See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/232945293

An evaluation of the brief multidimensional measure of

religiousness/spirituality in older patients with prior depression or anxiety

Article  in  Mental Health Religion & Culture · February 2012

DOI: 10.1080/13674676.2011.566263

CITATIONS READS

13 85

8 authors, including:

Amber B Amspoker John Paul Jameson

U.S. Department of Veterans Affairs Appalachian State University
71 PUBLICATIONS   813 CITATIONS    24 PUBLICATIONS   317 CITATIONS   

SEE PROFILE SEE PROFILE

Terri L Barrera Gina Dorothy Evans

Michael E. DeBakey VA Medical Center Swansea University
43 PUBLICATIONS   527 CITATIONS    1 PUBLICATION   13 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Handbook of Rural School Mental Health View project

Identifying and delivering point-of-care information to improve care coordination View project

All content following this page was uploaded by Amber B Amspoker on 15 May 2017.

The user has requested enhancement of the downloaded file.

This article was downloaded by: [Melinda Stanley]
On: 08 July 2011, At: 13:26
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Mental Health, Religion & Culture

Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/cmhr20

An evaluation of the brief

multidimensional measure of
religiousness/spirituality in older
patients with prior depression or
anxiety
a b c d
Amber L. Bush , John P. Jameson , Terri Barrera , Laura L.
e d c d c
Phillips , Natascha Lachner , Gina Evans , Ajani D. Jackson
c d f
& Melinda A. Stanley
a
HSR&D Center of Excellence, Design and Analysis, MEDVAMC 152,
2002 Holcombe Blvd., Houston, 77030 USA
b
Department of Psychology, Appalachian State University, P. O.
Box 32109, Boone, 28608, Houston, USA
c
Baylor College of Medicine, Psychiatry and Behavioral Sciences,
One Baylor Plaza, Houston 77030, USA
d
HSR&D Center of Excellence, MEDVAMC 152, 2002 Holcomb
Blvd., Houston, 77030, USA
e
Olin E. Teagur VAMC, Mental Health & Behavioral Medicine, Bldg.
204, Unit 5K, Temple, 76504, USA
f
VA South Central Mental Illness Research, Education and Clinical
Center, Houston, 77030, USA

Available online: 1 January 2011

To cite this article: Amber L. Bush, John P. Jameson, Terri Barrera, Laura L. Phillips, Natascha
Lachner, Gina Evans, Ajani D. Jackson & Melinda A. Stanley (2011): An evaluation of the brief
multidimensional measure of religiousness/spirituality in older patients with prior depression or
anxiety, Mental Health, Religion & Culture, DOI:10.1080/13674676.2011.566263

To link to this article: http://dx.doi.org/10.1080/13674676.2011.566263

PLEASE SCROLL DOWN FOR ARTICLE

 Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-
conditions

This article may be used for research, teaching and private study purposes. Any
substantial or systematic reproduction, re-distribution, re-selling, loan, sub-licensing,
systematic supply or distribution in any form to anyone is expressly forbidden.

The publisher does not give any warranty express or implied or make any representation
that the contents will be complete or accurate or up to date. The accuracy of any
instructions, formulae and drug doses should be independently verified with primary
sources. The publisher shall not be liable for any loss, actions, claims, proceedings,
demand or costs or damages whatsoever or howsoever caused arising directly or
indirectly in connection with or arising out of the use of this material.
Downloaded by [Melinda Stanley] at 13:26 08 July 2011
 Mental Health, Religion & Culture
2011, 1–13, iFirst

An evaluation of the brief multidimensional measure of religiousness/

spirituality in older patients with prior depression or anxiety
Amber L. Busha*, John P. Jamesonb, Terri Barreracd, Laura L. Phillipse,
Natascha Lachnerd, Gina Evanscd, Ajani D. Jacksonc and Melinda A. Stanleycdf
a
HSR&D Center of Excellence, Design and Analysis, MEDVAMC 152, 2002 Holcombe Blvd.,
Houston, 77030 USA; bDepartment of Psychology, Appalachian State University, P. O. Box
32109, Boone, 28608, Houston, USA; cBaylor College of Medicine, Psychiatry and Behavioral
Sciences, One Baylor Plaza, Houston 77030, USA; dHSR&D Center of Excellence,
MEDVAMC 152, 2002 Holcomb Blvd., Houston, 77030, USA; eOlin E. Teagur VAMC,
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

Mental Health & Behavioral Medicine, Bldg. 204, Unit 5K, Temple, 76504, USA;
f
VA South Central Mental Illness Research, Education and Clinical Center,
Houston, 77030, USA
(Received 22 December 2010; final version received 22 February 2011)

The Primary objective of the study was to examine the psychometric properties of
the Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS)
in older adults. Older adults (N ¼ 66) completed a survey in-person or over the
phone. Measures included the BMMRS, Religious Problem Solving Scale, Brief
Religious Coping Scale, Functional Assessment of Chronic Illness Therapy –
Spiritual Well-being, Satisfaction with Life Scale, Geriatric Anxiety Inventory,
and Geriatric Depression Scale. Cronbach’s alphas evaluated internal consis-
tency, zero-order correlations tested construct validity, and multiple regressions
assessed the association of BMMRS domains with well-being. Most BMMRS
domains were reliable and valid. Collectively, they explained 26% to 68% of the
variance in well-being and psychological symptoms. Daily spiritual experiences
uniquely predicted spiritual well-being, satisfaction with life, and depressive
symptoms. The BMMRS is useful in older populations and may help identify
those who could benefit from religious or spiritually integrated therapy.
Keywords: religion; spirituality; measurement; elderly; depression; anxiety; brief
multidimensional measure of religiousness and spirituality

Religion and spirituality are increasingly being integrated into clinical practice as a method
of increasing treatment acceptability and improving outcomes. Although not entirely
distinct, spirituality refers to one’s relationship with God or a higher being and religion
refers to a set of specific beliefs and behaviours shared by an organisation (Hodge, 2006).
Research has shown that adults with mental illness often desire to speak about religious
or spiritual concerns with their therapist (Lindgren & Coursey, 1995; Rose, Westfefeld, &
Ansley, 2001), and a majority of those with serious mental illness report religious beliefs
or practices as a way to cope with their symptoms and daily problems (Tepper, Rogers,

*Corresponding author. Email: amspoker@bcm.edu

ISSN 1367–4676 print/ISSN 1469–9737 online

ß 2011 Taylor & Francis
DOI: 10.1080/13674676.2011.566263
http://www.informaworld.com
 2 A.L. Bush et al.

Coleman, & Malony, 2001). Moreover, negative forms of religious coping are associated
with long-term increases in depression among medically ill older adults (Pargament,
Koenig, Tarakeshwar, & Hahn, 2004). There is also evidence for the efficacy of explicitly
incorporating religious or spiritual components into treatment for mental health
symptoms. Recent reviews and meta-analyses demonstrate moderate effects for spiritually
based interventions (effect size ¼ 0.51; Smith, Bartz, & Richards, 2007) and effects of
religious-accommodative treatment that are equivalent to or greater than those for
traditional treatment (Hodge, 2006; Paukert, Phillips, Cully, Romero, & Stanley, in press).
More recently, a randomised controlled trial of an internet-based intervention for
subclinical anxiety found that individuals who underwent spiritually integrated treatment
reported greater reduction in stress and worry relative to those in a wait-list control
condition (Rosmarin, Pargament, Pirutinsky, & Mahoney, 2010).
Religion or spirituality may be especially important predictors of well-being in older
adults. Most older adults report that religion is an important part of their lives (Newport,
2006). Older adults also endorse somewhat higher levels of spiritual well-being than
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

younger adults (Peterman, Fitchett, Brady, Hernandez, & Cella, 2002) and report using
religion as a method of coping with illness (Koenig, 1998). Additionally, religiously
involved older adults often report higher self-esteem and self-worth than those who are not
religiously involved (Krause, 1995), as well as lower blood pressure, anxiety, and
depression (Koenig, 1995; Levin, 1994). In a sample of depressed older adults receiving
clinical care, those who engaged in more public religious practices, more positive coping,
or less negative religious coping reported less depression at baseline. In addition, those
who engaged in more positive religious coping reported a greater reduction in depression
from baseline to six-month follow-up, relative to those with less positive religious coping
(Bosworth, Park, McQuoid, Hays, & Steffens, 2003).
These studies suggest that religion and spirituality have important links to well-being in
older adults. Although the quantity of research on religion and spirituality has increased
substantially over the last 20 years, there is room for improvement in the quality of the
research (Weaver, Flannelly, Strock, Krause, & Flannelly, 2005). One problem with this
work is that measurement of religion or spirituality varies greatly across studies. Some
measures assess a single construct, such as strength of religious faith (e.g., Santa Clara
Strength of Religious Faith; Plante & Boccaccini, 1997) or religious or spiritual coping
(e.g., Brief Religious Coping Scale; Pargament, Smith, & Koenig, 1998), while other
measures assess multiple components simultaneously (e.g., the Royal Free Interview for
Religious and Spiritual Beliefs; King, Speck, & Thomas, 1995). The wide variety of
measures employed to assess various components of religion and spirituality results in little
consistency across studies and difficulty in comparing studies and drawing firm
conclusions. Further, though many studies have recently begun to examine multiple
dimensions of religion and spirituality (Johnstone, Yoon, Franklin, Schopp, & Hinkebein,
2009), many multidimensional measures still continue to assess a relatively small number
of religious or spiritual domains (Weaver et al., 2005).
The Brief Multidimensional Measure of Religiousness/Spirituality (BMMRS) is a self-
report survey designed to measure multiple distinct aspects of religion and spirituality in
heterogeneous populations (The Fetzer Institute and the National Institute of Aging
Working Group, 1999). This measure has several notable strengths, including its separate
consideration of religion and spirituality, multidimensionality, brevity, flexibility,
psychometric support, and specific development for use in health research. In addition
to collecting information regarding religious history, preferences, and commitment, the
BMMRS assesses nine domains of religious and spiritual life: three that assess
 Mental Health, Religion & Culture 3

behavioural, cognitive, or perceptual components of religion only (i.e., private religious

practices, congregation help, and congregation problems); four assessing such components
of spirituality only (i.e., daily spiritual experiences, meaning, forgiveness, and values/
beliefs); and two that combine both religion and spirituality (i.e., religious and spiritual
coping and intensity). The measure was specifically designed to be brief and flexible
and may be used in pieces or in full to promote clinical acceptance and feasibility
(Johnstone et al., 2009).
Some domains in the BMMRS relate to each other in predictable directions, suggesting
that they are not completely independent. However, many dimensions are not related to
each other; and most of the significant correlations are low-to-moderate, indicating that
they represent distinct aspects of religious or spiritual experience (Idler et al., 2003). In
addition, confirmatory factor analyses support the factor structure of the BMMRS (Neff,
2006). Further, nearly all the BMMRS domains evidence convergent and discriminant
validity and display good-to-excellent internal reliability (forgiveness, values/beliefs, and
negative religious coping were exceptions, with coefficient alphas of 0.66, 0.64, and 0.54,
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

respectively; Idler et al., 2003).

The BMMRS in its entirety or selected domains has been studied in a national sample
(Idler et al., 2003), adolescents (Desrosiers & Miller, 2007), young adults (Tartaro,
Luecken, & Gunn, 2005), and those with chronic pain (Rippentrop, Altmaier, Chen,
Found, & Keffala, 2005) or significant health disorders (Johnstone et al., 2009) and has
been associated with mental or physical health outcomes in several of these studies.
Specifically, congregation benefits were associated with fewer depressive symptoms in
adolescents than for those without them (Desrosiers & Miller, 2007); and overall religion
and spirituality (calculated as a composite of all domains of the BMMRS), forgiveness,
religious/spiritual intensity, and private religious practices were associated with lower
cortisol responses to stressors in young adults than for those with lower religious/spiritual
scores (Tartaro et al., 2005). Whereas forgiveness, daily spiritual experiences, religious
support, and religious/spiritual intensity were positively associated with reported mental
health, private religious practices were negatively associated with reported physical health
in musculoskeletal chronic pain patients (Rippentrop et al., 2005). Although these data are
correlational, they suggest that religious or spiritual coping may have many benefits,
particularly for individuals with poor health. Up to this point the BMMRS has not been
studied in older adults, which may be a fundamental omission. With its emphasis on a
variety of religious and spiritual domains, the BMMRS may serve as an especially
important tool for better understanding older-adult populations, which are more
susceptible to health declines and tend to place a greater emphasis on religion and/or
spirituality relative to younger populations.

The current study

The current study had two primary goals. First, the reliability and validity of the BMMRS
were examined in a sample of older adults, for whom spirituality and religion may be
especially relevant. Second, links between different aspects of religion and spirituality as
measured by the BMMRS and well-being were examined. We examined the extent to
which the BMMRS domains were associated with well-being, both as a set and uniquely.
Well-being was defined as spiritual well-being, satisfaction with life, and anxiety-
depression symptoms.
 4 A.L. Bush et al.

Method
This study was approved by the institutional review boards of Baylor College of Medicine
and the Michael E. DeBakey Veterans Affairs Medical Center.

Participants and procedures

Participants were recruited from samples of adults who were age 55 or older who had
participated in prior studies of cognitive-behavioural therapy (CBT) for late-life anxiety
and/or depression in primary care (Cully, Paukert, Falco, & Stanley, 2009; Stanley et al.,
2009). The sample included patients who had received either CBT for anxiety and/or
depression or supportive care as part of an enhanced-usual-care approach. A total of 142
participants from prior studies were invited via letter to participate. If there was no
response within two weeks, participants were contacted via phone to assess interest in
participating. Two patients were ineligible, 20 did not respond, 54 refused to participate,
and 66 signed consent. Of the 66 who participated, most were female (n ¼ 44, 66.67%),
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

non-Hispanic Caucasian (n ¼ 43; 65.15%), and married (n ¼ 39; 59.09%). Overall,

participants were educated, with 35 (53%) having received at least an undergraduate
degree. Average age was 69.35 (SD ¼ 5.94). Most participants (91%; n ¼ 60) indicated
current identification with a particular religious group, with 90% (n ¼ 54) Christian, 3.3%
(n ¼ 2) Jewish, and 6.7% (n ¼ 4) other. Of those who identified themselves as Christian,
51.9% (n ¼ 28) were Protestant, 38.9% (n ¼ 21) were Catholic, 7.4% (n ¼ 4) were
nondenominational, and 1.8% (n ¼ 1) was Pentecostal. Most participants indicated that
their religious identification had been since childhood (59%; n ¼ 39), with 24% (n ¼ 16)
indicating that it had been since middle life and 17% (n ¼ 11) since later life. Furthermore,
most participants reported that religion and/or spirituality played a significant role in their
lives at present (n ¼ 48; 73%). Participants completed all measures in person or over the
phone (see Stanley et al., in press for more details).

Measures
BMMRS
The BMMRS (The Fetzer Institute and the National Institute on Aging Working Group,
1999) measures 12 religious and spiritual characteristics thought to be related to health
outcomes. Eight domains of the BMMRS were used in the current study: daily spiritual
experiences, forgiveness, congregation benefits, congregation problems, values and beliefs,
private religious practices, meaning, and religious and spiritual intensity. The other four
domains (i.e., religious and spiritual history, commitment, preference, and coping) were
excluded because of their inability to specifically assess religious/spiritual constructs
(Johnstone et al., 2009) and because of the redundancy between these domains and other
measures included in the study in an effort to keep participant burden at a minimum.
(1) Daily spiritual experiences included six items rated on a 6-point scale
[1 ¼ ‘‘Many times a day’’; 6 ¼ ‘‘Never’’] that assessed the frequency with
which one finds strength and comfort in religion, is spiritually touched by the
beauty of creation, and/or feels God’s presence. Internal consistency
(Cronbach’s alpha) was 0.91 in a prior national sample (Idler et al., 2003).
(2) Forgiveness consisted of three items rated on a 4-point scale [1 ¼ ‘‘Almost or
Almost Always’’; 4 ¼ ‘‘Never’’] and assessed forgiveness of oneself, others, and/
or acknowledgement of God’s forgiveness. Alpha was 0.66 (Idler et al., 2003).
 Mental Health, Religion & Culture 5

(3 and 4) Congregation benefits and Congregation problems each consisted of two items
rated on 4-point scales [1 ¼ ‘‘A great deal’’; 4 ¼ ‘‘None’’ for congregation
benefits and 1 ¼ ‘‘Very often’’; 4 ¼ ‘‘Never’’ for congregation problems] and
assessed positive and negative aspects of religious support, respectively. Alphas
were 0.86 and 0.64, respectively (Idler et al., 2003).
(5) Values and beliefs were assessed with four items designed to capture beliefs and
feelings shared by an organised community about religion, including belief in a
God and life after death. Belief in a God and feeling a sense of responsibility
for reducing pain and suffering were rated on 4-point scales [1 ¼ ‘‘Strongly
agree’’; 4 ¼ ‘‘Strongly disagree’’], belief in an afterlife was assessed with a 3-
point scale [1 ¼ ‘‘Yes’’; 2 ¼ ‘‘Uncertain’’; 3 ¼ ‘‘No’’], and the extent to which
one’s whole approach to life was based on religion was rated on a 5-point scale
[1 ¼ ‘‘Strongly agree’’; 5 ¼ ‘‘Strongly disagree’’]. Alpha was 0.64 (Idler et al.,
2003).
(6) Private religious practices consisted of five items designed to capture frequency
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

of prayer, meditation, reading religious literature, and other religious activities.

Participants indicated how often prayers or grace are said before or after meals
at their homes, on a 5-point scale [1 ¼ ‘‘At all meals’’; 5 ¼ ‘‘Never]. The
frequency with which one prays privately outside church or synagogue,
meditates, watches, or listens to religious programmes on television or radio,
and reads religious literature was rated on an 8-point scale [1 ¼ ‘‘More than
once a day’’; 8 ¼ ‘‘Never’’]. Alpha was 0.72 (Idler et al., 2003).
(7) The Meaning subscale consisted of two items that assessed perceived purpose
of one’s life. Participants rated whether the events in their life unfold according
to a divine or greater plan and whether they have a sense of mission or calling
in their own life on 4-point scales [1 ¼ ‘‘Strongly agree’’; 4 ¼ ‘‘Strongly
disagree’’].
(8) Finally, religious/spiritual intensity consisted of two questions that assessed the
extent to which one considered oneself a religious person and the extent to
which one considered oneself a spiritual person [1 ¼ ‘‘Very’’; 4 ¼ ‘‘Not at all’’].
Alpha was 0.77 (Idler et al., 2003).
Due to differential response options and ranges, each of the four items for values/
beliefs and each of the five items for private religious practices was normalised; and the
resulting z scores were summed to create overall values/beliefs and private religious
practices scores. In order to provide context for responses on these dimensions, means and
standard deviations for raw items will be provided. Responses were reverse scored such
that higher scores reflected more frequent daily spiritual experiences, forgiveness,
congregation help, congregation problems, and private religious practices, as well as
stronger sense of meaning, values/beliefs, and religious/spiritual intensity.

Religious coping
Two measures of religious coping were used to establish construct validity for the
BMMRS domains: the Religious Problem Solving Scale and the Brief Religious
Coping Scale.
The Religious Problem Solving Scale – Short Version (RPSS; Pargament et al., 1998)
consists of 18 items that assess frequency of collaborative (RPSS-Collaborative; e.g.,
‘‘When considering a difficult situation, God and I work together to think of possible
 6 A.L. Bush et al.

solutions), deferring (RPSS-Defer; e.g., ‘‘When a situation makes me anxious, I wait for
God to take those feelings away’’) and self-directive (RPSS-Self-Directed; e.g.,
‘‘When deciding on a solution, I make a choice independent of God’s input’’) religious
problem-solving strategies. Each item was rated on a 5-point scale [1 ¼ ‘‘Never’’;
5 ¼ ‘‘Always’’]. Internal consistency and test-retest reliability are strong for all subscales
(Fox, Blanton, & Morris, 1998). Internal reliabilities for the collaborative, self-directed,
and deferring problem-solving styles in the current sample were 0.94, 0.95, and 0.91,
respectively.
The Brief Religious Coping Scale (Pargament et al., 1998) consists of two subscales
that assess the extent to which one engages in positive (RCOPE-Pos; e.g., ‘‘Looked for a
stronger connection with God’’) and negative religious coping (RCOPE-Neg; e.g., ‘‘Felt
punished by God for lack of devotion’’) when dealing with major life problems. Each
subscale comprises seven items rated on a 4-point scale [0 ¼ ‘‘I Didn’t do This’’; 3 ¼ ‘‘I Did
This a Lot’’]. Internal consistency and validity are adequate (Pargament et al., 1998).
Internal reliabilities for the RCOPE-Pos and RCOPE-Neg in the current study were 0.94
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

and 0.84, respectively.

Well-being and psychological symptoms

Two measures of well-being and two measures of psychological symptoms were used to
examine the predictive validity of the BMMRS domains.
The Functional Assessment of Chronic Illness Therapy - Spiritual Well-being (FACIT-
Sp; Peterman et al., 2002) assesses spiritual well-being, with an emphasis on sense of
meaning in life, harmony, peacefulness, and sense of strength and comfort derived from
one’s faith (e.g., ‘‘I feel a sense of purpose in my life,’’ and ‘‘I find comfort in my faith or
spiritual beliefs’’). The measure consists of 12 items that are each rated on a 5-point scale
[1 ¼ ‘‘Not at All’’; 5 ¼ ‘‘Very Much’’] and demonstrates good internal reliability and
convergent validity with other measures of religion and spirituality (Peterman et al., 2002).
Internal reliability in the current study was 0.92.
The Satisfaction with Life Scale (SWLS; Diener, Emmons, Larson, & Griffin, 1985)
contains five items rated on a 7-point scale [1 ¼ ‘‘Strongly disagree’’; 7 ¼ ‘‘Strongly agree’’]
that measure domain-free global life satisfaction (e.g., ‘‘If I could live my life over, I would
change almost nothing’’). The SWLS demonstrates good internal and test-retest reliability,
as well as high construct validity (Diener et al., 1985; Pavot & Diener, 1993). Internal
reliability in the current study was 0.86.
The Geriatric Anxiety Inventory (GAI; Pachana et al., 2006) was designed to assess
severity of anxiety symptoms in older adults. Participants indicated their agreement
[1 ¼ ‘‘Agree’’; 0 ¼ ‘‘Disagree’’] with 20 statements, such as ‘‘My own thoughts often make
me anxious.’’ Psychometric properties of the measure are adequate in normal older people
and geriatric psychiatry patients (Pachana et al., 2006). Internal reliability in the current
study was 0.88.
The Geriatric Depression Scale – Short Form (GDS; Yesavage et al., 1983) consists of
15 items and assesses severity of depressive symptoms in older adults. Participants
indicated whether they endorsed each item [1 ¼ ‘‘Agree’’; 0 ¼ ‘‘Disagree’’] (e.g., ‘‘Do you
feel that your situation is hopeless?’’). The measure demonstrates good psychometric
properties among primary care patients (Evans & Katona, 1993), nursing-home residents
(McGivney, Mulvihill, & Taylor, 1994), and psychogeriatric outpatients (Burke, Nitcher,
Roccaforte, & Wengel, 1992). Internal reliability in the current study was 0.83.
 Mental Health, Religion & Culture 7

Data analyses
Cronbach’s alphas were calculated to examine the internal consistency reliability of each
BMMRS domain. Zero-order correlations among the BMMRS domains and between
each domain and religious or spiritual coping variables (i.e., RCOPE and RPSS) were
obtained to examine convergent and discriminant validity. To examine associations
between BMMRS subscales and health outcomes, zero-order correlations between each
BMMRS subscale and measures of spiritual well-being, general satisfaction with life, and
anxiety/depressive symptoms were examined. Finally, four sets of simultaneous multiple
regressions were conducted to examine whether the BMMRS domains predict well-being
and psychological symptoms as a whole or uniquely. Variance inflation factor (VIF) and
tolerance (TOL) statistics were examined in conjunction with multiple regression analyses
to examine issues of multicollinearity. Statistical tests were two-sided with an alpha of
0.05. All analyses were carried out with SAS (Version 9.2, SAS Institute, Cary, NC).
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

Results
Internal consistency (Cronbach’s alpha) of most domains of the BMMRS was fair to
excellent (i.e., 0.62 to 0.90). However, congregation problems and religious/spiritual
intensity revealed poor internal consistency (alphas of 0.59 and 0.46, respectively), which
suggests that these two domains may be relatively less useful in older-adult populations.
Zero-order correlations between domains were positive and moderate; but they did not
fully covary and, thus, seem to represent distinct aspects of religious and spiritual
experience (see Table 1). In fact, the percentage of shared variance never exceeded 55%
(for the association between daily spiritual experience and values/beliefs). Of note, daily
spiritual experiences revealed the strongest correlations with the majority of other domains
(rs between 0.42 and 0.74); whereas congregation problems was not related to any other
domains, including congregation help (rs between 0.03 and 0.17).
There was evidence for convergent validity in all domains (except congregation
problems) with measures of religious coping (see Table 2). Specifically, nearly all BMMRS
domains were positively correlated with collaborative and deferring religious problem-
solving styles, as well as positive religious coping, and negatively correlated with self-
directed religious problem solving. Once again, the only exception was the congregation-
problems domain of the BMMRS, which was minimally related to measures of religious
coping (only a negative association with collaborative religious problem solving). Finally,
domains were unrelated to negative religious coping.
There was evidence for the predictive validity of most domains of the BMMRS, as
nearly all domains were positively associated with spiritual well-being as measured by the
Facit-Sp (once again, congregation problems was the exception). However, domains were
differentially associated with satisfaction with life and depressive/anxiety symptoms. Zero-
order correlations revealed that congregation help was associated with all measures of
well-being such that those higher in congregation help reported greater satisfaction with
life as well as fewer anxiety and depressive symptoms (see Table 3).
Multicollinearity was not an issue for any domains of the BMMRS (all VIF 510 and
all TOL 40.10). Therefore, simultaneous multiple regressions allowed us to examine the
ability of the BMMRS domains to predict well-being and psychological symptoms both as
a set and uniquely. Collectively, the set of eight BMMRS domains explained between 26%
and 68% of the variance in measures of well-being and psychological symptoms. Notably,
daily spiritual experiences uniquely predicted all outcomes (with the exception of anxiety),
 Downloaded by [Melinda Stanley] at 13:26 08 July 2011

Table 1. Means, standard deviations, reliability, and zero-order correlations between BMMRS domains.

BMMRS domain Mean (SD) 1 2 3 4 5 6 7 8

1. Daily spiritual experiences 26.18 (6.56) 0.88 0.61*** 0.42** 0.03 0.74*** 0.71*** 0.63*** 0.64***
2. Forgiveness (n ¼ 65) 9.97 (2.02) 0.76 0.34* 0.09 0.44*** 0.56*** 0.36*** 0.51***
3. Congregation benefits (n ¼ 55) 6.51 (1.61) 0.90 0.06 0.26 0.37** 0.23 0.52***
4. Congregation problems (n ¼ 55) 2.91 (1.11) 0.59 0.03 0.03 0.12 0.17
5. Values and beliefs (standardised) 0 (2.91) 0.70 0.68*** 0.67*** 0.58***
I believe in a God who watches over me 3.45 (0.91)
I feel a deep sense of responsibility for reducing pain and suffering 3.17 (0.74)
in the world
My whole approach to life is based on my religion 3.59 (1.19)
Belief in life after death 2.61 (0.60)
6. Private religious practices (standardised) 0 (3.94) 0.85 0.63*** 0.52***
How often do you pray privately in places other than at church 6.32 (2.19)
or synagogue?
A.L. Bush et al.

Within your religious or spiritual tradition, how often do you 5.26 (2.32)
meditate?
How often do you watch or listen to religious programs on TV 3.38 (2.27)
or radio?
How often do you read the Bible or other religious literature? 4.64 (2.36)
How often are prayers or grace said before meals in your home? 3.03 (1.44)
7. Meaning 6.05 (1.31) 0.62 0.36**
8. Intensity 6.23 (1.38) 0.46

Note: *p 5 0.05, **p 5 0.01, ***p 5 0.001. Cronbach’s alphas are listed along the major diagonal. N ¼ 66 unless otherwise noted. BMMRS ¼ Brief
Multidimensional Measure of Religiousness/Spirituality; SD ¼ standard deviation; means for individual items for values and beliefs and private religious
practices have been reverse scored.
 Mental Health, Religion & Culture 9

Table 2. Zero-order correlations between BMMRS domains and other measures of religion/
spirituality.

RPSS RPSS RPSS RCOPE RCOPE

BMMRS domain (Self-directed) (Collaborative) (Defer) (Pos) (Neg)

1. Daily spiritual experiences 0.77*** 0.78*** 0.66*** 0.85*** 0.15

2. Forgiveness 0.58*** 0.56*** 0.42*** 0.51*** 0.24
3. Congregation benefits 0.33* 0.34* 0.42*** 0.48*** 0.13
4. Congregation problems 0.07 0.27* 0.20 0.01 0.11
5. Values and beliefs 0.75*** 0.76*** 0.58*** 0.81*** 0.14
6. Private religious practices 0.76*** 0.74*** 0.61*** 0.80*** 0.04
7. Meaning 0.62*** 0.54*** 0.58*** 0.63*** 0.11
8. Intensity 0.54*** 0.56*** 0.43*** 0.57*** 0.08

Note: *p 5 0.05, **p 5 0.01, ***p 5 0.001. RPSS ¼ Religious Problem-Solving Scale,
RCOPE ¼ Brief Religious Coping Scale.
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

Table 3. Zero-order correlations between BMMRS domains and measures of well-being and
psychological symptoms.

BMMRS domain FACIT-Sp SWLS GAI GDS

1. Daily spiritual experiences 0.69*** 0.27* 0.25* 0.22

2. Forgiveness 0.45*** 0.19 0.24* 0.24
3. Congregation benefits 0.45*** 0.33* 0.34* 0.35**
4. Congregation problems 0.09 0.06 0.00 0.01
5. Values and beliefs 0.48*** 0.01 0.00 0.08
6. Private religious practices 0.63*** 0.11 0.16 0.15
7. Meaning 0.52*** 0.12 0.15 0.05
8. Intensity 0.46*** 0.20 0.23 0.17

Note: *p 5 0.05, **p 5 0.01, ***p 5 0.001. FACIT-Sp ¼ Functional Assessment of Chronic Illness
Therapy – Spiritual Well-being Scale, SWLS ¼ Satisfaction with Life Scale, GAI ¼ Geriatric Anxiety
Inventory, GDS ¼ Geriatric Depression Scale.

such that more frequent engagement in daily spiritual experiences was associated with
greater spiritual well-being, more satisfaction with life, and fewer depressive symptoms
(see Table 4).

Discussion
These preliminary findings suggest that the BMMRS is by and large a reliable and valid
measure for use in older populations. Aside from congregation problems and religious and
spiritual intensity, the domains have good internal consistency and appear suitable for use
in an older population. Internal consistency was notably larger in the current study relative
to previous psychometric work in a national sample (Idler et al., 2003) for forgiveness,
values/beliefs, and private religious practices. The congregation problems subscale has
illustrated lower reliability in other studies (e.g., Idler et al., 2003), suggesting that this
factor of the BMMRS is not consistent and may be of limited value. Additionally,
 10 A.L. Bush et al.

Table 4. Simultaneous multiple regression predicting well-being and psychological symptoms.

FACIT-Sp SWLS GAI GDS

BMMRS domain  SE  SE  SE  SE

1. Daily spiritual experiences 0.52*** 0.21 0.47* 0.26 0.26 0.19 0.42* 0.11
2. Forgiveness 0.06 0.53 0.06 0.67 0.02 0.50 0.06 0.29
3. Congregation benefits 0.04 0.54 0.13 0.67 0.11 0.50 0.18 0.29
4. Congregation problems 0.09 0.67 0.06 0.84 0.02 0.62 0.03 0.37
5. Values and beliefs 0.08 0.41 0.36y 0.51 0.36y 0.38 0.47* 0.22
6. Private religious practices 0.32** 0.29 0.08 0.36 0.01 0.27 0.04 0.16
7. Meaning 0.00 0.79 0.01 0.98 0.11 0.73 0.11 0.43
8. Intensity 0.20 0.82 0.19 1.03 0.35y 0.76 0.27 0.45
R2 0.68*** 0.29* 0.26 0.31*

Note: yp 5 0.08, *p 5 0.05, **p 5 0.01, ***p 5 0.001. FACIT-Sp ¼ Functional Assessment of
Chronic Illness Therapy – Spiritual Well-being Scale, SWLS ¼ Satisfaction with Life Scale,
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

GAI ¼ Geriatric Anxiety Inventory, GDS ¼ Geriatric Depression Scale.

intensity was the only BMMRS domain we examined that included both religious and
spiritual components by assessing intensity of religious beliefs and intensity of spiritual
beliefs. Although internal consistency of intensity was good in a national sample (Idler
et al., 2003), the poor internal consistency in the current study suggests that religion and
spirituality may be fundamentally distinct in an older-adult population and may be best
represented as separate constructs.
Many BMMRS domains are associated with positive religious coping and various
forms of religious problem solving, providing convergent validity for the measure.
Congregation problems revealed a different pattern than the other domains, as it was
rarely associated with the religious coping measures. This lack of association could be
attributed to its poor internal consistency. Additionally, many BMMRS domains have
value in predicting spiritual well-being, satisfaction with life, and mental health outcomes
in older populations. In particular, the extent to which one feels one has a strong religious
support system (congregation benefits) may be an especially important predictor of general
and psychological well-being. This is consistent with prior work on the BMMRS in
adolescents (Desrosiers & Miller, 2007) and chronic pain patients (Rippentrop et al.,
2005). The eight domains of the BMMRS examined in the current study as a whole are
useful in predicting well-being and psychological symptoms, explaining a good proportion
of the variance in these outcomes. The frequency with which one finds strength and
comfort in religion, is spiritually touched by the beauty of creation, and/or feels God’s
presence (i.e., Daily Spiritual Experiences) consistently emerged as the single best predictor
of spiritual well-being, satisfaction with life, and depressive symptoms. This implies that
frequently feeling intrapersonal peace and comfort is beneficial for one’s spiritual and
mental well-being, regardless of religious or spiritual behaviours (i.e., private religious
practices), interpersonal processes (i.e., social support, forgiveness), specific values/beliefs,
intensity of beliefs, and perceived meaning in one’s life. Working towards cultivating more
frequent daily spiritual experiences may be especially beneficial to one’s well-being.
This may perhaps be especially important for religious or spiritually oriented individuals,
like most of those in the current study.
Although the current study provides a useful evaluation of a multidimensional
measure of religion and spirituality in older adults, the study also has several notable
 Mental Health, Religion & Culture 11

limitations. First, the sample is small and non-representative, consisting of 90% who
identified themselves as Christians and nearly three fourths who reported that religion
and/or spirituality play a significant role in their life. The biased sample is likely a
product of inviting individuals to participate in a survey related to religion and
spirituality, as mostly those who were interested in this topic may have agreed to take
part. Although the BMMRS was designed for use within various religious affiliations
and among those with a variety of different beliefs, the current findings may not
generalise to samples of older adults who are less spiritually or religiously oriented or
who are members of other religious/spiritual affiliations. Second, the current study
examined the reliability and validity of eight domains of the BMMRS. A more
comprehensive evaluation of the measure would include all 12 domains. However, as
the BMMRS is intended to be used either in its entirety or in pieces, evaluation of the
reliability and validity of the eight domains described in this study is still useful and
suggests that the measure is largely appropriate for religiously or spiritually involved
older-adult populations. Further, although the reliability of most domains was
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

acceptable, congregation problems and religious and spiritual intensity demonstrated

poor internal consistency. Although these domains were assessed with only two items
(which automatically lowers internal consistency), their low reliability limits drawing
strong conclusions regarding these domains. Congregation problems has poor internal
consistency in other samples (Idler et al., 2003), suggesting that it may not be a useful
domain in general. The poor internal consistency for religious and spiritual intensity
within the current sample suggests that it may be best to measure religious intensity
and spiritual intensity separately within the older-adult population. Finally, the results
of the multiple regression analyses should be interpreted with some caution, given that
the ratio of predictors to participants (i.e., eight predictors and 66 participants) may
compromise the reliability of the results. However, post-hoc power analyses conducted
using G*Power3 (Faul, Erdfelder, Buchner, & Lang, 2009) revealed that there was
adequate power (0.80) to detect medium to large effects. Although we can have
confidence in the effects that were detected, subsequent evaluations of the uniqueness
of each domain of the BMMRS may be strengthened by use of a larger sample size in
order to potentially detect smaller unique effects.
The next step in this program of research would be to examine the potential value of
the BMMRS for integrating religion or spirituality in therapy. Those with certain religious
and spiritual qualities captured by the BMMRS might be more likely to favour integration
of religion or spirituality into therapy or more likely to benefit from spiritually integrated
therapy. The BMMRS will have enhanced usability and inform clinical practice to the
extent that it can help identify such individuals.
In sum, the BMMRS is a useful measure for the examination of various aspects of
religion and spirituality in older adults. Although the BMMRS accounts for a large
amount of the variance in outcomes, domains are largely distinct and are differentially
associated with satisfaction with life, as well as spiritual and mental well-being. Although
future work is needed, researchers may benefit from using the BMMRS in its entirety or in
pieces to identify older adults who may be especially good candidates for spiritually
integrated therapy.

Acknowledgements
This work was supported in part by the Health Services Research and Development Center of
Excellence [HFP90-020] and by a grant from the Veterans Affairs South Central Mental Illness
 12 A.L. Bush et al.

Research, Education and Clinical Center (MIRECC). The views expressed reflect those of the
authors and not necessarily those of the Department of Veterans Affairs (Baylor College of
Medicine).

References

Bosworth, H.B., Park, K.S., McQuoid, D.R., Hays, J.C., & Steffens, D.C. (2003). The impact of
religious practice and religious coping on geriatric depression. International Journal of Geriatric
Psychology, 10, 905–914.
Burke, W.J., Nitcher, R.L., Roccaforte, W.H., & Wengel, S.T. (1992). A prospective evaluation of
the geriatric depression scale in an outpatient geriatric assessment center. Journal of the American
Geriatric Society, 40, 1227–1230.
Cully, J.A., Paukert, A., Falco, J., & Stanley, M.A. (2009). Cognitive-behavioral therapy:
Innovations for cardiopulmonary patients with depression and anxiety. Cognitive and
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

Behavioral Practice, 16, 394–407.

Desrosiers, A., & Miller, L. (2007). Relational spirituality and depression in adolescent girls. Journal
of Clinical Psychology, 63, 1021–1037.
Diener, E., Emmons, R.A., Larson, R.J., & Griffin, S. (1985). The Satisfaction With Life Scale.
Journal of Personality Assessment, 49, 71–75.
Evans, S., & Katona, C. (1993). Epidemiology of depressive symptoms in elderly primary care
attenders. Dementia and Geriatric Cognitive Disorders, 4, 327–333.
Faul, F., Erdfelder, E., Buchner, A., & Lang, A.G. (2009). Statistical power analyses using
G*Power 3.1: Tests for correlation and regression analyses. Behavioral Research Methods, 41,
1149–1160.
Fetzer Institute/National Institute on Aging Working Group. (1999). Multidimensional measurement
of religiousness/spirituality for use in health research. Kalamazoo, MI: John E. Fetzer Institute.
Fox, C.A., Blanton, P.W., & Morris, M.L. (1998). Religious problem-solving styles: Three styles
revisited. Journal for the Scientific Study of Religion, 37, 673–677.
Hodge, D.R. (2006). Spiritually modified cognitive therapy: A review of the literature. Social Work,
51, 157–166.
Idler, E.L., Musick, M.A., Ellison, C.G., George, L.K., Krause, N., . . . , Ory, M.G. (2003).
Measuring multiple dimensions of religion and spirituality for health research: Conceptual
background and findings from the 1998 General Social Survey. Research on Aging, 25, 327–363.
Johnstone, B., Yoon, D.P., Franklin, K.L., Schopp, L., & Hinkebein, J. (2009). Re-conceptualizing
the factor structure of the brief multidimensional measure of religiousness/spirituality. Journal of
Religious Health, 48, 146–163.
King, M., Speck, P., & Thomas, A. (1995). The Royal Free interview for religious and spiritual
beliefs: Development and standardization. Psychological Medicine, 25, 1125–1134.
Koenig, H.G. (1995). Research in religion and aging. Westport, CT: Greenwood.
Koenig, H.G. (1998). Religious attitudes and practices of hospitalized medically ill older adults.
International Journal of Geriatric Psychiatry, 13, 213–224.
Krause, N. (1995). Religiosity and self-esteem among older adults. Journal of Gerontology:
Psychological Sciences, 50, 236–246.
Levin, J.S. (1994). Religion in aging and health. Thousand Oaks, CA: Sage.
Lindgren, K.N., & Coursey, R.D. (1995). Spirituality and serious mental illness: A two-part study.
Psychosocial Rehabilitation Journal, 18, 93–111.
McGivney, S.A., Mulvihill, M., & Taylor, B. (1994). Validating the GDS depression screen in the
nursing home. Journal of American Geriatric Society, 42, 490–492.
Neff, J.A. (2006). Exploring the dimensionality of ‘‘religiosity’’ and ‘‘spirituality’’ in the Fetzer
multidimensional measure. Journal for the Scientific Study of Religion, 45, 449–459.
 Mental Health, Religion & Culture 13

Newport, F. (2006). Religion most important to blacks, women, and older Americans. Retrieved
February 11, 2010 from http://www.gallup.com/poll/25585/Religion-Most-Important-Blacks-
Women-Older-Americans.aspx
Pachana, N.A., Byrne, G.J., Siddle, H., Koloski, N., Harley, E., & Arnold, E. (2006).
Development and validation of the Geriatric Anxiety Inventory. International
Psychogeriatrics, 18, 1–12.
Pargament, K.I., Koenig, H.G., Tarakeshwar, N., & Hahn, J. (2004). Religious coping methods as
predictors of psychological, physical and spiritual outcomes among medically ill elderly patients:
A two-year longitudinal study. Journal of Health Psychology, 9, 713–730.
Pargament, K.I., Smith, B.W., & Koenig, H.G. (1998). Patterns of positive and negative religious
coping with major life stressors. Journal for the Scientific Study of Religion, 37, 710–724.
Paukert, A.L., Phillips, L.L., Cully, J.A., Romero, C., & Stanley, M.A. (in press). Systematic review
of the effects of religion-accommodative psychotherapy for depression and anxiety. Journal of
Contemporary Psychotherapy.
Pavot, W., & Diener, E. (1993). Review of the Satisfaction With Life Scale. Psychological
Assessment, 5, 164–172.
Peterman, A.H., Fitchett, G., Brady, M.J., Hernandez, L., & Cella, D. (2002). Measuring spiritual
Downloaded by [Melinda Stanley] at 13:26 08 July 2011

well-being in people with cancer: The functional assessment of chronic illness therapy – spiritual
well-being scale. Annuals of Behavioral Medicine, 24, 49–58.
Plante, T.G., & Boccaccini, M.T. (1997). The Santa Clara Strength of Religious Faith Questionnaire.
Pastoral Psychology, 45, 375–387.
Rippentrop, A.E., Altmaier, E.M., Chen, J.J., Found, E.M., & Keffala, V.J. (2005). The relationship
between religion/spirituality and physical health, mental health, and pain in a chronic pain
population. Pain, 116, 311–321.
Rose, E.M., Westefield, J.S., & Ansley, T.N. (2001). Spiritual issues in counseling: Clients’ beliefs
and preferences. Journal of Counseling Psychology, 48, 61–71.
Rosmarin, D.H., Pargament, K.I., Pirutinsky, S., & Mahoney, A. (2010). A randomized controlled
evaluation of a spiritually integrated treatment for subclinical anxiety in the Jewish community,
delivered via the internet. Journal of Anxiety Disorders, 24, 799–808.
Smith, T.B., Bartz, J., & Richards, P.S. (2007). Outcomes of religious and spiritual adaptations to
psychotherapy: A meta-analytic review. Psychotherapy Research, 17, 643–655.
Stanley, M.A., Bush, A.L., Camp, M.E., Jameson, J.P., Phillips, L.L., Barber, et al. (in press). Older
adults’ preferences for religion/spirituality in treatment for anxiety and depression. Aging and
Mental Health.
Stanley, M.A., Wilson, N.L., Novy, D.M., Rhoades, H.M., Wagener, P.D., . . . , Kunik, M.E. (2009).
Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care.
JAMA, 301, 1460–1467.
Tartaro, J., Luecken, L.J., & Gunn, H.E. (2005). Exploring heart and soul: Effects of religiosity/
spirituality and gender on blood pressure and cortisol stress responses. Journal of Health
Psychology, 10, 753–766.
Tepper, L., Rogers, S.A., Coleman, E.M., & Malony, H.N. (2001). The prevalence of religious
coping among persons with persistent mental illness. Psychiatric Services, 52, 660–665.
Weaver, A.J., Flannelly, L.T., Strock, A.L., Krause, N., & Flannelly, K.J. (2005). The quantity and
quality of religion and spirituality in four major gerontology journals between 1985 and 2002.
Research on Aging, 27, 119–135.
Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V.S., . . . , Adey, M.B. (1983).
Development and validation of a geriatric depression screening scale: A preliminary report.
Journal of Psychiatric Research, 17, 37–39.

View publication stats