Abstract
Introduction
Caring for people with schizophrenia has consequences, one of which is stressors during care. Families as caregivers often using coping strategies that involve relationships with self, others, or the transcendent/God or nature and also may include religious/spiritual practices.
Objectives
This literature review aims to identify the benefit of using spiritual coping as used by a family schizophrenia caregiver. The variable is spiritual coping.
Methods
This literature review method used PRISMA methodology for systematic reviews. Search was conducted in March 2017, updated in August 2022 and submitted in April 2023 for the publication process, limited to English by using electronic databases: Scopus, ScienceDirect, Sage, ProQuest, and PubMed.
Results
Fifteen studies were included in this review. Two synthesized findings emerged: spiritual coping strategies used by family caregivers give positive effects for family.
Conclusion
When the stress or crisis phase is experienced while caring for people with schizophrenia, the family who acts as a caregiver reveals the meaning of life they have and that they feel hopelessness and helplessness. In an effort to overcome the family's burden as caregivers, they often use spiritual coping, which is important to increase the caregiver's wellbeing.
Introduction
There are various advantages to religion, some of which can offer people motivation to take action. The traditional responses that religion offers its followers to events include prayer, seeking spiritual guidance, and participating in religious ceremonies (Delaney, 2005; Pargament et al., 2014). By assisting caregivers in processing traumatic events, discovering meaning, coming up with hopeful expectations, and putting coping strategies into action, these religious schemas and hearth practices can enable positive coping outcomes (Pargament et al., 2014; Serfaty et al., 2020). Spiritual needs, such as finding purpose in life and hope, as well as spiritual or religious practices that can help them cope with stressful situations, are present in families caring for people with chronic illnesses like schizophrenia (Casaleiro et al., 2022a).
Schizophrenia is a persistent mental illness that endangers people, their families, and society as a whole (World Health Organization, 2019). In conjunction with the development of deinstitutionalization, patients move the responsibility for providing care to their family, particularly close relatives. The patient's experience of family care is influenced by the backdrop of spiritual suffering (Roze des Ordons et al., 2018). Even though nurses typically see spiritual care as important, it is rarely offered (Neathery et al., 2020). According to a study, encouraging spiritual coping is necessary to control maladaptive behavior (Robinson-Lane et al., 2021) furthermore it is crucial to include in the health services offered (Turner & Hodge, 2020).
Schizophrenia is a chronic mental disorder that affects 20 million people worldwide characterized by distortions in thinking, perception, emotion, language and behavior as well as an inability to make interpersonal relationships with other people in time, place and environment (Townsend & Morgan, 2018; Videbeck, 2020; WHO, 2019). Transference of patients with schizophrenia to home shifts the responsibility of care to relatives or people closest to the patient so that they need to making adaptations in their personal lives. The problems faced by families caring for family members who have schizophrenia at home, as well as community perceptions about schizophrenia, the rising cost of care and basic necessities, and challenges connecting socially with the community, all have an impact on the families. In addition, the stress that the caregiver feels when giving care at home is actually increased by the perceived burden by the caregiver (Fitrikasari et al., 2012).
Therefore, in order to manage the responsibilities and difficulties that come with caring for family members who have schizophrenia, caregivers need to have strong coping mechanisms. According to earlier studies findings, spiritual coping is one type of coping used by caregivers of schizophrenia patients. In order to maintain their spiritual wellbeing, caregivers can make benefits from spiritual coping by finding self-satisfaction, healthy relationships with other people, the environment, and God (Fisher, 2010). Indicators of spiritual wellbeing include self-esteem and the capacity to deal with issues as they arise. Additionally, earlier studies have shown that those who have a strong relationship with God have greater life satisfaction, less stress, and are psychologically healthier (Darvyri et al., 2014). Caregivers or families often develop coping strategies that involve relationships with self, others, or transcendence/God or nature and these may include religious/spiritual practices.
Several studies found, by comparing perceived physical or psychological responses between noncaregivers and caregivers, higher levels of distress, anxiety, sleep disturbances and depression as well as more psychosomatic disorders such as hypertension, cardiovascular disorders, and obesity among the caregivers. From previous studies’ results, it was also found that families who served as caregivers received more prescriptions for psychotropic drugs than the general population. Thus, it can be explained that families who serve as caregivers experience more psychological and physical health problems, which can interfere with their ability to provide care to people with schizophrenia. This in turn can increase the healthcare costs for care givers and the people they care for.
Burden on caregiver is considered as important indicator of caregiver health and has been defined as the stress that caregivers typically experience from their caregiving duties. These usually include physical, mental, financial, and social stresses that can affect health-related quality of life (HRQoL) (LoboPrabhu et al., 2006). Identifying these factors can help to ease the burden of caregiving and then will assist health professionals and policy makers in designing and funding effective interventions and educational programs. Many factors have been reported to influence the health condition of caregivers. Being a family as well as the main caregiver for family members of relatives with severe mental disorders often has an impact on quality of life, physical, and mental health. The use of coping strategies related to spirituality can improve physical and mental wellbeing.
Various factors can affect the health status of families who become caregivers of people with schizophrenia, one is the use of spirituality as a coping strategy. Spiritual coping (SC) can help families who serve as caregivers to better cope with stress and crises experienced by mobilizing beliefs and practices. Literature shows a growing body of research confirming the association between SC and better health outcomes in caregivers. Research also shows that families or caregivers who do not use spiritual coping strategies have a higher risk of depression and anxiety. The results of another study stated that the level of spiritual/religious coping was relatively high in caregivers of families with chronic illnesses. In addition, studies have found spiritual/religious coping makes for better adaptation, lower levels of parenting burden and less use of mental health services in spiritual groups or religious caregivers. Many people with schizophrenia rely on their family members for support and help with daily tasks. Because of this, caregivers may be more likely to have mental health issues like depression, anxiety, and caregiver stress (Saffari et al., 2018).
In this literature review, we aim to identify the benefits of using spiritual coping that is used by family caregivers with schizophrenia. The PCC framework (P = population; C = concept; C = context) was used to construct the research questions. The research questions are based on the population of families who directly care for people with schizophrenia. Due to the nature of the research topic, there were no specific focus interventions. An interesting explanation is the reason families use spiritual coping while caring for people with schizophrenia. The target outcomes are themes related to the benefits of using spiritual coping. The main research question was: “What are the benefits of using family spiritual coping in treating people with schizophrenia?”
Methods
The 2020 PRISMA checklist for systematic reviews and meta-analyses is followed when conducting a systematic review (Page et al., 2021). Reviewers can use the 15 criteria on the checklist to ensure transparent reporting. Articles were searched on Scopus, Sage, ScienceDirect, PubMed, and ProQuest as part of an extensive literature search for published studies. Additionally, the reference list of the articles that were retrieved was checked for other articles. Studies had to be written in English within the previous seven years (2017–2022) and submitted by April 2023. Regular keywords were combined with MeSH terms to ensure more relevant articles were displayed in search results. Table 1 summarizes the list of regular keywords and MeSH terms used in this search strategy.
Regular Keywords and MeSH Terms.
To combine keywords and search terms, Boolean connectors are employed. Figure 1 provides a summary of the search approach, as well as the boundaries and filters applied. The peer-reviewed, English-language articles about spiritual coping in families with schizophrenia that were chosen for review were published in the journals identified. For the review, only primary studies were chosen. Because systematic reviews are secondary research and there is no purpose in incorporating a secondary study into another secondary study, secondary studies such as scoping reviews, systematic reviews, and other literature reviews were thus eliminated. Student dissertations and theses, organizational reports, and government publications are excluded. The keywords that correspond to the MesH utilized are shown in Table 1.
PRISMA flow diagram.
Results
The identified articles were filtered using inclusion and exclusion criteria after the aforementioned search approach was used. The selection of the studies involved no automation. Instead, two impartial reviewers conducted the process. Reviewers individually examined each document. For instance, independent reviewers made independent choices when applying inclusion and exclusion criteria, which were then compared for further processing. If the two reviewers disagreed, a third reviewer was asked to conduct a second, independent evaluation of the records or reports in question. The majority of the review's findings were taken into account.
Two independent reviewers used inclusion and exclusion criteria to omit the full text of the remaining 75 articles, of which 34 were eliminated because they were deemed irrelevant, lacked the required details, or had a focus unrelated to spiritual coping. In light of this, the two impartial reviewers decided to eliminate 34 papers at this time. Only 26 of the remaining 41 articles were deemed suitable for inclusion in this code by the independent reviewers. Of these, 11 were subsequently dropped for quality grounds. A third independent reviewer looked over the final 15 articles, after which the final 15 articles were presented. An overview of the search procedure is shown in Figure 1 (the PRISMA flowchart). A total of 231 study findings were discovered using a literature search, as shown in Figure 1 below, which displays the search results using the modified PRISMA flowchart 2009 (Moher et al., 2009). Fifteen papers were eventually chosen, and data were gathered and displayed in Table 1. Each component was evaluated to discover how using spiritual coping affected the situation. An integrated quantitative and qualitative research approach was used. The study sample size was in the middle, and the majority of the information was gathered by questionnaires.
Following the title screening, initially 20 citations were found in Sage, seven citations in Scopus, 25 in ScienceDirect, six in PubMed, and 165 in ProQuest. Eleven articles were automatically eliminated with the current tools, four articles were excluded for specific reasons, and seven because they were duplicates or reported the same research findings in different versions of the articles or across the five databases. Finally, two independent reviewers assessed the abstracts of 201 publications. They concurred that 126 records were omitted due to the fact that they did not satisfy all exclusion requirements, the majority of which were preprinted, they did not satisfy the requirements for peer review, and the remainder demanded full-text deletion, which was not possible in the free and subscription modes (Tables 2 and 3).
Inclusion and Exclusion Criteria.
Results of Literature Study.
Note. ACIT-SP = the functional assessment of chronic illness therapy-spiritual well-being; COPE = coping orientation to problems experienced; DSM IV = diagnostic and statistical manual of mental disorders, 5th ed.; RMSEA = root-mean-square error of approximation; CFI = comparative fit index; IFI = incremental Fit Index; GFI = goodness-of-fit index; MANOVA = multivariate analysis of variance; PTM = penyakit tidak menular/non-communicable disease.
Based from the results of the literature study above, it was found that the benefits of using spiritual coping used by families were:
Increasing mental or physical wellbeing (Health Status) (Park et al., 2021); Giving comfort to the mind, find hope (Gojer et al., 2017); Build meaning, greater religious support and positive caregiving experience (Guo et al., 2017); Coping was associated with a positive caregiving experience and greater religious support. Religious coping methods that used by family caregiver may be particularly relevant and adaptive for dealing with the stress of caring for a person with a mental illness (Guo et al., 2017); Decreasing burden and stress of family (Casaleiro et al., 2022a); Increasing spiritual wellness (Budiarto & Hamid, 2019); Better patient outcomes and lower levels of morbidity or psychological distress (Rao et al., 2020).
Discussion
An important finding from this study is that family coping influences family health. Doornbos' Family Health Theory (2002) shows that coping mechanisms affect family health (Doornbos, 2007). Family caregivers experience burdens or stress or even difficult times that arise while caring for people with schizophrenia. To address this, caregivers mention switching to the use of spiritual/religious practices. The term “spirituality” refers to a person's connection, whether religious or not, to what they perceive to be a nonphysical reality (Jordan et al., 2020; Rosmarin et al., 2021). Religious coping is defined as “an attempt to understand and deal with the existence of a stressor or life event in a way that is related to the sacred being” (Pargament et al., 2011, p. 12). Higher levels of spirituality and religion (R/S) have been linked to better mental health (Park et al., 2021). Spiritual intelligence can be employed as a coping mechanism to control and deal with the stressor in stressful situations (Moafi et al., 2021). Many caregivers of people with major mental illness find that religion is a significant part of their coping mechanisms (Guo et al., 2017). To foster a high level of spiritual wellbeing in the family, families with schizophrenia family members use spiritual coping as one of their coping mechanisms. According to studies, religion and spirituality can improve mental health by fostering constructive religious coping, a sense of belonging and support, and constructive beliefs. Additionally, research demonstrates that religion and spirituality can harm mental health due to unfavorable religious coping mechanisms, misunderstandings and miscommunication, and unfavorable views (Weber & Pargament, 2014).
Based on the results of 25 main studies that looked at the spiritual aspect of the experience of caring for a family with mental health problems, they suggested that spiritual needs, such as hope and finding meaning in life, and spiritual or religious practices help cope with stressful situations. Spiritual coping strategies for families in charge of caring for people with schizophrenia are an important component that must be provided and facilitated by health workers. This is because the use of coping strategies related to spirituality can improve physical and mental wellbeing, so a spiritually specific approach is needed to promote coping strategies in families with schizophrenia. After controlling for nonreligious forms of coping, religious coping was linked to increased objective caregiving burden, increased care recipient demand, decreased mental health awareness, and decreased use of mental health services (Guo et al., 2017).
Based on the results of the study, it was found that religiosity and spirituality can help build meaning, and find hope (Smith Lee et al., 2020). In general, religion and spirituality have long been regarded as important social determinants of human health, and there is some of research to support this (Colenda & Blazer, 2022). Research results show that spirituality and religiosity can have a positive impact on various health outcomes (Launius et al., 2022; Roze des Ordons et al., 2018) and become one of the healing program to increase quality of life (Saiz et al., 2021). Based on past studies, the coping strategies commonly used by families in caring for people with mental disorders include spiritual coping (80%) (Robinson-Lane et al., 2021). Therefore it is also very important for nurses to provide spiritual care to families or individuals who have psychiatric mental health needs (Gall & Guirguis-Younger, 2012; Neathery et al., 2020). This is also explained in a study which states that a strong spiritual, religious or personal belief system has a positive influence on active and adaptive coping skills in schizophrenia patients during remission, thereby helping individuals to overcome disease-related stress (Das et al., 2018a). Other research also explains that higher levels of religiosity and spirituality are associated with better treatment adherence (Kandeger et al., 2018).
The most frequent forms of spiritual adaptation consist of integrating religious content to carry out cognitive restructuring, psychoeducation and motivation, involvement in religious activities such as behavioral activation, meditation, or prayer to assist cognitive restructuring, using religious values and coping strategies (de Abreu Costa & Moreira-Almeida, 2022). In another study it was mentioned that religion and religious coping methods may be very relevant and adaptive for dealing with the stress of caring for someone with mental illness. In general, families caring for schizophrenics reported high levels of religious involvement and frequently used and perceived helpful religious coping strategies (Clark & Emerson, 2021). Likewise, other studies have shown that families who care for people with schizophrenia often turn to religion and spirituality for support (Das et al., 2018b). As in a study of Hindu family members with schizophrenia, 90% of participants reported praying to God to solve problems and seeing religion as a source of comfort, strength, and guidance in coping with the demands of parenting.
Another study showed that family members of people with serious mental illness who had higher levels of personal religiosity (i.e., the importance of religion and finding comfort and strength from God) also reported higher levels of mastery, self-esteem, and self-care. The use of religious coping was associated with adaptive coping and with better patient outcomes and higher rates of morbidity or distress (Rao et al., 2020; Zerach & Levin, 2018). This is consistent with research showing that there are significant disparities in the spiritual health of family members who have schizophrenia among caregivers (Budiarto & Hamid, 2019; Rosmarin et al., 2021).
Overall, the study's findings support the idea that people who are facing challenging circumstances turn to religion for solace (Pargament, 2001). When one has exhausted one's own human capacity and when religion is “available and accessible,” many individuals are more likely to rely on it (Pargament et al., 1988). Instead of explicitly shielding caregivers from suffering poor results, religion may have a greater impact in this situation by promoting and enhancing happy emotions and experiences amid feelings of stress and load. In other words, religion might give carers the tools they require to discover meaning and purpose in challenging and trying circumstances (Pearce et al., 2002). For instance, a study of those who cared for cancer patients who had reached the end of their lives revealed that those who turned to religion for solace experienced both greater caregiving burden and greater caregiving satisfaction (Pearce et al., 2002).
Implication for Practice
Mental health nursing care should take into account the spiritual requirements and coping mechanisms of family caregivers of a relative suffering from a severe mental illness. When fostering coping mechanisms for the family caregivers of a member with serious mental illness, a spiritually sensitive approach should be adopted. Apart from that, there are also several applications in the field of education where holistic nursing care, starting from physical, psychological, social, and spiritual, is very important for students in the health or nursing field to master in order to be able to provide comprehensive nursing care, especially meeting spiritual needs with a professional care approach.
Practice implications: Spirituality should be taken into consideration based on the beliefs and requirements of each caregiver, as it may provide significant resources for overall wellbeing and a feeling of purpose.
Conclusion
Family spiritual coping can improve the spiritual wellbeing of caregivers of family members with schizophrenia. Therefore, nurses can provide assistance to families with schizophrenia by following up at least once a month by providing consulting services, health education, and collaborating with local religious leaders to provide spiritual services. Health workers can support and remind caregivers of family members with schizophrenia to optimize spiritual coping to find comfort in faith such as praying and remembering God.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
