices such as private prayer, meditation and reading
religious materials such as the Bible (Allport, 1950). Extrinsic religion will refer to religious
practices that are organized, such as church attendance, attending a religious retreat or taking part
of a religious group activity (Allport).
Research has shown that significant outcomes have varied depending on whether the
religious involvement was either intrinsic or extrinsic in nature (Aranda, 2008; Elisson, Burdette,
& Hill, 2009). For example, intrinsic religion was not associated with depressive disorder in one
study, (Aranda), nor with anxiety in another study (Elisson, Burdette & Hill), yet was positively
associated with a decrease in hopelessness and depression (Cruz et al., 2009) and an increase in
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 17
functioning over time (Tepper et al., 2001) in other studies. Similarly, extrinsic religion in the
form of church attendance was associated with lower risk of depressive disorder (Aranda, 2008),
higher self-efficacy (Fukui, 2012) and lower depression symptoms for African Americans
(Mouzon et al., 2017). Conversely, extrinsic religion was associated with greater anxiety-PTSD
symptomology for Latinos in a different study (Koenig et al., 2018).
There is a need to continue to investigate and gain a clearer understanding of the role of
religion and religious involvement for persons with a serious mental illness as the benefits have
been documented (Bonelli & Koenig, 2013). It remains a prominent source of coping for persons
with a serious mental illness calling for continued research particularly for persons with
schizophrenia of understudied ethnic minority groups such as Latinos. A recent study of
inpatient adults diagnosed with a psychotic disorder such as schizophrenia or schizoaffective
disorder, found that religious involvement in both forms of intrinsic and extrinsic religion was a
predictor for lower levels of suicidality (Abdel Gawad et al., 2018). Moreover, a study of 63
adults diagnosed with schizophrenia and schizoaffective disorder, found that 91% of the sample
reported engaging in intrinsic religious involvement and almost 70% reported engaging in
extrinsic religious practice (Nolan et al., 2012).
Religion and Latinos
There are numerous studies in the Latino behavioral health literature that have evidenced
the salience of religion associated with the Latino cultural context (Calzada, Fernandez & Cortes,
2010; Comas-Diaz, 2006; Garcia, Ellison, Sunil & Hill, 2013; Guarnaccia, Parka, Deschamps,
Milstein & Argiles, 1992; Hernandez & Barrio, 2015; Hernandez et al., 2019; Organista &
Muñoz, 1996; Yamada et al., 2009). Relative to other family caregivers, Latinos are more likely
to rely on religion for coping (Dilworth-Anderson, Williams & Gibson, 2002; Mausbach, Coon,
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 18
Cardenas, & Thompson, 2003). In one study, a statewide probability sample of 1,504
community-dwelling adults in Texas aged 18 and older found that Latinos who regularly attend
church were more likely to abstain from alcohol and report to never have smoked (Garcia et al.,
2013). In contrast, the study found that Latinos with no religious affiliation showed patterns of
binge drinking and endorsed being current smokers (Garcia et al.). Investigating the role of
religion as a resource for Latinos can no longer be ignored, particularly due to recent findings for
Latinos with schizophrenia and their family caregivers (Hernandez et al., 2019; Pearce, Medoff,
Lawrence & Dixon, 2016; Weisman, Rosales, Kymalainen & Armesto, 2005; Yamada et al.,
2009).
Family Caregivers: Stigma, Biopsychosocial Factors and Gender
Although Latino family caregivers may experience a sense of purpose (Coon et al., 2004)
and fulfillment of God’s will (Weisman et al., 2005), the tolls of caregiving are ever-present
(Hegde, Chakrabarti & Grover, 2019) such as an increase in depression rates (Magana et al.,
2007). One reason for the differences in rates of depression is perceived stigma. Latino family
caregivers have reported experiencing stigma (Hernandez & Barrio, 2015; Rivera-Segarra et al.,
2016), which has been found to be associated with Latino family caregivers’ depressive
symptoms (Magana et al., 2007). Factors specific to Latino family caregivers such as stigma
may compound with lower education levels, which have been found to be associated with an
increase risk of depression and burden (Magana et al., 2007). In addition to lower income,
Latino family caregivers may also face other obstacles such as physical (Gelman, 2010) and
emotional health problems, (Hegde et al., 2019; Hernandez & Barrio, 2015) and adverse social
conditions (Jenkins & Schumacher, 1999). Latino family caregivers may struggle with managing
their own personal health problems such as diabetes, arthritis or cancer (Gelman, 2010).
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 19
Relative to non-caregivers, Latino family caregivers have been found to have lower odds of
receiving preventative care services for their own health problems (Mendez-Luck, Walker &
Luck, 2016).
Noteworthy is that research has found that the caregiver experience may differ by gender
(Friedemann & Buckwalter, 2014) in that women may experience higher levels of burden.
Women may feel added pressure to be caregivers as compared to men who may feel less social
pressure (Campbell, 2010). Factors such as being a female caregiver, a spouse and of low
income (Gelman, 2010) may compound to increase burden (Friedemann & Buckwalter, 2014).
Latino Family Caregiver Values
Nevertheless, Latino family members may experience some rewards from their roles as
caregivers. Latino family caregivers are culturally influenced to provide care in part due to their
strong value of familismo (Scharlach et al., 2006). Researchers have found that Latino family
caregivers have positive associations with caregiving as they relate to family-centered values
(Anthony, Geldhof & Mendez-Luck, 2017; Gelman, 2010; Scharlach et al., 2006) The nature of
the caregiving situation seems to reflect Latino cultural values such as collectivism, religion,
humility, and esteeming la familia (Anthony et al., 2017; Flores, Hinton, Barker, Franz, &
Velasquez, 2009; Gelman, 2010; Scharlach et al., 2006; Weisman et al., 2005). Also, for Latino
female caregivers their caregiving may be reinforced by marianismo, a sense of self-sacrifice for
their loved ones (Arévalo-Flechas, Acton, Escamilla, Bonner & Lewis, 2014). They may also
experience as a sense of meaning (Coon et al., 2004) and comfort (Yamada et al., 2009).
As much as caregiving may be rewarding and tied to their values, Latino family
caregivers are subject to a number of stressors and it is important to identify coping tools that
may support them in their roles. Latino family caregivers have identified religion and spirituality
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 20
as a source of coping, which has helped them accept and better manage their role and
responsibilities (Hernandez & Barrio, 2015). Still, there is a gap in the literature in
understanding their perspectives on how the role of religion and religious involvement may serve
as coping mechanisms. In depth analysis from their unique perspectives is an important next
step.
Providers
It is also important to examine whether participants feel comfortable discussing religion
with their providers. This is critical information for providers, as respecting and supporting a
person's religious journey has been identified as an important component of the Recovery Model
(Lukoff, 2007). Persons diagnosed with a serious mental illness have esteemed religion as an
integral part of their journey towards recovery (Mizock, Millner & Russinova, 2012).
Further, research shows that persons diagnosed with schizophrenia may not disclose their
religious beliefs with providers for the fear of being hospitalized or labeled as having religious
delusions (Huguelet, Mohr, Borras, Gillieron & Brandt, 2006). This may be in part to the
historically opposing viewpoints between psychiatry and religion in that mental health
professionals may have a negative view on the mental health effects of religion (Dein, 2018).
Mental health practitioners may deem religious coping as non-empirical or associated with poor
outcomes for seriously mentally ill patients (Dein).
Moreover, when compared with psychiatrist and psychologists, their patients have been
found to have higher levels of religiosity (Crosby & Bossley, 2012). Providers’ understanding of
participants’ subjective perceptions in discussing religion as a resource may decrease providers’
hesitation to discuss it in treatment. To this end, it is important to examine participants’
subjective perceptions regarding their comfort in discussing religion with providers.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 21

Conceptual Framework
This qualitative secondary data analysis study used Pargament’s conceptual framework of
religion and coping as a theoretical lens. Pargament’s conceptual framework of religion and
coping (Pargament et al., 1990) outlines that (a) religion can be a part of the coping process, (b)
religion can contribute to the coping process, and (c) religion can be a result of the coping
process (Pargament et al.; Phillips, Lakin, & Pargament, 2002).
Pargament’s framework describes that religion can be part of the coping process in the
form of religious activities. For example, engaging in religious activities such as a funeral,
church attendance, meeting with a pastor, participating in a religious ceremony such as a
baptismal or a Bar Mitzvah are examples of how religion can be part of the coping process. The
second component of the framework states that religion can contribute to the coping process.
Next, Pargament et al., (1990) pose that religion can contribute to the coping process. An
example of how religion contributes to the coping process is that a person’s religion may
engender changes in them, such as motivate a them to stop drinking or change a their outlook on
life. Pargament et al. use the example of how more religious persons may be less likely to use
drugs. The third component of Pargament’s framework states that religion can be a result of the
coping process. That is, a person who is not religious may become religious following a
significant life event. For example, a person’s response to a significant life event, such as a birth
of a child or being diagnosed with a terminal illness may be associated with an increase or
decrease in their religious belief.
This conceptual framework allowed for the examination of religion and religious
involvement from many dimensions and angles. Similar studies related to participants of ethnic
minority groups have found Parament's framework applicable and helpful in examining coping
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 22
with stressful life events (Abu-Raiya, Pargament, & Mahoney, 2011; Ahmadi, 2006; Ahmadi,
Erbil, Ahmadi & Cetrez, 2018). The three components of the framework, religion can be part of
the coping process, religion can contribute to the coping process and religion can results from the
coping process guided the interpretation of the findings.
Summary
This qualitative secondary data analysis study seeks to investigate the role of religion and
religious involvement from the distinctive perspective of both consumers and their family
caregivers. The findings of this study will build on previous quantitative findings that religious
involvement was associated with quality of life for Latino consumers and only extrinsic religious
involvement was associated with decreased burden for Latino family caregivers (Gaona et al¸
2019). Although the previous quantitative study provided valuable information regarding the
relationship between religion and quality of life for consumers and religion and burden for
family caregivers, details in respect to the participants’ distinct points of view were not
examined. The current study’s qualitative analytic approach will be helpful in that participants’
self-reported perspectives will serve as fundamental information needed to inform the
development of future studies.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 23

CHAPTER III: METHODS
This study was qualitative in nature and used secondary data from a parent study
(Hernandez & Barrio, 2017). The current study’s research question was both aligned with the
focus of the parent study’s aim and the fit well with data previously collected. The author of this
study found that the parent study’s data would adequately address the research questions
(Johnston, 2017). Additionally, in our case, one of the advantages of using secondary data
analysis was associated with avoiding respondent burden (Szabo & Strang,1997) as consumers
and family caregivers may already be taxed with day to day responsibilities. Moreover, our use
of secondary analysis allows for the maximum use of data without contributing to the demands
of consumers and family caregivers (Szabo & Strang).
Although the author of this study did not participate in primary data collection efforts, as
recommended by Johnston (2017), the author consulted with the researchers of the parent study
to ensure there was a fit between the research question and the data. Further, the author became
well informed with documentation from the original study including published findings and was
involved in a previous study that examined this data set (Hernandez et al., 2019). The author
engaged in continuous consultation with the original researchers throughout the formative to
final stages of the current study.
Parent Study
The parent study data is part of a National Institute of Mental Health R36 (NIMH R36
MH102077) that examined the role of protective factors on outcomes for Latinos with
schizophrenia (Hernandez & Barrio, 2017). The parent study aimed to examine consumer and
family caregiver perceptions of prominent treatment outcomes as well as explore participants’
perceptions of other factors such as hope, family cohesion, religion/spirituality, mental health
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 24
and stigma. The parent study was associated with a previous study, a National Institute of
Mental Health R34 (NIMH R34 MH076087), which was a controlled trial for a multifamily
group intervention developed for Latino families of adults diagnosed with schizophrenia (Barrio
& Yamada, 2010). The previous study consisted of a total of 64 Latino adults diagnosed with
schizophrenia and 64 family caregivers (see Figure 1).
Sample and Data Collection
The aim of the parent study (Hernandez & Barrio, 2017) was to recruit a total of 20
consumer-family caregiver dyads (see Figure 1), from the 64 participants who were a part of the
origin study (Barrio & Yamada, 2010). Purposive sampling methods were used to recruit a final
sample of 14 consumer-family dyads and six additional family members whose relatives with
schizophrenia were not available for the study. The six family members’ relatives were not
available to participate in the study due to school or work schedules, or because they lived in a
board in care or they were unavailable due to their illness.
As such, our current study was of secondary data analysis that examined the qualitative
data from the parent study consisting of semi-structured interviews from the 14 consumers and
20 family caregivers (see able1). The consumers were recipients of mental health services at Los
Angeles County Department of Mental Health Clinics. The DSM IV was used to establish
diagnosis of a schizophrenia spectrum disorder for participants 18 years or older. Participants
with a substance use disorder were excluded from the study.
A semi-structured interview guide that inquired about the role of religion with open-
ended questions regarding participants’ religious involvement was used (see Appendix). Our
analysis also included a question regarding participants’ comfort in discussing religion with their
providers. Although the primary aim of the study was to examine the role of religion and
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 25
religious involvement, the researcher deemed this question as relevant to this study as it would
provide important information regarding implications for the role of religion in social work
practice.
The open-ended questions allowed the participants the flexibility to expand on their
answer to the questions. Trained bilingual, bicultural researchers collected the data at the
location preferred by the participant. The majority of the interviews, 32, were conducted at the
participants’ homes and two were conducted at the University associated with study. The study
was approved by the University’s IRB.
Data Analysis
This secondary data analysis study of qualitative interviews used thematic analysis
(Gibbs, 2007; Gibson & Brown, 2011; Harding, 2013) as the primary method in which the data
was analyzed. Second, the constant comparative approach, a method used in grounded theory
(Cho & Lee, 2014; Glaser & Strauss, 1967; Strauss & Corbin 1990) was utilized to compare the
coded transcripts between and across transcripts of consumer and family caregivers.
Thematic analysis was chosen as the primary method as this approach allowed the
researchers to be guided by the aims of the study (Gibson & Brown, 2011; Harding, 2013).
Thematic analysis has been used in similar studies with this data set by the original researchers
(Hernandez et al., 2019). The use of thematic analysis allowed for an examination of the
similarities and differences between the codes in the data as well as an examination of
relationships between the codes, categories and themes (Gibson & Brown, 2011). The
relationship between the themes and interpretation of the study findings were guided by
Pargament’s conceptual framework (1990).
Although this study was guided by Pargament’s conceptual framework (1990), given it
was exploratory in nature it included the use of the constant comparative approach, an approach
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 26
established in grounded theory, in which findings in one transcript are compared to the findings
across other transcripts (Chapman, Hadfield, & Chapman, 2015; Gibbs, 2012). This approach
has been used in similar qualitative exploratory studies conducted with a larger sample, from
which the current study sample participants were recruited (Hernandez & Barrio, 2015).
The co-coders continuously categorized the data and findings in one transcript and
compared the findings across other transcripts (Chapman, Hadfield, & Chapman, 2015; Gibbs,
2012). The constant comparative method allowed for a deeper examination of the role of religion
and religious involvement between and across consumers and family caregivers as the
similarities and differences between the transcripts were compared (Chapman et al; Gibbs).
The use of a co-coder and peer debriefing was used to increase validity of the study
findings (Creswell, 2014. Both coders were bilingual, bicultural with previous experience in
qualitative data analysis methods. As a result, the coders were able to read and analyze the raw
transcripts in the native language of the participants (either English or Spanish). Both co-coders
had extensive of practice experience with Latinos diagnosed with schizophrenia and family
caregivers, which facilitated the analytic process.
Using thematic analysis, the co-coders first cleaned and organized the data, then read the
raw data and documented ideas and preliminary codes (Bazeley, 2013; Gibson & Brown, 2011;
Harding, 2018; Saldaña, 2009). The co-coders then met to debrief on initial reading of the data
and established agreement of preliminarily codes. Following the development of the preliminary
codes the co-coders coded three transcripts independently, and then reconvened to compare
codes and establish co-coder agreement. The coders were in agreement with 80-90% of the
codes from the first three transcripts. The codes that the coders disagreed on were discussed
until the coders reached consensus (Ryan, 1999). Upon consensus, the co-coders developed the
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 27
codebook and conducted open coding (Bazeley, 2013; Harding, 2018; Saldaña, 2009) as well as
the constant comparative approach (Chapman, Hadfield & Chapman, 2015; Gibbs, 2012;
Harding, 2018;) to compare differences and similarities within and across consumer and family
caregiver transcripts (Cornish, Gillespie & Zittoun, 2013; Denzin & Lincoln, 2008).
After large subsets of transcripts were coded, the co-coders convened to compare codes.
The co-coders once again compared codes and found to be in agreement in which the codes were
applied to the same text 90% of the time. The coders discussed 10% of the codes that were not
in agreement until consensus was reached. The coders again applied the constant comparative
method in which they compared findings from the coded transcripts within and across consumer
and family caregiver transcripts (Chapman, Hadfield & Chapman, 2015). Upon completion of
coding all transcripts, the researchers compared findings from transcripts within and across
consumer and family transcripts and combined the codes to create categories and themes
(Bazeley, 2013; Cornish, Gillespie & Zittoun, 2013; Denzin & Lincoln, 2008; Ryan, 1999).
The co-coders confirmed that saturation was reached (Chapman, Hadfield, & Chapman, 2015;
Gibbs, 2012; Glaser & Strauss, 1967;) in that no additional themes related to the research aims
were salient from the data.
The final step entailed an interpretation of the findings by means of the application of
theory and existing literature. To help ensure qualitative reliability, the transcripts were
examined for errors, detailed notes of data analysis procedures were recorded, a codebook was
developed upon co-coder agreement and there was continuous comparison of the data and codes
between coders (Creswell, 2014, p. 203; Ryan, 1999). The computer software, NVivo version 12
was used to organize and analyze the data.

AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 28

CHAPTER IV: RESULTS
The study aimed to explore the role of religion and religious involvement for consumers
and family caregivers. First we will discuss how the data revealed that the role of religion was
prominent for both consumers and family caregivers. The majority of participants highly valued
religion and sought religion as the first order of mental health treatment. Second, guided by
Pargament’s conceptual framework of religious coping, we will discuss the following thematic
results, a) religion was part of the coping process, b) religion contributed to the coping process,
and c) religion was a result of the coping process (Pargament et al., 1990) as indicated in Table
2. Although not related to the Pargament’s conceptual framework, the data revealed an
additional theme, the participants’ value of religious freedom. This theme may be associated
with the participants’ culture. Lastly, the study’s examination of participants’ comfort in
discussing religion with providers will be discussed.
The Prominent Role of Religion
Our study inquired what role religion played in the participants’ lives. The data revealed
that the role of religion was prominent in the lives of the participants. The prominence of religion
was salient for both consumers and family caregivers. Participants emphasized how their faith
and belief in God was very important and their first source of healing and support. For example,
one consumer stated, “…Believing in God is the only thing! Believing in God is the only thing
that sustains one.” Likewise, a family member underscored “…The first doctor is God. If we
do no ask God, he will not heal us. I ask him, then I go to the doctor” and also, “…after God,
then medication.” Overall, both consumers and family members agreed that their religion served
as a fundamental resource and their first resource when seeking help.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 29

Thematic Results Guided by Pargament’s Conceptual Framework
Religion as Part of the Coping Process
Intrinsic religious involvement. As indicated in Table 2, the theme, religion as part of
the coping process revealed two subthemes, intrinsic and extrinsic religion. Table 3 illustrates
that both consumers and family caregivers described participating in intrinsic and extrinsic
religious involvement as part of the coping process as it related to the consumer’s mental illness.
Intrinsic religious activities that both consumers and family caregivers endorsed included prayer,
watching church services on television, praying the rosary and reading the bible. Prayer revealed
to be one of the leading forms of intrinsic religious activities for both consumers and family
caregivers. In regards to prayer, one consumer shared, “It does help to feel relief” and another
shared “I do say my prayers and stuff, so it makes me feel better about myself. A whole lot
better”. A family member shared how prayer helped her find a mental health clinic for her son,
“I was desperate…I told my son, I'm going to pray that God will guide us to where I am
supposed to take you…with so much faith I prayed. Then I finished praying, picked up the
telephone and called the third number on the list and that was it. Thanks be to God.”
For both consumers and family caregivers, prayer was attributed as a helpful resource and
with positive feelings such as relief and hope. Religious involvement differed by consumer and
family member. For example, consumers but not family caregivers endorsed the intrinsic
religious involvement of meditation. On the other hand, family caregivers but not consumers
endorsed praying to the Virgin Mary and to Catholic saints. One family member shared, “I pray
to my saints and I also pray to God.”
Extrinsic religious involvement. For both consumers and family caregivers church
attendance was the most widely endorsed form of extrinsic religious involvement (Table 3).
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 30
Church attendance was attributed to a number of positive factors such as helping to deal with the
mental illness, increased motivation, a sense of social support and community, a decrease in
loneliness and helping them to keep going.
In regards to church attendance, a family member shared,
“It gives one more motivation in life. Gives more motivation in life and the necessity to
find God because everyone at one point feels alone and when we feel alone is when you
need to look for God.”
Consultation with pastors and participating in prayer groups at church were also
associated with positive factors of support and helpfulness. For example, one family member
stated, “it is helpful when the pastor tells me, ‘be patient, he is your son, you cannot abandon
him, you cannot just throw him out’ like that…it makes me feel better.” As noted in Table 3,
consumers and not family caregivers endorsed participating in religious community groups.
Conversely, family caregivers and not consumers endorsed attending religious retreats
Religion Contributes to the Coping Process
The subthemes associated with the theme that religion contributed to the coping process
were that it helped participants cope with the mental illness and it engendered thankfulness and
praise towards God (Table 4).
Religion helps to cope with mental illness. Participants shared that religion helped
them to cope with the mental illness by increasing hope, offering guidance and increasing
motivation (Table 4). For example, a consumer stated, “When talking to God from my inner self,
just me with God and asking, 'God, help me to understand what is happening', He helps me
understand the reality of what is happening.” One family caregiver stated…“I tell all of my
problems to God and yes, He helps me and yes, He provides me with answers and I am thankful
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 31
to Him…because I was also beginning to feel depressed.” Likewise, a different family member
shared, “….God listens to me. Knowing that God is listening to me, if I speak to God and ask
him for help, He helps me.”
The data revealed that only consumers reported that religion contributed to their coping
with symptoms of schizophrenia. One consumer reported, “…There are things that through
meditation I can take, I could endure more of the symptoms easier.”
Religion contributed to the coping of family caregivers as they reported that they
experienced a greater sense of wellbeing as a result of their religion. For example, a family
stated, “…I find a peace in speaking with other church members…” Similarly, another family
member reported, “…it is like a renewed strength, I go [to church] feeling heavy burdened and
when I leave I feel better.”
Credit, thankfulness and praise towards God. Religion contributed to the coping
process for both consumers and family caregivers in that they credited God for answered prayers
and experienced a sense of thankfulness and expressed praise towards God. In this subtheme,
participants reported credit, thankfulness and praise towards God for numerous positive
outcomes. For example, both consumers and family caregivers praised God for answered
prayers related to improvement of the consumer’s mental illness. Still, consumers shared more
general credit for positive aspects of life compared to family caregivers. For instance, one
consumer shared, “I do take the Man seriously, he gives me, I go to sleep, I wake up. He gives me
another day to, you know to appreciate.”
Family caregivers differed from consumers in that they appeared to identify specific
events from their environments as answered prayers. The events were related to their loved
one’s health and they credited and praised God for them. One example is when a family
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 32
caregiver reported credit and praise towards God after her son agreed to get a haircut. She
reported praying for her son to cut his hair as he was disheveled and was recently discharged
from a psychiatric hospital. The family caregiver shared that at discharge from the hospital her
son refused to cut his hair, however her prayers were soon answered. The family member
shared, “…And I said, ‘thank you God that you are giving me these opportunities with him’, and
he left. Yes, he got a hair cut.” Another family member credited God for answering her prayers
that her son would find mental health care.
She stated, “…I asked God a lot that God would open a door for my soon to receive help.
I asked God a lot, a lot. I would say, ‘Blessed God…if you are all powerful, why don’t
you open the door for a place where he can receive help?’.”
Similarly, another family member credited, thanked and praised God for her son’s recovery
“…there were times when I felt, and it’s not that I am negative, but since he looked ill, I believed
my son would not be able to recuperate, but thanks be to God, yes.”
Religion as a Result of the Coping Process
The last theme guided by Pargament’s conceptual framework, religion as a result of the
coping process was associated with the subthemes, participant increase in religion after the
mental illness or a decrease in religious belief after the mental illness for some consumers (Table
5). Overall, there appeared a dominant subtheme of increase in religion after the consumer’s
mental illness. A family member stated, “Now it is completely different, I wake up, I pray to
God our Father for all things…it has helped us to be better with our sons, our grandson’s and
with my husband’s mental illness.” One consumer shared his reliance on faith to cope with his
diagnosis, “It makes me feel that I can get through this with religion.” Similarly, a family
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 33
member shared a change in how she has relied more heavily on church members for support,
“…it helps…before I did not want anyone to know what my life was like.”
However, a few consumers reported that they had experienced a decrease in religion after
their mental illness. For example, one consumer shared,
“Before it was more sugar coated, more like westernized kinda like it’s all positive and
when I got sick, I said ‘no’, there’s…there’s always going to be the bad thing or the
negative. So that happened to me, so then I thought I kinda have a more balance view of
it. I know a lot of people think that’s it about being good and stuff, but I think there’s bad
too in spirituality. That’s how it is, it’s a fact of life. For me, at least. So now, I have a
balanced view. Like, I think I’m more careful now like what I get involved like what they
label spirituality. I’m not as easy fooled...”
Similarly, another consumer shared that he used to be religious, yet his religious
involvement has decreased over the years,
“…to church my mom and I would go... but now I don’t know. I’m not too big on church
now you could say. I met some great people, they are very good people, but I kind of do
my thing now...at church I was mostly bored. Sometimes I would find hope in it and other
times I saw bad things in it, like how they saw unfavorable on other people…”
Conversely, another consumer shared that he used to attend church and plans to re-engage in
religious involvement,
“…I have participated in the past. It has been a long time since I have gone [to
church]…maybe I am afraid of something because I don't go but hopefully God willing I
will start going again…that helps a lot sometimes.”

AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 34
Religious Freedom
The data revealed an additional theme, the value of religious freedom that did not appear
to be associated with Pargament’s conceptual framework. Our analysis found that consumers
and family caregivers both shared and exercised the value of religious freedom. Participants
reported that they respected an individual’s freedom of choice in regards to religion and religious
practice. For example, one consumer explained that he saw nothing wrong with the differences
in religious practices between Christians and Catholics,
“…I believe that Christians have a lot of faith in God, even though they don't believe in
the Virgin Mary and they set her aside; they only believe in God, but I think they have
helped people…God gives them miracles because they believe in God and I don't think
that there is anything wrong with that...”
Similarly, family caregivers expressed the sentiment of taking a nonjudgmental stance
towards religious freedom. One family member shared her discussion with someone who was
encouraging her to just pray to God and not saints, “…They told me, ‘you have to ask God
directly’…and I said, ‘yes, I ask God, but I also ask my saints…I am very sorry’, I said, ‘You do
things your way and I will do them my way’.” Further, some family caregivers shared that
although their religious involvement may differ from the consumers, they did not discourage or
encourage the consumer to adhere to their point of view, but rather supported the consumer’s
preferences and right to religious freedom. For example, one family member, whose mother is
the consumer expressed,
“…I know my mom is way, way much more religious than I am…much more spiritual
than I. I try to take that into consideration and also try to foster a spiritual connection
between mother and daughter…so that I also care for her spirituality, to be honest. To
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 35
care for how she feels within. And so on Sundays I tell her, come on mom, church. I
record it just in case we miss it because we are doing something else”
Similarly, another family member shared, “…only one [of my children] accompanies me to
church but all of them know and have some type of knowledge but it is personal and no one is
forced to come, simply if they want to.”
Discussing Religion with Providers
The interview question that inquired about whether participants felt comfortable
discussing religion with their providers indicated that indeed consumers and family caregivers
felt comfortable speaking with providers about their religion. The participants reported that
religion has never been discussed with their providers. Nonetheless, they agreed that they
would feel comfortable speaking with providers if providers asked them about their religion.
One consumer reported,
“…I never talk to my doctor, the doctor about it too much. But with my family, with my
mom and dad and everything. With my mom I do, I kind open up a little bit. I go to
church and come back and tell her about it.”
Another consumer shared, “… in their daily work it’s all secular, so it’s like,
the missing component is always the spiritual aspect. I know maybe they’re not supposed
to talk about their religious point of view, but I think when they are open about that, you
feel comfortable. Oh, I feel comfortable.”
Similarly, when a family member was asked if they thought their loved one would feel
comfortable speaking about religion with their provider, they responded,
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 36
“Of course! With all liberty! Of course he would feel comfortable. I think yes. To this
day he hasn’t been asked by the doctor anything about his religion…with his doctor no,
but I do hear him speak about his religion.”
In general, one family member’s response appeared to be a common theme for all participants,
“I feel comfortable. I don’t see why not.”
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 37

CHAPTER V: DISCUSSION
This qualitative secondary data analysis study aimed at examining the role of religion and
religious involvement for consumers and family caregivers. The majority of findings in our
study demonstrate support for the applicability of Pargament’s conceptual framework of religion
and coping as a lens for examining the role of religion and religious involvement for Latinos
diagnosed with schizophrenia and their family caregivers.
First, our study indicated that the role of religion was prominent for both consumers and
family caregivers. Next, the data revealed salient themes and subthemes that were appropriately
associated with Pargament’s conceptual framework that religion is a part of, contributes to and is
a result of the coping process (Table 2). However, the data revealed one salient finding, the
value of religions freedom, which may be explained by the participants’ culture. Finally, our
inquiry to whether participants felt comfortable discussing religion with providers indicated that
they would.
The Prominent Role of Religion
Similar to previous studies, our inquiry regarding the role of religion in participants’ lives
showed that religion was prominent for both consumers (Abdel Gawad et al., 2018; Huguelet et
al., 2016; Mohr et al., 2012; Nolan et al., 2012) and family caregivers (Gelman et al., 2010;
Hernandez et al., 2019; Rivera-Segarra, Fernández, Camacho-Acevedo, Ortiz & López-
Robledo). In a recent study, consisting of a diverse sample of persons diagnosed with
schizophrenia (Abdel Gawad et al., 2018) found that 58% of the sample, endorsed high
religiosity. Consistent with a recent review on religion and as it relates to persons diagnosed
with schizophrenia, Grover, Davuluri and Chakrabarti (2014) note that the role of religion and
spirituality appears to be associated with purpose, meaning and hope.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 38
Noteworthy is that leaning on religion appeared to be the first source of support for the
treatment of schizophrenia. It appeared as though religion was sought as the first line of help for
dealing with the mental illness. Similarly, research has shown that consumers and Latino family
caregivers have indicated seeking healing for the mental illness by means of culturally relevant
and familiar resources (Moreno & Cardemil, 2013) such as doctors in Mexico or experimenting
with herbal remedies (Yamada et al., 2009). More research is needed in this area in an effort to
gain a better understanding of the pathways to care for consumers and family caregivers.
Thematic Results Guided by Pargament’s Conceptual Framework
Religion as a Part of the Coping Process
Results indicated that for both consumers and family caregivers prayer and church
attendance appeared to be the most widely endorsed type of religious involvement. One recent
similar study examined religion and spirituality for an ethnically diverse sample of young adults
with a severe mental illness and found that prayer was the most common coping strategy used by
the consumers (Oxhandler, Narendorf & Moffatt, 2018). Further, prayer was reported as a
fundamental resource in helping them to overcome challenging times. Similarly, consumers
shared that they have experienced direct intervention from God in the form of healing, physical
help or guidance.
Similar to results of other studies (Koerner, Shirai & Pedroza, 2013), Latino family
caregivers endorsed engaging in a variety of both intrinsic and extrinsic religious activities such
as private prayer, reading the Bible, and church attendance. Interestingly, both consumers and
family caregivers endorsed watching church services on television. Watching church services on
television may help consumers who experience severe symptomology and/or have been deemed
unable to drive themselves or freely travel outside of the home alone an opportunity to
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 39
participate in an activity they may esteem as important. It may also be a particularly helpful
resource for caregivers who have a challenging time managing the demands of caregiving.
Interestingly, there were slight differences in religious involvement between consumers and
family caregivers. Consumers but not family caregivers reported involvement in activities such
as meditation and participating in religious community groups. Conversely, family caregivers
but not consumers endorsed praying to the Virgin Mary, Saints and attending church retreats.
These slight differences in religious involvement may highlight acculturation differences as
family caregivers had an older mean age of 59 relative to consumers’ average age of 38. This is
helpful information as it relates to the importance of keeping acculturation in mind when
developing treatment plans for participants. Further, religiously or spiritually infused mental
health interventions should consider the manner in which their intervention is being infused as
the acculturation level of the participant may play a role in their desire to engage in the activity.
Another suggestion is that perhaps the differences in religious involvement may have been
related to gender. Similar to other studies regarding Latino family caregivers (Koerner, Shirai &
Pedroza, 2013), our sample, consisted of primarily female family caregivers. Given our study
was exploratory, there is a continued need to examine if there are any patterns of religious
involvement for these populations based on factors such as gender.
Religion Contributes to the Coping Process
Religion helps to cope with the mental illness. Both consumers and caregivers shared
that religion and religious involvement contributed to their ability to cope with the mental illness.
These findings are similar to established literature that documents the strengths associated with
religion for persons with schizophrenia (Abdel Gawad et al., 2018) and for their family
caregivers (Hernandez et al., 2019; Weisman, et al., 2005). The participants’ responses were in
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 40
alignment with Pargament’s conceptual framework in that religion appeared to contribute and aid
the coping process for example with increased hope or motivation, as was identified by our
sample.
Our findings mirror the findings of previous studies in which Latino family caregivers
identified their religion as a source of hope (Hernandez et al., 2019), guidance and as being
helpful to their well being (Koerner et al, 2013). Unlike other studies (Herrera et al., 2009) our
data did not reveal themes of maladaptive religious coping such as negative coping. Negative
religious coping has been associated with significantly predicting depression for Latino family
caregivers (Herrera et al., 2019). Similar to findings in other studies (Koerner, Shirai & Pedroza,
2013), none of the family caregivers associated caregiving as a punishment from God, which is a
form of negative religious coping (O'Brien et al., 2018; Park, Holt, Le, Christie & Williams,
2018). Future studies should consider mixed methods designs that capture the use of negative
and positive religious coping.
Credit, thankfulness and praise towards God. Findings indicated that religion
contributed to the coping process by engendering thanksgiving and praise for answered prayers.
The data revealed that both consumers and family caregivers credited God for answered prayers
and freely expressed thankfulness and praise towards God. This thanksgiving and praise may
contribute to the coping process by engendering hope and resilience for participants who may be
struggling to cope with the mental illness.
It seemed as though evidence from an event in the environment appeared to engender a
perception of an answered prayer, which in turn generated praise towards God (Figure 2). In
turn, praise towards God was associated with a greater belief in their religion. Notably,
consumers appeared to give thanks and praise to God for more general blessings, such as being
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 41
thankful for another day. Family caregivers were highly specific in their examples of reasons
why they gave praise to God. Perhaps family caregivers are more mindful of specific prayer
requests that they have made in regards to caring for their loved one. According to a study by
Rob Whitley (2011) thanksgiving towards God may also be a reflection of an individual’s
matured relationship with God in which they recognize God’s grace in their life.
Research also shows that there is an increase in faith over the life course (Hayward &
Krause, 2013). Perhaps this maturity in faith is related to family caregivers’ ability to identify
specific prayer requests that were answered. Hayward and Krause (2013) found that there is
change in the content of prayer with age as there appears to be more trust based prayers in that
individuals believe in waiting patiently for God’s will do be done. Further, the authors found
that there is an increase in the diverse content of prayers over the life course (Hayward &
Krause, 2013). This may be associated with our findings in that consumers, who were on
average, younger in age, reported thankfulness for more general blessings as opposed to family
caregivers.
Interestingly, research shows that there is some evidence in the types of prayers by ethnic
group. Krause et al. (2004) found that African Americans are more likely to trust in God’s will
regarding their prayer request compared to European Americans. Although these findings may
differ for Latinos, it is interesting to consider that there may be differences based on ethnic
group, especially for Latino family caregivers. Research also shows that trust based prayers, in
which the person prays in trusting in God’s will for the outcome, are also related to higher self-
esteem (Krause et al., 2004). Future research should examine the role of trust-based prayers as
they may relate to level of burden for Latino family caregivers.

AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 42
Religion as a Result of the Coping Process
Our data revealed that for some participants their religious beliefs were altered in that
they increased or decreased after their mental illness. Consumers and family caregivers both
endorsed an increase in their religion, faith and activities such as watching church via television
since the mental illness. Further, a few family caregivers reported being non-practicing to
becoming practicing after their ill relative’s diagnosis. However, the data did not reveal this
pattern for consumers. Some consumers reported a decrease in religious involvement after their
initial diagnosis, however none of the consumers reported that their illness was negatively
attributed to religion, for example, that it was a punishment from God.
Consistent with previous findings (Oxhandler, Narendorf, & Moffatt, 2018), although
some consumers expressed a decrease in religious involvement, they also expressed some
positive attributes of religion such as that there were some good people at church or that religion
was helpful for some. They appeared to have a dialectical, balanced view in which they
acknowledged both positive and negative aspects of religion. This may be associated with the
theme of valuing religious freedom.
Religious Freedom
Our study revealed a theme of the value of religious freedom, which was not associated
with Pargament’s conceptual framework. Our indication is that this theme is associated with the
participants’ culture. Both consumers and family caregivers adhered to the value of religious
freedom in which they were supportive of the choices of religious freedom of every individual.
They appeared to hold a dialectical, nonjudgmental view regarding the religion and religious
involvement of others.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 43
Our findings differed from results by Chan and Ho (2017) who examined the
discrepancies in religion and spirituality between Chinese consumers diagnosed with
schizophrenia and their family caregivers. For example, in our sample of Latino participants, of
majority Mexican-American descent, there appeared to be support of religious differences
between consumer and family caregiver. On the contrary, Chan and Ho (2017) found that
discrepancy in the religious and spiritual beliefs between the Chinese consumers and their family
caregivers was often a source of strain on their relationship. The researchers found that family
caregivers assumed their loved ones shared their same religious and spiritual beliefs and thus, at
times, overlooked the consumer’s unique needs. The study also found that consumers were
aware of the divergent beliefs yet often compromised their beliefs to adhere to the caregivers’
beliefs (Chan & Ho, 2017).
Perhaps our findings highlight the cultural dynamic of familismo, associated with tightly
woven relationships in which the values of humility, collectivism and an esteem for la familia is
exercised (Anthony, Geldhof & Mendez-Luck, 2017; Flores, Hinton, Barker, Franz, &
Velasquez, 2009; Scharlach et al., 2006). As such, among our sample, despite diverging
religious beliefs between Latino consumers and family caregivers, support and collectivism was
exercised in the form of support of religious freedom. In our sample of Latino participants, the
value of familismo may overshadow divergent religious beliefs, as it may be more important to
maintain cohesive support of each individual member of the family unit.
The value of religious freedom as it may be associated with familismo and family
cohesion may be identified as strength for Latino consumers and family caregivers. One study
examining ethnicity, family cohesion and religiosity among persons diagnosed with
schizophrenia and their family caregivers (Weisman, Rosales, Kymalainen & Armesto, 2005)
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 44
found that the perception of one’s family as being unified and cohesive was associated with
greater emotional well-being for consumers and Latino and African American family caregivers,
but not for European Americans. Nevertheless, given our study is exploratory, it is important to
be mindful of dynamics between Latino consumers and family caregivers as it relates to religious
freedom in an effort to support a positive consumer-family caregiver dyadic relationship.
Discussing Religion with Providers
Results indicated that both consumers and family caregivers reported that they had never
discussed religion with a provider. One consumer shared that this may be due in part because of
the secular nature of a providers work. The consumer shared how this is a missing component
in regards to services provided. Participants agreed that they would feel comfortable and would
welcome a dialogue regarding religion as a resource if asked by a provider. In line with previous
studies, one study found that patients diagnosed with schizophrenia had a high interest in
discussing religion and spirituality with their providers (Huguelet et al., 2011). However,
providers reported only moderate interest in discussing religion and spiritually, despite
acknowledging that religion may be important to the patient (Huguelet et al., 2011).
Another recent study examined attrition rate of an intervention that had a spiritually
infused component for family caregivers for a relative with schizophrenia (Gurak, Weisman de
Mamani, & Ironson, 2017). Interestingly, researchers found that greater religiosity was
associated with attending less therapy treatment sessions (Gurak et al., 2017). The authors
suggest that this may have been due to the “religiosity gap” theory (Crosby & Bossley, 2012)
which states that participants may believe that there is a gap in belief systems between them and
their providers, thus may have reservations about treatment. The authors note that the majority
of the family caregivers with greater religiosity dropped out of the intervention before the
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 45
spiritually infused module was introduced. The authors suggest that perhaps the caregivers were
also receiving a great amount of support from their religious affiliations. This emphasizes the
importance of providers being open to discussions with their patients about their patients’ beliefs
regarding the role of religion.
Implications and Future Directions
This study examined the role of religion and religious involvement for consumers and
family caregivers and has shed light on evidence that may inform future studies on this
understudied culturally relevant resource. The study findings build on recent quantitative
research findings by providing the self-perceptions of religion and religious involvement as
reported by consumers and family members. In practice, study results may provide practitioners
with awareness of the prominence of religion as reported by participants. This coupled with
findings that participants are open to discussing religion as a resource with their providers may
inform providers of the importance of exploring religion with consumers and family caregivers.
Further, findings shed light on the different type of religious activities that consumers and
family members engage in. This is helpful as it informs providers of culturally relevant religious
activities that participants favor and can help shape psychosocial treatment plan development.
Practitioners may also find the results helpful for psychoeducation both consumers and family
caregivers. For providers, the results may also highlight that participants generally reported
comfort in discussing religion with them.
Limitations
Some of the limitations of our study are associated with the fact that it is a secondary
analysis study. Limitations include the lack of control from how the data was collected and
whether the sample size is adequate so that saturation may occur (Szabo & Strang, 1997).
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 46
However, a minimum number of participants required for qualitative data analysis has been said
to depend on the study design (Creswell, 2013). In a study of similar design, Guest, Bunce, and
Johnson (2006) sampled 60 participants and found that saturation began occurring after
analyzing 12 interviews. As it was in our study, the authors suggest that if purposive sampling is
used, a homogenous sample is obtained and semi-structured interviews are conducted, saturation
is highly probable at 12 interviews. Malterud (2001) suggests that 15 interviews of a
homogenous sample collected via purposive sampling may suffice. Another limitation is that our
study is a retrospective, cross sectional study and we do not examine data of a comparison group
of consumers or caregivers. Finally, the data in our sample consisted of primarily Spanish-
speaking Catholic participants of Mexican origin. Therefore, the findings may not generalize to
Latinos of other religions or geographic areas.
Conclusion
This qualitative secondary data analysis study sought to examine the role of religion and
religious involvement for Latino consumers diagnosed with schizophrenia and family caregivers.
The findings of this study highlight the prominent role of religion for both consumers diagnosed
with schizophrenia and their family caregivers in that religion appeared to be the participants’
first order in seeking treatment for the mental illness. Our study found that Pargament’s
religious coping framework was adequate in its applicability towards examining our findings.
Results illustrated that both consumers and family caregivers engage in a variety of forms of
religious involvement with prayer and church attendance being leading forms of engagement.
The data revealed slight differences in religious involvement between consumers and family
caregivers.
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 47
Results indicated religion contributing to the coping process in that it was associated with hope,
guidance and motivation. Further, participants experienced thankfulness and expressed praise
towards God for answered prayers. Additional findings included participants’ value of religious
freedom. Lastly, participants shared that they felt comfortable discussing religion with their
providers. Future studies may examine the role of religion for Latinos of different religions and
Latino sub-groups. Literature regarding the role of religion and religious involvement for
Latinos diagnosed with schizophrenia and family caregivers is lacking. Thi qualitative
secondary data analysis study is foundational for future research in this important area.

AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 48
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AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 61
Table 1.
Demographic Profile of Study Sample
Consumer (N=14) Range Family Caregiver (N=20) Range
Age M(SD) 38(12.00) 26-75 59(8.48) 39-72
Gender, n (%)
Male

11(79)

4(20)

Female 3(21) 16(80)
Length of illness
a
16.38 (11.72) 7-50
Family Caregiver Relation, n (%)
Mother 12(60)
Father 3(15)
Spouse 2(10)
Other
b
3(15)
Religious preference
c
, n (%)
Catholic 9(64) 16(80)
Christian 1(5)
Pentecostal 2(14) 2(10)
Jehovah Witness 1(5)
Country of birth, n (%)
United States 8(57) 1(5)
Mexico 4(29) 18(90)
El Salvador (14) 1(5)
Interview language, n (%)
English 8(57) 2(10)
Spanish 6(43) 18(90)
Note.
a
Length of illness in years;
b
Aunt, daughter or grandmother;
c
Religious preference is
missing for three participants
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 62

Table 2.
Thematic Results Guided by Pargament’s Conceptual Framework
Themes Subthemes
Religion as Part of the Coping Process

Intrinsic Religion

Extrinsic Religion

Religion Contributes to the Coping
Process
Religion helps to cope with the mental illness

Credit and Praise Towards God

Religion as a Result of the Coping
Process
Overall participant increase in religion after
mental illness

Decrease in religion for some consumers after
the mental illness
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 63
Table 3.
Religion as Part of the Coping Process
Variables Consumer
Family
Member
Attributed to Religion
Intrinsic Religious Involvement
Prayer Yes Yes Helpful, relief, hope
TV Church service Yes Yes Helpful, peace, feels
nourished by God’s
word
Meditation Yes No Helps with symptoms
Rosary Yes Yes Helpful
Pray to Virgin Mary No Yes
Pray to Saints No Yes
Read Bible Yes Yes
Extrinsic Religious Involvement
Attend church Yes Yes Helps with mental
illness, increased
motivation, social
support, sense of
community, decrease
loneliness, helps to keep
going
Attend religious community groups Yes No Social support, helpful
Attend church with family Yes Yes Support
Consult with pastor at church Yes Yes Helpful
Attend prayer group at church Yes Yes
Attend church retreat No Yes

AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 64

Table 4.
Religion Contributes to the Coping Process
Consumer Family Member
Religion helps to cope with the mental illness
Increases hope Yes Yes
Offers guidance Yes Yes
Increases sense of motivation Yes Yes
Helps with symptoms of schizophrenia Yes No
Helps with caregiver wellbeing No Yes
Credit, thanksgiving and praise towards God Yes Yes
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 65

Table 5.
Religion as a Result of the Coping Process
Variable Consumer Family Member
Increase in religion after diagnosis of schizophrenia Yes Yes
Religious faith has increased Yes Yes
Increase in church attendance via television Yes Yes
Non-practicing, but increased practice after illness No Yes
Decrease in religious belief since diagnosis Yes No
Decrease in religious involvement since diagnosis Yes No
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 66

Figure 1. Flow Chart of Parent and Current Study Sample
a
National Institute of Mental Health R34 MH076087 (Barrio & Yamada, 2010)

b
National Institute of Mental Health R36 MH102077 (Hernandez & Barrio, 2017)
Origin Study
a
Sample
64 Consumers &
64 Family Caregivers
Parent Study
b
Sample Goal
20 Consumers &
20 Family Caregivers
Parent
b
and Current Study Final
Sample
N= 34
14 Consumers &
20 Family Caregivers

6 Consumers were not
available to participate
due to work, school,
living in a board in care or
feeling ill
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 67

Figure 2. Latino Family Caregiver Praise Towards God Model
Belief in
Religion
AN EXPLORATORY STUDY OF THE ROLE OF RELIGION 68

APPENDIX: Interview Guide Questions
What role does religion/spirituality have in your life?
Have you noticed any changes in your level of religion/spirituality over your lifetime? Stayed
the same? If so, what do you attribute that change?
Does it influence your view of mental illness? Can you tell me how?
Has it influenced your view of treatment? Can you tell me how?
Do you feel comfortable talking about your R/S with your doctor, case manager, or therapist?

Abstract (if available)

Abstract Schizophrenia is a debilitating mental illness associated with numerous individual and societal costs. It is important to examine resources for Latinos diagnosed with schizophrenia, often identified as a vulnerable population, more likely to experience stressors associated with issues such as acculturation, low socioeconomic status, low education, and multiple barriers to accessing care, yet are also an understudied population. Family caregivers, many living with the family member, may experience heavy caregiving burden and psychological distress. Although many Latinos diagnosed with schizophrenia and their family caregivers identify religion as a helpful resource, there is little research that examines this in-depth. This qualitative secondary data analysis study explored the role of religion and religious involvement from the perspectives of 14 Latinos diagnosed with schizophrenia and 20 family caregivers. Transcripts of 34 interviews were analyzed using thematic analysis and a constant comparative method. Findings generally aligned with Pargament’s theory which asserts that religion may be experienced as a part of the coping process, as contributing to the coping process and as a result of the coping process. The role of religion was prominent for many participants, appearing to help them cope with mental illness by increasing hope, offering guidance and increasing motivation. There were only slight differences in the types of religious activities in which consumers and family caregivers were actively engaged. After the onset of schizophrenia there appeared to be a change in some participants’ religious beliefs and involvement

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Asset Metadata

Creator Gaona, Lizbeth (author)

Core Title An exploratory study of the role of religion and religious involvement among Latinos with schizophrenia and family caregivers

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 04/30/2019

Defense Date 03/18/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag caregiver,Family,Latino,Latinx,OAI-PMH Harvest,Religion,schizophrenia,serious mental illness

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Barrio, Concepcion (committee chair), Yamada, Ann Marie (committee chair), Baezconde-Garbanati, Lourdes (committee member)

Creator Email lgaona@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-161596

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Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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