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The role of attachment to God in

secular and religious/spiritual ways of
coping with a serious disease
a a a
Rosalinda Cassibba , Sonia Papagna , Maria T. Calabrese ,
a b c
Elisabetta Costantino , Angelo Paterno & Pehr Granqvist
a
Dept of Educational Science, Psychology and Communication,
University of Bari, Bari, Italy
b
Dept of Nephrology and Dialysis, Di Venere Hospital, Bari, Italy
c
Dept of Psychology, Stockholm University, Stockholm, Sweden
Published online: 14 May 2013.

To cite this article: Rosalinda Cassibba, Sonia Papagna, Maria T. Calabrese, Elisabetta Costantino,
Angelo Paterno & Pehr Granqvist (2014) The role of attachment to God in secular and religious/
spiritual ways of coping with a serious disease, Mental Health, Religion & Culture, 17:3, 252-261,
DOI: 10.1080/13674676.2013.795138

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 Mental Health, Religion & Culture, 2014
Vol. 17, No. 3, 252–261, http://dx.doi.org/10.1080/13674676.2013.795138

The role of attachment to God in secular and religious/spiritual

ways of coping with a serious disease
Rosalinda Cassibbaa*, Sonia Papagnaa, Maria T. Calabresea, Elisabetta Costantinoa,
Angelo Paternob and Pehr Granqvistc
a
Dept of Educational Science, Psychology and Communication, University of Bari, Bari, Italy; bDept of
Nephrology and Dialysis, Di Venere Hospital, Bari, Italy; cDept of Psychology, Stockholm University,
Stockholm, Sweden
Downloaded by [New York University] at 00:38 06 October 2014

(Received 6 March 2013; final version received 9 April 2013)

This study investigated the role of security in one’s attachment to God in relation to both
secular and religious/spiritual ways of coping with a serious illness. The main objective was
to test whether attachment to God and type of disease were related to secular coping
strategies, when controlling for the effects of religious/spiritual coping. Study participants
(N = 105) had been diagnosed either with cancer (i.e., an acute disease) and were under
chemotherapy/awaiting surgery or with renal impairment (i.e., a chronic disease) and were
attending dialysis. Results showed that secure attachment to God was uniquely related to
fighting spirit, whereas insecure attachment to God was uniquely linked to hopelessness,
suggesting that security, unlike insecurity, in one’s attachment to God may impact
favourably on adjustment to the disease. The only coping strategy related to type of disease
was cognitive avoidance, which was linked to chronic disease.
Keywords: attachment to God; religious coping; secular coping

When people are coping with a life-threatening stressor, they need to activate all the resources
they have available. Attachment-related internal working models (IWMs) may be some of
these inner resources contributing to dealing with stress (e.g., Mikulincer & Florian, 1998), but
the role of one’s IWMs specifically with regard to God remains largely unexplored. Thus, in
the present study we asked whether individual differences in the security of one’s attachment
to God relate to the general ways in which people cope with a serious illness. And does it
matter whether the illness is chronic or acute?

Coping, adjustment and physical health

Lazarus and Folkman (1984, p. 141) defined the process of coping as the “constantly changing
cognitive and behavioural efforts to manage specific external and/or internal demands that are
appraised as taxing or exceeding the resources of the person”. In general, there are differences
both in the situational (e.g., controllability and severity of the stressor) and personal character-
istics (e.g., cognitive, affective, behavioural and physiological ones) related to coping. Depending
on a stressor’s severity, individuals resort to different personal and social resources. According to

*Corresponding author. Email: rosalinda.cassibba@uniba.it

© 2013 Taylor & Francis

 Mental Health, Religion & Culture 253

Bodenmann’s (2005) stress cascade model, for example, individuals turn to social support when
the stressor exceeds available personal coping strategies. Other studies have reported spirituality
and religious coping methods to be among the most common ways of coping with physical
illness-related stressors (Gall et al., 2005; Pargament, 1997; Wallston et al., 1999).
Coping strategies are relevant in relation to physical health because maladaptive (passive or
negative) forms of coping are predictive of poor outcomes in adjustment to disease and in non-
compliance with medical therapies (Ayres et al., 1994; Carroll, Cassidy, & Côté, 2006; Greer,
Morris, & Pettingale, 1979; Leyshon, 2009; Turner, Jensen, & Romano, 2000; Watson, Haviland,
Greer, Davidson, & Bliss, 1999). Serious diseases such as cancer or chronic impairment are major
life stressors that could threaten survival or strongly damage the quality of a person’s life.
Greer and associates have proposed a model of mental adjustment to cancer in which they sum-
marised the most significant responses in five different strategies (Greer et al., 1979; Greer & Watson,
1987; Morris, Blake, & Buckley, 1985). Mental adjustment is interpreted as composed of appraisal
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(i.e., the individual perception of the implications of cancer) and the ensuing reactions to the stressor
(i.e., the patient’s thoughts and strategies to reduce threat). The main strategies defined by Greer and
associates were fighting spirit, anxious preoccupation, fatalism, hopelessness–helplessness and cog-
nitive avoidance. Each is associated with specific levels of depression or anxiety (Watson et al.,
1994). More specifically, hopelessness and anxious preoccupation have been found to be
highly positively correlated with anxiety and depression levels, while fighting spirit has been nega-
tively associated with anxiety and depression (Watson et al., 1994). Fighting spirit has also been posi-
tively related to more compliance to treatments and higher levels of adjustment (Ayres et al., 1994;
Grassi, Rosti, Lasalvia, & Marangolo, 1993). These coping strategies have been found relevant also
in mental adjustment to other diseases, such as muscular dystrophy, stroke or HIV-infection
(Ahlstrom & Sjoden, 1994; Kelly et al., 2000; Lewis, Dennis, O’Rourke, & Sharpe, 2001).

Attachment, religion and coping

According to Bowlby’s (1969) attachment theory, one’s evolved attachment behavioural system is
activated when people are confronted with natural clues to danger and it makes them look for their
attachment figure, who functions as a “safe haven” and a “secure base”. Calibrated during child-
hood, the attachment behavioural system, including IWMs about self and others, become inte-
grated into the personality structure, so that the availability and responsiveness (i.e.,
sensitivity) of an attachment figure could give a strong sense of felt security throughout the life-
cycle (Bowlby, 1969). The caregiver’s characteristic behaviour is responsible for the development
of specific qualities of attachment (i.e., secure, insecure/avoidant, insecure/ambivalent and inse-
cure/disorganised attachment) on the part of the developing child (Ainsworth, 1985).
According to Bowlby (1969), three kinds of situations activate the attachment system: (a)
illness or injury, (b) separation or threat of separation from attachment figures and (c) frightening
or alarming environmental events. Even in adulthood, serious chronic disease and life-threatening
illness are strong triggers for the activation of the attachment system. Mikulincer and Shaver
(2003) suggest that the attachment system is activated whenever a situation is subjectively
appraised as threatening.
A number of studies in the literature show that individual differences in IWMs are related to
different coping strategies and support seeking (Li, Li, & Dai, 2008; Mikulincer & Florian, 1998;
Mikulincer & Shaver, 2007; Reiner, Anderson, Lewis Hall, & Hall, 2010; Schottenbauer et al.,
2006). In adulthood, individuals could turn to a romantic partner and/or God to receive
support when they feel threatened. Also, both the romantic bond and the perceived relationship
with God often meet established criteria for characterising attachment relationships (Granqvist
& Kirkpatrick, 2008; Hazan & Shaver, 1987; Kirkpatrick, 2005).
 254 R. Cassibba et al.

An avoidant style predicts a more distancing strategy and lower seeking of social support for
major stressors, and a preoccupied style predicts an emotion-focused coping for major stressors
(Holmberg, Lomore, Takacs, & Price, 2011). Shields, Travis, and Rosseau (2000) have also found
that an avoidant attachment style in individuals coping with cancer is consistently related to
poorer adjustment.
Religion plays an important role in the coping process for many patients (Pargament, 1997),
particularly those facing severe illness (Plakas, Boudioni, Fouka, & Taket, 2011; Tix & Frazier,
1998; Zwingmann, Wirtz, Müller, Körber, & Murken, 2006). Religious practices, beliefs and atti-
tudes towards a higher power are related to personal meanings and explanations (Pargament,
1997). These cognitive and representational aspects could determine the appraisal and coping
strategies an individual activates, leading to a more positive or negative adaptation. More specifi-
cally, Belavich and Pargament (2002) have found that attachment to God predicts spiritual coping
and that spiritual coping mediates a relationship between attachment to God and adjustment.
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Securely attached persons tend to view God as a source of strength for coping and to use positive
spiritually based coping methods (Cooper, Bruce, Harman, & Boccaccini, 2009). Moreover, in
line with a “compensation hypothesis”, individuals with an insecure attachment history have
been found more prone to involve God as a safe haven in stressful situations, especially when
raised in non-religious families (Granqvist, 2005).

Missing pieces and the present study

The present study investigated the relationship between attachment to God and the use of general
“secular” coping strategies among people faced with severe or chronic illnesses. Individual differ-
ences in coping, both secular and religious/spiritual, have often been investigated using retrospective
investigations or imagined stressors, resulting in problems with clarifying the effects of the nature of
the stressors. Previous studies have also tested the relationship between attachment to God and reli-
gious coping. Other studies have investigated the relationship between romantic attachment and
secular coping. However, we are aware of no study that has considered whether attachment to
God is related to secular coping strategies. Thus, that was the main objective of the present study.
As for our specific research questions, we asked first whether attachment to God and type of
disease were related to religious/spiritual coping. It was predicted that attachment security
towards God, characterised by expectations of God’s availability, would be related to higher
levels of religious/spiritual coping. Based on the idea that the more stressful an event is, the
more likely it is to evoke a religious response (Pargament, 1997), we also anticipated that an
acute disease would be linked to higher religious/spiritual coping than a chronic disease.
Second, we asked whether attachment to God and type of illness were related to different
secular ways of coping with the disease. It was predicted that attachment security towards God
would be related to specific and generally more functional coping strategies (e.g., fighting
spirit) and attachment insecurity towards God would be linked to more dysfunctional strategies
(e.g., hopelessness–helplessness). These differences in secular coping were examined while con-
trolling for possible effects of religious/spiritual coping. Finally, possible interactions between
attachment to God and type of disease were explored.

Method
Participants and procedures
The sample consisted of 105 adults from the south of Italy, in-patients of two hospitals in city:
Oncologic Hospital “Giovanni Paolo II” (n = 30) and “Di Venere” Hospital (n = 75). Patients
 Mental Health, Religion & Culture 255

from the Oncologic Hospital had various types of cancer and they were waiting for surgery or
chemotherapy. Breast cancer was the most common tumour in this sub-sample (n = 21), followed
by colon-rectum tumour (n = 4). None of them was at the terminal stage of tumour at the time of
the study. Patients from “Di Venere” Hospital had various types of renal impairments and they
were undergoing dialysis during the period of this study. Some of them were waiting for
kidney transplant (n = 17).
The oncology sample consisted of 16.7% (n = 5) male participants and the mean age was 56
years (SD = 11.9; range = 33–80). The dialysis sample consisted of 62.7% (n = 47) male partici-
pants and the mean age was 62 years (SD = 10.9; range = 30–81).
The data collections were made at hospitals, during chemotherapy or dialysis therapy or in
private hospital rooms for those patients who were waiting for surgery. Participants were informed
about the confidentiality of participation and the aim of the study. The aim was presented as an
investigation of the differences between people in religiousness and coping with illness. The ques-
tionnaires (described below) were filled out in 30–45 minutes.
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Measures
Questionnaires were used to assess all constructs of the study. The following variables were
included (measurement characteristics and descriptive statistics are given in Table 1).

Attachment to God security

Kirkpatrick and Shaver’s (1992) three brief forced-choice attachment-to-God paragraphs were
used to classify participants into secure (God is viewed as warm and responsive to the self;
57%, n = 61), or insecure attachment-to-God groups. As our research questions concerned a
secure–insecure split and the cell sizes for the insecure groups was limited, the insecure group
included both avoidant (God is viewed as distant and inaccessible to the self; 13%, n = 14)
and ambivalent (God is viewed as inconsistently responsive to the self, 27%, n = 29) patients.1
Three participants omitted answering this part.

Religious/spiritual coping
The Systems of Belief Inventory (SBI-15R; Holland et al., 1998) was used to measure both reli-
gious and spiritual thoughts and actions and their impact on how patients cope with a life-threa-
tening illness. The SBI-15R investigates religious rituals and practices and belief in a supreme
being (“Religion is important in my day-to-day life” and “Prayer or meditation has helped me
cope during times of serious illness”), as well as the support one gets from one’s religious com-
munity (“When I feel lonely, I rely on people who share my spiritual or religious beliefs for
support”). In this study, we considered both dimensions. Reliability and validity have been estab-
lished for the SBI-15R (Holland et al., 1998).

Secular coping strategies

The short version of mental adjustment to cancer (Mini MAC; Grassi et al., 2005; Watson et al.,
1994) was used to assess cognitive and behavioural responses to illness. This measure operatio-
nalised the Greer and Morris model of coping and adaptation strategies in cancer patients (Greer
& Watson, 1987; Morris et al., 1985). The most significant responses have been summarised by
the authors in five different strategies: Hopelessness–helplessness, i.e., the tendency to adopt a
pessimistic attitude towards illness (“I can’t handle it”); Anxious preoccupation, i.e., the tendency
 256 R. Cassibba et al.

to experience illness with high levels of anxiety and tension (“I suffer great anxiety about it”);
cognitive avoidance, i.e., the tendency to avoid confrontation with illness-related issues (“I
make positive efforts not to think about my illness”); fatalism, i.e., the tendency to have a fatalistic
attitude about illness (“I’ve put myself in the hands of God”); fighting spirit, i.e., the tendency to
actively face the illness (“I am determined to beat this disease”). The instrument has been used
also for patients with diseases other than cancer (Ahlstrom & Sjödén, 1994; Kelly et al., 2000;
Lewis et al., 2001) so we used it to assess coping and adjustment strategies for illness in both
sub-samples. Reliability and validity have been established for Mini MAC (Grassi et al., 2005;
Watson et al., 1994).

Statistical analyses
To test whether attachment to God and/or type of illness were related to religious/spiritual and
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secular ways of coping, we conducted eight 2 (attachment to God) × 2 (type of illness)

ANCOVA (ANalysis of COVAriance), one for each religious/spiritual and secular coping strat-
egy. Using additional ANCOVA, we also tested whether attachment to God and/or type of
illness were related to secular coping when controlling for the effect of religious/spiritual
coping. Due to the difference in gender distributions across illness groups, gender was included
as a covariate across these analyses (see further below). As the sample size, and thus statistical
power, was somewhat limited, we considered trend-significance (p < .10) as meaningful in
addition to full significance (p < .05). Besides significance, attention was paid to effect sizes,
using Cohen’s (1988) rules of thumbs for small, medium and large effects.

Results
Table 1 lists means, standard deviations, scale ranges and number of items for all scales used in
this study, combining the two sub-samples.

Preliminary analyses
Results from preliminary analyses showed statistically significant differences between genders
both on religious/spiritual and secular coping. Regarding the beliefs and practices dimension
of religious/spiritual coping, women (M = 32.94; SD = 5.72) showed higher levels than men
(M = 29.52; SD = 7.68), t(103) = 2.59; p = .01. Regarding the anxious preoccupation dimension
of secular coping, women (M = 19.55; SD = 4.10) again showed higher levels than men (M =
17.21; SD = 4.39), t(103) = 2.81, p < .01. Thus, for these reasons as well, gender was included
as a covariate in subsequent ANCOVA.

Table 1. Summary table of means, standard deviations, scale ranges and number of items for all scales.
M SD Range No. of items Cronbach alpha
Belief and practices 3.12 0.69 1–4 10 0.88
Social Support 2.35 0.85 1–4 5 0.92
Global SBI 2.86 0.68 1–4 15 0.90
Hopelessness/helplessness 2.18 0.61 1–4 9 0.88
Cognitive avoidance 2.63 0.63 1–4 7 0.80
Anxious preoccupation 2.81 0.75 1–4 4 0.85
Fatalism 3.09 0.57 1–4 4 0.65
Fighting spirit 2.86 0.56 1–4 5 0.60
 Mental Health, Religion & Culture 257

Tests of research questions

As for our first objective, results from the ANCOVA showed statistically significant differences
between groups, as reported in Tables 2 (for religious/spiritual coping) and 3 (for secular coping).
Regarding the effects of attachment to God on religious/spiritual coping, in comparison with inse-
cure participants, secure participants showed higher levels of beliefs and practices, F = 15.82, p <
.001, social support from the religious group, F = 3.94, p = .005 and of global religious/spiritual
coping, F = 10.78, p < .001.
Regarding the effects of attachment to God on secular coping strategies, in comparison with
insecure participants, secure participants showed higher levels of fatalism, F = 2.65, p < .05, fight-
ing spirit, F = 2.57, p < .05, lower levels of anxious preoccupation, F = 3.98, p = .005 and hope-
lessness, F = 2.73, p < .05. Regarding the effects of type of illness, even if the global model was
not significant, we found a significant univariate effect on cognitive avoidance (F = 6.27; p < .05);
dialysis patients showed higher levels of cognitive avoidance (Table 3).
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As for our second objective, most differences between groups on secular coping remained
when we controlled for the effects of religious/spiritual coping. Regarding the effects of attach-
ment to God, in comparison with insecure participants, secure participants showed higher levels
of fighting spirit, F = 4.49, p < .05, and marginally higher levels of fatalism, F = 2.90, p = .09.
Insecure participants showed marginally higher values on hopelessness, F = 3.32, p = .07.

Table 2. Summary table of two-way (attachment to God × type of illness) analysis of covariance conducted
on religious/spiritual coping (SBI), controlling for gender.
Secure Insecure
Oncology Dialysis Oncology Dialysis
Spiritual/religious coping strategies M SD M SD M SD M SD F η2
Belief and practices 3.73 0.34 3.34 0.36 2.84 0.68 2.65 0.75 15.82** .39
Social support from 2.59 0.87 2.62 0.73 1.80 0.90 2.11 0.79 3.94** .14
religious group
Total SBI 3.35 0.43 3.09 0.41 2.49 0.71 2.47 0.71 10.78** .30
Note: **p < .01.

Table 3. Summary table of two-way (attachment to God × type of illness) analysis of covariance conducted
on secular coping, controlling for gender.
Secure Insecure
Oncology Dialysis Oncology Dialysis
Secular coping strategies M SD M SD M SD M SD F η2
Hopelessness/helplessness 1.99 0.52 2.07 0.51 2.27 0.85 2.44 0.61 2.73* .10
Cognitive avoidance 2.66 0.96 2.93 0.67 2.46 1.00 2.86 0.60 1.82 .13
Anxious preoccupation 2.71 0.68 2.43 0.58 3.05 0.66 2.70 0.57 3.98** .14
Fatalism 3.34 0.48 3.20 0.54 2.88 0.62 2.92 0.54 2.65* .10
Fighting spirit 3.07 0.56 2.92 0.49 2.52 0.73 2.79 0.53 2.57* .10
Notes: *p < 0.05.
**p < 0.01.
 258 R. Cassibba et al.

Regarding the effects of type of illness, we again found one significant effect, F = 6.79; p < .05, on
cognitive avoidance; dialysis patients showed higher levels of this coping strategy.
All of these effects were of medium effect size strength, except the large effect of security in
Attachment to God on belief and practices (Cohen, 1988). We also examined possible interaction
effects between attachment to God and type of illness. No significant interactions emerged.

Discussion
Results from this study attested that security in one’s attachment to God is related not only to reli-
gious/spiritual coping but also to secular ways of coping with a serious disease. More specifically,
a secure attachment to God was linked to fighting spirit and tended to be linked to fatalism. In
contrast, an insecure attachment to God tended to be linked to hopelessness and anxious preoc-
cupation. The acuteness of the illness (cf. stressor) was generally not related to specific coping
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strategies, although renal/dialysis patients (cf. chronic stressor) scored higher on cognitive avoid-
ance than did cancer/oncology patients (cf. acute stressor). Moreover, these results largely
remained intact when we controlled for the potentially confounding effect of religious/spiritual
coping.
These results partially confirmed the hypotheses we assumed. God attachment security was
indeed related to a generally functional strategy to cope with disease (i.e., fighting spirit). The
sense of a personal relationship with a loving and protective God was related to recurring to fight-
ing spirit and fatalism. Hopelessness, a strategy that generally has worse outcomes as far as
adjustment is concerned (Watson et al., 1994), was related to insecurity in God attachment.
While previous studies of coping strategies have linked fighting spirit to positive outcomes in
psychological adjustment to disease and compliance to therapies, the relationship between fatal-
ism and adjustment is less clear (Grassi et al., 2005; Watson et al., 1994). The lack of clear associ-
ations between fatalism and adjustment could, at least in part, be due to different ways of
submitting to God’s will. For example, the belief that everything that happens in the world is
part of God’s plan (cf. fatalism), including pain and suffering, could lead to passive ways of
coping (“God will take care of me and decide what is right for me, I can’t do nothing”)
instead of giving a reason to fight illness (“God will take care of me and I have to do my
best”). Passivity and a deferring style in response to a life-threatening illness could hinder a posi-
tive adjustment, while an active and collaborative style could be associated to a greater sense of
personal control (Pargament, 1997) and better adjustment. As those with a secure attachment to
God scored higher on fatalism, we speculate, however, that fatalism may have implied assurance
in the benevolence of God (cf. a positive fate) for these individuals.
It was expected from the literature on coping (Lazarus & Folkman, 1984) that different stres-
sors should activate different strategies to cope. However, we did not find many differences
between dialysis/chronic and cancer/acute patients. The one exception to this was the finding
that dialysis patients did show elevated tendencies to avoid thoughts about disease and treatments,
in accordance with some studies that found higher levels of avoidance strategies in other chronic
conditions. More active coping strategies were positively related to the emergence of physical
symptoms, whereas avoidance coping was negatively related (Moneyham et al., 1998).
Some limitations of the study should be noted. The choice of self-report questionnaires to
collect data is one of them. The Mini MAC (Watson et al., 1994) investigates both coping and
adjustment strategies. Nordin, Berglund, Terje, and Glimelius (1999) suggest that some dimen-
sions, such as hopelessness and anxious preoccupation, can be interpreted as measures of adjust-
ment, while other dimensions, such as fatalism and cognitive avoidance, may be conceptualised in
terms of coping. Also, the measure of attachment to God (Kirkpatrick & Shaver, 1992) is very
simple, and researchers have developed a somewhat more advanced multidimensional self-
 Mental Health, Religion & Culture 259

report instruments to assess this construct (Beck & McDonald, 2004; Rowatt & Kirkpatrick,
2002). Future studies could also use different and stronger instruments to reduce questionnaire-
related biases.
Second, the differences we have found in our groups could be affected by the stage of disease.
It is important to note that patients occasionally use less adaptive strategies but this may not be an
indicator of poor adjustment to a cancer diagnosis; rather, it may simply be part of the oscillating
adjustment process itself (Grassi et al., 2005; Watson et al., 1994). Future studies should control
for the effects of the adjustment process, investigating the illness stage in which the patient finds
him-/herself. Moreover, the cross-sectional research design utilised in this study does not allow us
to verify process directions. Thus it is an open question whether attachment to God affects coping
strategies or vice versa. Future longitudinal studies should be conducted to help disentangle
process direction.
Another question left open for future research regards the relation between secular attachment
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style, attachment to God and secular coping strategies. In fact, secular attachment style could be a
possible mediator for the association between attachment to God and secular coping, which could
profitably be tested in future prospective longitudinal studies. Finally, the limited sample size in
our study could be related to limited statistical power. Presumably for this reason, some results
were not fully significant, in spite of reasonable effect sizes.
Despite these limitations, this study has some points of strength. Compared to previous
research on coping, both secular and religious, participants in our study come from populations
facing well-defined stressors at that time. Moreover, this is the first study of which we are aware,
that has examined attachment to God in relation to secular coping. Previous studies focused their
attention on the relationship between attachment in interpersonal relations, such as romantic ones,
and general coping strategies, or between attachment to God and religious coping. Finally, we
controlled statistically for the effect of religious/spiritual coping that would otherwise have
been a potential confound for attachment to God. In conclusion, both attachment to God and
severity of illness seem to be important in the coping process. As demonstrated here, security
of attachment to God is related to ways of coping that may express major adjustment to
disease, most notably a fighting spirit in facing it.

Note
1. We conducted a one-way (ambivalent vs. avoidant attachment to God) MANCOVA on our key depen-
dent variables, secular coping strategies, before collapsing the two groups (controlling for gender). No
statistically significant difference was found.

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