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Patterns of Positive and Negative Religious Coping with Major Life Stressors
Abstract
Kenneth I. Pargament, Bruce W. Smith, Harold G. Koenig, Lisa Perez, Patterns of Positive and Negative Religious Coping with Major Life Stressors, Journal for the Scientific Study of Religion, Vol. 37, No. 4 (Dec., 1998), pp. 710-724
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“However, other studies reported that sometimes religion and/or spiritual coping are maladaptive (ie, negative religious coping), including deferring all responsibility to God, feeling abandoned by God when support is needed, or blaming God for difficulties.128,129”
From Pain and Evil: From Local Nociception to Misery Following Social Harm (2020) · cites this paper as [128]
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Hill, P. C., & Pargament, K. I. (2003) · American Psychologist · doi:10.1037/0003-066x.58.1.64 · Cited by 1,948
“…quality of life, panic disorder, and suicidality (Exline et al., 2000; Hays, Meador, Branch, & George, 2001; Krause, Ingersoll- Dayton, Ellison, & Wulff, 1999; Pargament et al., 2000; Pargament, Smith, Koenig, & Perez, 1998; Pargament, Zinnbauer, et al., 1998; Trenholm, Trent, & Compton, 1998).”
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“23,24 Given that global health outcomes are influenced by health care access, and considering increases in patient dissatisfaction and clinician burnout, addressing spirituality is both relevant and timely.”
The Brief RCOPE: Current Psychometric Status of a Short Measure of Religious Coping
Pargäment, K. I., Feuille, M., & Burdzy, D. C. (2011) · Religions · doi:10.3390/rel2010051 · Cited by 1,193
“Factor analysis of that abbreviated scale revealed a twofactor solution which accounted for approximately 33% of the variance [25].”
InfluentialPrati, G., & Pietrantoni, L. (2009) · Journal of Loss and Trauma · doi:10.1080/15325020902724271 · Cited by 978
Pargament, K. I., Koenig, H. G., Tarakeshwar, N., & Hahn, J. (2004) · Journal of Health Psychology · doi:10.1177/1359105304045366 · Cited by 912
“In contrast, researchers have linked several negative religious coping methods crosssectionally to poorer spiritual, psychological and physical health: spiritual discontent, punitive religious reframing, self-directing religious coping and congregational discontent (e.g. Exline, Yali, & Lobel, 1999; Koenig, Pargament,…”
BackgroundSelf-citationPositive Adjustment to Threatening Events: An Organismic Valuing Theory of Growth through Adversity
Joseph, S., & Linley, P. A. (2005) · Review of General Psychology · doi:10.1037/1089-2680.9.3.262 · Cited by 991
Pargament, K. I., Koenig, H. G., Tarakeshwar, N., & Hahn, J. (2001) · Archives of Internal Medicine · doi:10.1001/archinte.161.15.1881 · Cited by 759
“Positive religious coping and religious struggle with the illness at baseline were measured with the Brief RCOPE.(12) This is a 14-item questionnaire that assesses the extent to which the patient uses specific methods of religious coping.”
BackgroundMethodInfluentialSelf-citationTheorizing Religious Effects Among American Adolescents
Smith, C. S. (2003) · Journal for the Scientific Study of Religion · doi:10.1111/1468-5906.t01-1-00158 · Cited by 691
“Most American religions comprise and foster many beliefs and practices that can strengthen young people's ability effectively to cope with life's problems (Pargament et al. 1998; Ellison 1991; Koenig, George, and Siegler 1988).”
BackgroundThe Religious and Spiritual Struggles Scale: Development and initial validation.
Exline, J. J., Pargament, K. I., Grubbs, J. B., & Yali, A. M. (2014) · Psychology of Religion and Spirituality · doi:10.1037/a0036465 · Cited by 682
“The most comprehensive is the full RCOPE (Pargament, Koenig, & Perez, 2000).”
MethodInfluentialGod and the government: Testing a compensatory control mechanism for the support of external systems
Kay, A. C., Gaucher, D., Napier, J. L., Callan, M. J., & Laurin, K. (2008) · Journal of Personality and Social Psychology · doi:10.1037/0022-3514.95.1.18 · Cited by 809
Measuring Multiple Dimensions of Religion and Spirituality for Health Research
Idler, E. L., Musick, M. A., Ellison, C. G., George, L. K., KRAUSE, N. M., Ory, M. G., Pargäment, K. I., Powell, L. H., Underwood, L. G., & Williams, D. R. (2003) · Research on Aging · doi:10.1177/0164027503025004001 · Cited by 639
“The items we propose assess (1) positive religious coping reflective of benevolent religious methods of understanding and dealing with life stressors and (2) negative religious coping reflective of religious struggle and are taken from Pargament et al. (1998) and Pargament, Koenig, and Perez (2000).”
MethodTARGET ARTICLE: The Bitter and the Sweet: An Evaluation of the Costs and Benefits of Religiousness
Pargäment, K. I. (2002) · Psychological Inquiry · doi:10.1207/s15327965pli1303_02 · Cited by 606
WHOQOL SRPB Group (2005) · Social Science & Medicine · doi:10.1016/j.socscimed.2005.08.001 · Cited by 629
Religious and spiritual struggles.
(2012) · American Psychological Association eBooks · doi:10.1037/14045-025 · Cited by 567
Griffiths, R. R., Johnson, M. W., Richards, W. A., Richards, B. D., Jesse, R., MacLean, K. A., Barrett, F. S., Cosimano, M. P., & Klinedinst, M. A. (2018) · Journal of Psychopharmacology · doi:10.1177/0269881117731279 · Cited by 520
“…Protestant traditions (Benson et al., 1993); Brief RCOPE , a measure of religious/spiritual coping with stressful life events (Pargament, 1999; Pargament et al., 1998); Daily Spiritual Experience Scale , a measure of an individual’s perception of and interaction with the transcendent in daily…”
BackgroundReligion and Health: Public Health Research and Practice
Chatters, L. M. (2000) · Annual Review of Public Health · doi:10.1146/annurev.publhealth.21.1.335 · Cited by 537
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“These actions lead to less psychological distress (25).”
BackgroundRowatt, W. C., & Kirkpatrick, L. A. (2002) · Journal for the Scientific Study of Religion · doi:10.1111/1468-5906.00143 · Cited by 456
“This stress-buffering process might be partially responsible for positive influences of religion on coping (Pargament et al. 1998; Solomon et al. 1998) and on mental or physical health (cf.”
BackgroundReligion, Spirituality, and Health in Medically Ill Hospitalized Older Patients
Koenig, H. G., George, L. K., & Titus, P. (2004) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52161.x · Cited by 435
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“Negative religious coping is viewed as an expression from a less secure relationship with God who is distant and punishing, or as a religious struggle in the search for significance (Pargament et al., 1998).”
BackgroundAltruistic Social Interest Behaviors Are Associated With Better Mental Health
Schwartz, C. E., Meisenhelder, J. B., Ma, Y., & Reed, G. W. (2003) · Psychosomatic Medicine · doi:10.1097/01.psy.0000079378.39062.d4 · Cited by 405
“coping measure, the Brief RCOPE (40), which contains positive coping”
BackgroundMahoney, A., Pargament, K. I., Tarakeshwar, N., & Swank, A. B. (2001) · Journal of Family Psychology · doi:10.1037//0893-3200.15.4.559 · Cited by 393
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“Items from two scales, the Brief Measure of Religious Coping (RCOPE) 33 and the Multidimensional Measure of Religion/Spirituality (MMRS) 34 were used to assess the religious coping strategies used by the participants.”
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“Pargament et al. (1998) examine the role of religion as a coping tool, making a distinction between positive and negative religious coping.”
BackgroundThe epidemiology of religious coping: a review of recent literature
Harrison, M. O., Koenig, H. G., Hays, J. C., Eme-Akwari, A. G., & Pargäment, K. I. (2001) · International Review of Psychiatry · doi:10.1080/09540260120037317 · Cited by 394
Self-citationExline, J. J., Park, C. L., Smyth, J. M., & Carey, M. P. (2011) · Journal of Personality and Social Psychology · doi:10.1037/a0021716 · Cited by 389
“Recent work in psychology has focused on perceived attachment bonds with God (e.g., R. Beck & McDonald, 2004; Kirkpatrick, 1998, 2004) and the use of religion and spirituality as coping mechanisms (e.g., Pargament, 1997, 2007; Pargament et al., 1998).”
BackgroundMahoney, A., Pargäment, K. I., Tarakeshwar, N., & Swank, A. B. (2001) · Journal of Family Psychology · doi:10.1037/0893-3200.15.4.559 · Cited by 358
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Self-citationReligion, spirituality, and posttraumatic growth: a systematic review
Shaw, A., Joseph, S., & Linley, P. A. (2005) · Mental Health, Religion & Culture · doi:10.1080/1367467032000157981 · Cited by 538
“Pargament et al. (1998) found that posttraumatic growth was associated with both positive and negative religious coping.”
BackgroundKoenig, H. G., Zaben, F. A., Khalifa, D. A., & Shohaib, S. A. (2014) · Elsevier eBooks · doi:10.1016/b978-0-12-386915-9.00019-x · Cited by 347
Self-citationGall, T. L., Charbonneau, C., Clarke, N. H., Grant, K., Joseph, A., & Shouldice, L. (2005) · Canadian Psychology/Psychologie canadienne · doi:10.1037/h0087008 · Cited by 346
McConnell, K. M., Pargament, K., Ellison, C. G., & Flannelly, K. (2006) · Journal of Clinical Psychology · doi:10.1002/jclp.20325 · Cited by 342
“However, spiritual struggles have also been tied to posttraumatic growth (Pargament et al., 1998, 2000), suggesting that spiritual struggles are, at times, associated with personal improvement.”
BackgroundInfluentialSpiritual Struggles and Psychological Distress: Is There a Dark Side of Religion?
Ellison, C. G., & Lee, J. (2009) · Social Indicators Research · doi:10.1007/s11205-009-9553-3 · Cited by 319
“…(PTSD) among victims of the 1993 Midwest floods and members of churches located near the site of the Oklahoma City bombing (Pargament et al. 1994; Pargament et al. 1998; Smith et al. 2000); (c) higher levels of anxiety, phobic anxiety, depression, paranoid ideation, obsessive-compulsive…”
BackgroundByrd, D. R., & McKinney, K. J. (2012) · Journal of American College Health · doi:10.1080/07448481.2011.584334 · Cited by 315
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Spiritual Struggle: A Phenomenon of Interest to Psychology and Religion.
Pargament, K., Murray-Swank, N. A., Magyar, G. M., & Ano, G. (2005) · American Psychological Association eBooks · doi:10.1037/10859-013 · Cited by 301
Quality-of-life and spirituality
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Panzini, R. G., da Rocha, N. S., Bandeira, D. R., & Fleck, M. P. D. A. (2007) · Archives of Clinical Psychiatry (São Paulo) · doi:10.1590/s0101-60832007000700014 · Cited by 301
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Hebert, R., Zdaniuk, B., Schulz, R., & Scheier, M. (2009) · Journal of Palliative Medicine · doi:10.1089/jpm.2008.0250 · Cited by 285
“) reflects a tenuous relationship with God and is associated with worse well-being in people with cancer.(9,10) Unlike dispositional measures of religiousness, these measures focus more specifically on how people actually use religion in times of crisis.”
Daily Spiritual Experiences and Psychological Well-being Among US Adults
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“On the other hand, religiosity can also have negative or harmful effects mental health when it involves negative affective attitudes regarding God, negative religious behaviors, and spiritual struggles (Pargament et al. 1998).”
BackgroundGarcía, F. E., Barraza-Peña, C. G., Włodarczyk, A., Alvear-Carrasco, M., & Reyes‐Reyes, A. (2018) · Psicologia Reflexão e Crítica · doi:10.1186/s41155-018-0102-3 · Cited by 278
Religious coping among diverse religions: Commonalities and divergences.
Abu‐Raiya, H., & Pargäment, K. I. (2014) · Psychology of Religion and Spirituality · doi:10.1037/a0037652 · Cited by 302
“On conceptual and empirical grounds, Pargament et al. (1998) distinguished between two categories of religious coping: Positive religious coping and negative religious coping.”
BackgroundTrevino, K. M., Pargament, K. I., Cotton, S., Leonard, A. C., Hahn, J., Caprini-Faigin, C. A., & Tsevat, J. (2010) · AIDS and Behavior · doi:10.1007/s10461-007-9332-6 · Cited by 273
“Positive religious coping includes strategies such as seeking spiritual support, benevolent religious reappraisals (e.g., trying to find a lesson from God in the event), and purification rituals (Pargament et al. 1998).”
BackgroundMeasuring Religiousness in Health Research: Review and Critique
Hall, D. E., Meador, K. G., & Koenig, H. G. (2008) · Journal of Religion and Health · doi:10.1007/s10943-008-9165-2 · Cited by 264
“Establishing the Specific Context Although recent studies embody a preference for context-free approaches to religious measurement, many of the earliest attempts to measure religiousness pursued the alternate strategy of developing a unique instrument for each specific religious context (Hill and Hood 1999) and this s…”
BackgroundSelf-citationWitvliet, C. V., Phipps, K. A., Feldman, M. E., & Beckham, J. C. (2004) · Journal of Traumatic Stress · doi:10.1023/b:jots.0000029270.47848.e5 · Cited by 262
“Negative religious coping may be associated with greater mental and physical health problems (Koenig et al., 1998; Pargament et al., 1998), whereas positive religious coping may be associated with less psychological distress (Pargament et al., 1998).”
BackgroundMethodInfluentialHamby, S. L., Grych, J. H., & Banyard, V. (2017) · Psychology of Violence · doi:10.1037/vio0000135 · Cited by 304
“” The Religious Meaning Making scale consists of 11 items (Amato, 1990; Levin, Markides, & Ray, 1996; Pargament et al., 1998; Putney & Middleton, 1961) assessing engagement in religious and spiritual practices.”
BackgroundCEO early‐life disaster experience and corporate social performance
O’Sullivan, D., Zolotoy, L., & Fan, Q. (2021) · Strategic Management Journal · doi:10.1002/smj.3293 · Cited by 254
Religion, spirituality and cancer: Current status and methodological challenges
Stefanek, M. E., Green, P. A., & Hess, S. A. (2004) · Psycho-Oncology · doi:10.1002/pon.861 · Cited by 262
Fitchett, G. A., Murphy, P. E., Kim, J., Gibbons, J. L., Cameron, J. R., & Davis, J. A. (2004) · The International Journal of Psychiatry in Medicine · doi:10.2190/ucj9-dp4m-9c0x-835m · Cited by 246
“The measure of religious struggle employed for all three studies was the seven-item negative religious coping subscale from the Brief RCOPE [20].”
BackgroundMethodInfluentialStress-Related Growth: Predictors of Occurrence and Correlates with Psychological Adjustment
Park, C. L., & Fenster, J. R. (2004) · Journal of Social and Clinical Psychology · doi:10.1521/jscp.23.2.195.31019 · Cited by 260
Ivtzan, I., Chan, C. P. L., Gardner, H. E., & Prashar, K. (2011) · Journal of Religion and Health · doi:10.1007/s10943-011-9540-2 · Cited by 244
“There have been extensive reviews on the various mechanisms through which religion is beneficial, as well as detrimental, on specific aspects of psychological health (Pargament 1997; Pargament et al. 1998; Schumaker 1992).”
BackgroundSpirituality and health: What’s the evidence and what’s needed?
Thoresen, C. E., & Harris, A. H. S. (2002) · Annals of Behavioral Medicine · doi:10.1207/s15324796abm2401_02 · Cited by 244
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Reinert, K. G., & Koenig, H. G. (2013) · Journal of Advanced Nursing · doi:10.1111/jan.12152 · Cited by 266
“The nature of one’s spiritual experience varies and can either produce negative emotions (guilt, bitterness) during trying life experiences resulting in negative mental health outcomes (Pargament et al. 1998, Koenig et J Adv Nurs.”
BackgroundSelf-citationThe role of religion in medical rehabilitation outcomes: A longitudinal study.
Fitchett, G. A., Rybarczyk, B. D., DeMarco, G. A., & Nicholas, J. J. (1999) · Rehabilitation Psychology · doi:10.1037/0090-5550.44.4.333 · Cited by 238
Older adults’ preferences for religion/spirituality in treatment for anxiety and depression
Stanley, M. A., Amspoker, A. B., Camp, M. E., Jameson, J. P., Phillips, L. L., Barber, C. R., Zeno, D., Lomax, J. W., & Cully, J. A. (2011) · Aging & Mental Health · doi:10.1080/13607863.2010.519326 · Cited by 249
“Internal consistency and validity are adequate, and the Brief Religious Coping has been used in a variety of populations, including adults living with physical and mental illnesses (Pargament et al., 1998).”
Lucchetti, G., Góes, L. G., Amaral, S. G., Ganadjian, G. T., Andrade, I., Almeida, P. O. D. A., do Carmo, V. M., & Manso, M. E. G. (2020) · International Journal of Social Psychiatry · doi:10.1177/0020764020970996 · Cited by 247
“…individuals in a positive (e.g. meaning to be found, spiritual connection and benevolent religious reappraisals) or a negative way (e.g. religious struggle, punishment and reappraisal of God’s power) and, for this reason, it could have positive or deleterious consequences (Pargament et al., 1998).”
BackgroundExline, J. J., Yali, A. M., & Lobel, M. (1999) · Journal of Health Psychology · doi:10.1177/135910539900400306 · Cited by 225
Moadel, A. B., Morgan, C., Fatone, A., Grennan, J., Carter, J., LaRuffa, G. M., Skummy, A., & Dutcher, J. P. (1999) · Psycho-Oncology · doi:10.1002/(sici)1099-1611(199909/10)8:5 · Cited by 413
Nooney, J. G., & Woodrum, E. (2002) · Journal for the Scientific Study of Religion · doi:10.1111/1468-5906.00122 · Cited by 225
Yanez, B., Edmondson, D., Stanton, A. L., Park, C. L., Kwan, L., Ganz, P. A., & Blank, T. O. (2009) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0015820 · Cited by 223
Posttraumatic stress disorder and posttraumatic growth among Israeli ex‐pows
Solomon, Z., & Dekel, R. (2007) · Journal of Traumatic Stress · doi:10.1002/jts.20216 · Cited by 223
Coping (enfrentamento) religioso/espiritual
Panzini, R. G., & Bandeira, D. R. (2007) · Archives of Clinical Psychiatry (São Paulo) · doi:10.1590/s0101-60832007000700016 · Cited by 220
Religious delusions in patients admitted to hospital with schizophrenia
Siddle, R., Haddock, G., Tarrier, N., & Faragher, E. B. (2002) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s001270200005 · Cited by 218
Spirituality, Religion, and Health
Yuen, E. J. (2007) · American Journal of Medical Quality · doi:10.1177/1062860606298872 · Cited by 218
Addressing Patients’ Emotional and Spiritual Needs
Clark, P. A., Drain, M., & Malone, M. P. (2003) · The Joint Commission Journal on Quality and Safety · doi:10.1016/s1549-3741(03)29078-x · Cited by 214
The moral injury symptom scale-military version
Koenig, H. G., Ames, D., Youssef, N. A., Oliver, J. P., Volk, F., Teng, E. J., Haynes, K., Erickson, Z. D., Arnold, I., O’Garo, K., et al. (2018) · Journal of Religion and Health · doi:10.1007/s10943-017-0531-9 · Cited by 213
“Religious struggles were assessed by seven items taken from the negative religious coping subscale of the Brief RCOPE (Pargament et al. 1998).”
MethodSelf-citationPosttraumatic Resilience in Former Ugandan Child Soldiers
Klasen, F., Oettingen, G., Daniels, J. K., Post, M., Hoyer, C., & Adam, H. (2010) · Child Development · doi:10.1111/j.1467-8624.2010.01456.x · Cited by 213
Resilience: The Science of Mastering Life's Greatest Challenges
Southwick, S. M., & Charney, D. S. (2012) · Cited by 212
Bradley, R. G., Schwartz, A. C., & Kaslow, N. J. (2005) · Journal of Traumatic Stress · doi:10.1002/jts.20077 · Cited by 230
“As an example, one study of heart patients found that negative religious coping predicted morbidity (Pargament et al., 1998).”
Ai, A. L., Park, C. L., Huang, B., Rodgers, W., & Tice, T. N. (2007) · Personality and Social Psychology Bulletin · doi:10.1177/0146167207301008 · Cited by 186
“In the original article on these religious coping styles, both positive and negative types were cross-sectionally related to heightened distress (Pargament et al., 1998).”
BackgroundReligion and anxiety: A critical review of the literature
Shreve-Neiger, A., & Edelstein, B. A. (2004) · Clinical Psychology Review · doi:10.1016/j.cpr.2004.02.003 · Cited by 206
Ahmed, A. E., Ucbasaran, D., Cacciotti, G., & Williams, T. A. (2022) · Entrepreneurship Theory and Practice · doi:10.1177/10422587211046542 · Cited by 252
“Resilience does not exist in isolation of attempts to mitigate stressors, and can be influenced by efforts to adaptively copewith disruptive stress (e.g., Folkman, 2011; Hobfoll, 2011; Lazarus, 2000; Pargament et al., 1998).”
BackgroundKeefe, F. J., Affleck, G., Lefebvre, J., Underwood, L., Caldwell, D. S., Drew, J., Egert, J., Gibson, J., & Pargament, K. (2001) · The Journal of Pain · doi:10.1054/jpai.2001.19296 · Cited by 202
Heitzmann, C. A., Merluzzi, T. V., Jean‐Pierre, P., Roscoe, J. A., Kirsh, K. L., & Passik, S. D. (2010) · Psycho-Oncology · doi:10.1002/pon.1735 · Cited by 203
“The Brief Religious Coping Scale [32] is a 14-item measure that was designed to assess two rather distinct patterns of religious coping.”
BackgroundPargäment, K. I., & Abu‐Raiya, H. (2007) · Psyke & Logos · doi:10.7146/pl.v28i2.8398 · Cited by 209
Abu‐Raiya, H., Pargäment, K. I., & KRAUSE, N. M. (2015) · Quality of Life Research · doi:10.1007/s11136-015-1163-8 · Cited by 210
“Positive religious coping activities reflect a secure relationship with God, a belief in a greater benevolence in the universe, and a sense of spiritual connectedness with others [37].”
BackgroundReligiousness and Depressive Symptoms Among Adolescents
Pearce, M., Little, T. D., & Pérez, J. E. (2003) · Journal of Clinical Child & Adolescent Psychology · doi:10.1207/s15374424jccp3202_12 · Cited by 200
Thomas, J., & Barbato, M. (2020) · Religions · doi:10.3390/rel11100498 · Cited by 237
“The Brief RCOPE-14 (Positive Coping Subscale) Grounded in coping theory, the Brief RCOPE-14 (Pargament et al. 1998) assesses the extent to which religion plays an active role in an individual’s interpretation of, and responses to, major life stressors.”
MethodSpirituality moderates the effect of stress on emotional and physical adjustment
Kim, Y., & Seidlitz, L. (2002) · Personality and Individual Differences · doi:10.1016/s0191-8869(01)00128-3 · Cited by 202
Sullivan, M. J., Wood, L., Terry, J., Brantley, J., Charles, A., McGee, V., Johnson, D., Krucoff, M. W., Rosenberg, B., Bosworth, H. B., et al. (2009) · American Heart Journal · doi:10.1016/j.ahj.2008.08.033 · Cited by 188
Metadata
- Authors
- Pargament, K. I., Smith, B. W., Koenig, H. G., & Perez, L.
- Venue
- Journal for the Scientific Study of Religion
- Publisher
- JSTOR
- Published
- 1998-12
- Volume
- 37
- Issue
- 4
- Pages
- 710
- ISSN
- 0021-8294 (ISSN-L)
- OpenAlex
- W38293527
- Cited by
- 2,425
- References
- 36
- Citations by year
- 2026: 104 · 2025: 122 · 2024: 113 · 2023: 157 · 2022: 122 · 2021: 134 · 2020: 148 · 2019: 105 · 2018: 100 · 2017: 105 · 2016: 91 · 2015: 120 · 2014: 124 · 2013: 123 · 2012: 117
- FWCI
- 12.69
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal for the Scientific Study of Religion (publishedVersion)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Topics
- Social Sciences › Health › Religion, Spirituality, and Psychology
- Social Sciences › Sociology and Political Science › Religion and Society Interactions
- Social Sciences › Psychology › Applied Psychology › Optimism, Hope, and Well-being
- Keywords
- religious coping, positive religious coping, negative religious coping, religion and mental health
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