Clinical Scholarship

Spirituality and Distress In

Sheltered Battered Women
Janice Humphreys

Purpose: To examine the relationship between spiritual beliefs and psychological distress in
sheltered battered women.
Design: A convenience sample of 50 ethnically diverse women who had resided for at least 21
days in battered women’s shelters participated. Data were obtained over a 7-month period
in 1998 and 1999.
Methods: Participants completed the Spiritual Perspective Scale (SPS), Symptom Checklist-
90-Revised (SCL-90), Conflict Tactics Scale, and a demographic data sheet.
Results: These sheltered battered women placed high value on their spiritual beliefs and used
a variety of spiritual practices to aid them. The relationship between the Global Severity Index
as measured by the SCL-90 and SPS scores approached statistical significance (r = -.27, p = .06).
However, a significant inverse relationship was found between the SPS score and the
obsessive-compulsive score (r = -.34, p < .05), interpersonal sensitivity score (r = -.31, p <
.05), and hostility dimensions score (r = -.37, p < .01) of the SCL-90.
Conclusions: The findings indicated that, among these sheltered battered women, spirituality
may be associated with greater internal resources that buffer distressing feelings and calm
the mind. This study shows support of spirituality as a means of reducing distress through
greater connection to oneself and higher powers.

JOURNAL OF NURSING SCHOLARSHIP, 2000; 32:3, 273-278. ©2000 SIGMA THETA TAU INTERNATIONAL.

[Key words: women’s health, violence, spirituality]

* * *

S
piritual care is an important but often overlooked part have more resources and support in their lives. Social support
of nursing (Oldnall, 1996). Greater emphasis is placed and access to resources have been shown to significantly
on physical care of clients than on the spiritual influence battered women’s life experiences (Ulrich, 1998).
dimension (Cone, 1997). However, as Ellison (1983) Another possible explanation is that battered women who
suggested, “The spiritual dimension does not exist in isolation value their spiritual beliefs may perform spiritual practices
from our psyche and soma, but provides an integrative force” (e.g., prayer, meditation, or reading of religious texts) that
(p 332). Failure to attend to human spirituality conflicts with facilitate relaxation, thus improving sleep and reducing
theories of holism (Oldnall, 1996) and may lead to distress. In a recent meta-analysis of 66 studies of
overlooking important areas for interventions to reduce nonpharmacological interventions for insomnia, Murtagh
symptoms and distress (Weaver, Flannelly, Flannelly, Koenig, and Greenwood (1995) concluded that all types of
& Larson, 1998). nonpharmacologic interventions, including relaxation
A recent study of sheltered battered women’s sleep patterns techniques, were significantly better than placebo in
and distress indicated that spiritual beliefs were associated improving the quality of sleep. A third explanation is a
with improved sleep (Humphreys, Lee, Neylan, & Marmar, combination of the other two: women who value their
1999) and less psychological distress. Spirituality, defined as spiritual beliefs may perceive themselves to have more support
a sense of relationship with a higher power and a feeling of and perform practices that aid them. For the current study,
wholeness, has been reported to influence distress (Astin, the investigator sought to clarify the relationship between
Lawrence, & Foy, 1993) and spiritual healing has been
advocated for survivors of abuse (Farrell, 1996; Kreidler, Janice Humphreys, RN, PhD, CS, NP, Eta Rho, Assistant Professor, Department
of Family Health Care Nursing, University of California, San Francisco. This project
1995). Spirituality is more than religion and may or may not
was supported by a grant from the Academic Senate, University of California,
incorporate religious rituals, behaviors, or association with San Francisco. The author thanks Ann Golubjatnikov and the battered women’s
religious organizations (Oldnall, 1996; Peri, 1995). However, shelter staff and residents who made this study possible. Correspondence to Dr.
the process by which spiritual beliefs influence sheltered Humphreys, Box 0606, Department of Family Health Care Nursing, UCSF, San
Francisco, CA 94143-0606. E-mail: [email protected]
battered women’s symptoms is not clear. Battered women
Accepted for publication February 11, 2000.
who report valuing their spiritual beliefs may feel that they

Journal of Nursing Scholarship Third Quarter 2000 273

Spirituality

spiritual beliefs and psychological distress in sheltered candle or incense burning in the communal shelter
battered women to provide a basis for developing environment, were usually prohibited.
interventions to improve the lives of distressed women.
Instruments
Conceptual Model Demographic data were collected on age, ethnicity,
The framework for this study was the Model for Symptom relationship to abuser, number of children, employment
Management (UCSF School of Nursing Symptom status, and financial, educational, and health status.
Management Faculty, 1994). Symptoms are viewed as the Participants were asked about spiritual beliefs (before coming
primary reason people seek health care. The model has three to the shelter and after), spiritual practices (prayer, meditation,
interrelated dimensions: symptom experience, symptom religious readings, religious services) and their frequency, and
management strategies, and symptom outcomes. A basic religious affiliation. Participants also were asked to respond
assumption of the model is that effective symptom to open-ended questions about the helpfulness of their
management requires understanding of all three dimensions. spiritual beliefs and their management of difficult life
This study was designed to describe one major component experiences. Additional items pertained to environmental
(symptom experience) of the symptom management model. variables including shelter living arrangements and length of
Symptom experience is conceptualized as a dynamic stay.
involving the interaction of a person’s perception of the Battering experience. Psychological distress in battered
symptom, evaluation of the meaning of the symptom, and women has been correlated with the severity and frequency
response to a symptom. Variables that influence a person’s of abuse. The Conflict Tactics Scale (CTS) was used to assess
symptom experience are biopsychosocial factors in three battering experience. The CTS is composed of a list of 19
categories: personal (demographic, psychological, different strategies for conflict resolution ranging from
sociological, physiological), health and illness, and nonaggressive verbal strategies (“discussed an issue calmly”)
environmental variables. Most central to this study are to violent tactics (“used a knife or fired a gun”). Respondents
personal variables that exist before the symptom and were asked to indicate which of the strategies they experienced
influence perception of the symptom. Within the Symptom in the past year and how often their partners used each
Management Model, spirituality, including religion, is an strategy. In this study a question about sexual assault and
aspect of the sociological category of personal variables. These four questions about physical injury and severity resulting
personal variables are theorized to precede symptoms and to from conflicts were added to the CTS, because the original
influence, in this case, sheltered battered women’s distress. tool did not include either sexual coercion or consequences
of violent acts (Saunders, 1994). Reliability for measures of
physical aggression for the CTS have ranged from 0.88 to
Methods 0.95 in samples of husbands and wives. Construct validity
of the CTS is based on many studies in which the instrument
Design and Procedures was used. Findings have been consistent regardless of gender
The study included a convenience sample of 50 women of respondent, consistent with other research, and
who had resided for at least 21 days in one of four battered theoretically meaningful (Straus & Gelles, 1990).
women’s shelters in the San Francisco Bay Area. The purpose Psychological distress. Psychological distress was measured
of the study and eligibility criteria—English speaking, in using the Symptom Checklist-90-Revised (SCL-90)
residence at least 21 days—were briefly outlined on a flyer (Derogatis, 1994). Participants were asked to rate on a 5-
that was read at a regular shelter group meeting and then point scale of distress (0-4) ranging from Not at All to
posted in a communal area. The flyer indicated that Extremely their experience in the past 7 days with each of
participants in the study would be asked about their coping the 90 symptoms. The SCL-90 is scored and interpreted for
styles, spiritual beliefs, how they respond to stress, and how nine primary symptom dimensions: somatization, obsessive-
conflicts are resolved in their families. Eligible residents were compulsiveness, interpersonal sensitivity, depression, anxiety,
asked to indicate their interest. Then at an appointed time, hostility, phobic anxiety, paranoid ideation, and psychoticism.
the principal investigator or a research assistant came to the The primary dimensions are combined into three global
shelter and talked to interested women. After agreeing to indices: (a) the Global Severity Index (GSI), a combination
participate and giving informed consent, the women of symptoms and intensity of distress; (b) the Positive
completed the study instruments and were paid $10.00 in Symptom Total (PST), which is the overall sum of symptoms;
cash. Data were collected over a period of 7 months. Only and (c) the Positive Symptom distress Index (PSDI), which is
one eligible woman declined to participate. an intensity measure adjusted for the number of symptoms
Slightly different services were offered to residents in the present. The SCL-90 has internal consistencies for symptom
four participating shelters. However, none of the shelters dimensions ranging from 0.77 to 0.90 and test-retest reliabilities
provided assistance that specifically addressed the spiritual ranging from 0.68 to 0.90. Cronbach’s alphas with the current
needs of residents. Generally information about local houses sample ranged from 0.76 (hostility) to 0.98 (somatization).
of worship and assistance with transportation were provided Evidence of construct validity has been shown in the large
to residents upon request. Some spiritual practices, such as number of studies producing similar findings.

274 Third Quarter 2000 Journal of Nursing Scholarship

 Spirituality

With a sample of 266 crime victims and 111 nonvictims, Reported Spiritual Beliefs
Saunders, Arata, and Kilpatrick (1990) developed a 28- Participants rated the importance of their spiritual beliefs
item scale within the SCL-90 that successfully discriminated on a scale of 0 (not important) to 10 (very important) both
(89.3%) between people with posttraumatic stress disorder before they came to the battered women’s shelter (7.76 +
and those without current posttraumatic stress disorder 2.80) and afterward (9.16 + 1.49). No significant difference
(F(1,353) = 98.2, p < .001). Items had a high degree of was found in the importance of spiritual beliefs from the
internal consistency (alpha = .93), sensitivity (75%), and time before entry to the shelter and afterward (t = 4.33,
specificity (90%). Cronbach’s alpha for this 28-item scale p > .01). The most often mentioned spiritual practice was
with the current sample was .95. prayer. At the time of their participation 30 women reported
Spirituality. Spirituality was measured using the Spiritual praying at some time and 24 (48%) reported praying at least
Perspectives Scale (SPS; Reed, 1986), a 10-item scale that once a day. Reading the Bible or another holy book was
measures the extent to which one holds certain spiritual reported by 22 (44%) participants, and 16 (32%) indicated
views and engages in spiritually related interactions. they went to church or other religious services at least once
Spirituality in the SPS instructions “refers to an awareness a month. A religious affiliation was given by 41 of the 49
of one’s inner self and a sense of connection to a higher participants who responded, and all but two (Buddhist,
being, nature, others, or to some purpose greater than Moslem) cited a Christian religion. Forty-seven (94%)
oneself.” The instrument is based on the conceptualization participants indicated that their spiritual beliefs had been
of spirituality as a human experience particularly relevant helpful to them.
in later developmental phases of life and at times of
increased awareness of mortality. Thus the SPS was deemed Conflict Tactics Scale (CTS)
appropriate to use with women who reside in emergency CTS scores were calculated based on the frequency with
shelters as a result of recent battering or other threat of which each participant had experienced minor and severe
harm. The reliability of the SPS has been rated consistently assaults, including sexual assaults. Scores are shown in
above .90 with little redundancy among the items. Table 1. The majority of women had experienced a
Cronbach’s alpha for the current sample was .87. Reed combination of assaults. Thirty-eight (76%) participants had
(1986, 1991) has shown criterion-related validity and experienced 10 or more minor assaults (e.g., participants
discriminate validity of the SPS, and it has been used reported that something was thrown at them or that they
successfully with a variety of adult populations. were pushed, grabbed, shoved, or slapped). Only four (8%)
participants did not report severe assaults and 70% of the
women reported 10 or more severe assaults that included
Findings sexual assaults.

Sample Characteristics Physical Injury Severity Scale

The ethnicity of the 50 participants was as follows: 20 The four questions added to the CTS allowed measurement
African American, 11 European American, 11 Hispanic, 5 of the physical consequences of conflict resolution tactics.
Asian American, 1 Native American, and 2 other (mixed Physical injuries were scored for both the type of injury (mild,
or not given). The women ranged in age from 19 to 60 moderate, severe, or permanent) and the frequency, so that
years (33.9 + 8.9, Mdn = 34). Thirty-six (73.5%) had injuries that occurred repeatedly were weighted more heavily
completed high school and eight were employed at the time than injuries that happened less often. The resulting seven
of the study. The mean reported annual household income categories ranged from 1 (no injuries of any kind) to 7 (more
was $3,676. When asked how much of the household than 10 mild or moderate injuries and more than 10 severe
income they actually had access to, the women reported a or permanent injuries). Only 9 (18%) participants reported
mean of $2,525. All participants had been abused by the sustaining no injuries of any kind. Thirteen (26%)
husband or partner. Forty-one (82%) of the women had participants reported severe and permanent injuries occurring
children, but only 28 (66%) had their children with them five or more times. CTS scores and physical injury scores
in the shelter. Of those, the number of accompanying were highly correlated (r = .59, p < .001).
children ranged from one to four; the majority (75%) had
one or two children with them. All accompanying children
were lodged in the same room with their mothers. The Table 1. Conflict Tactics Scale Scores
number of people sleeping in participants’ rooms ranged
from one to five (2.5 + 1.2); only 12 women (24%) had Type of assault M Mdn SD Range
single rooms.
When participants were asked to rate their current health Minor assaults 31.2 23.5 25.6 0 to 75
status on a scale of zero (poor) to 10 (good or great), they Severe assaults 33.5 15.5 34.9 0 to 125
reported generally good health (8.0 + 2.1). Reported health Severe assaults including 39.9 25.0 39.3 0 to 150
problems included back or other musculoskeletal pain (n = sexual assaults
5), asthma (n = 4), and hypertension (n = 3).

Journal of Nursing Scholarship Third Quarter 2000 275

Spirituality

Psychological Distress participating in spiritual discussions or other practices about

Sheltered battered women’s psychological distress was once a week, but the range was from “not at all” to “about
measured using the SCL-90. When compared with a once a day.” Engaging in private prayer or meditation was
normative sample of women (Derogatis, 1994) of similar ages the most frequently cited practice.
(33.1 + 14.85), the sheltered battered women reported Spiritual practices reported by participants were highly
significantly more frequent and distressful symptoms on each correlated with SPS scores (p < .01 to .0005). The rating of
of the nine dimensions and three global indices, as shown in the importance of spiritual beliefs before and after entry into
Table 2. Experience with battering as measured by the CTS the shelter, prayer, meditation, religious reading, and
was highly correlated (p < .01) with all nine dimensions of the attendance at religious services were all positively correlated
SCL-90 as well as with the three global indices, but severity of with SPS scores.
physical injury was not correlated with SCL-90 scores. Additional analyses were conducted to determine if, as
Twenty-eight items from the SCL-90 were used to identify suggested by Reed (1987), older participants and those who
participants with current PTSD. As recommended by did not indicate a religious affiliation scored differently from
Saunders, Arata, and Kilpatrick (1990), the mean scale scores their counterparts on the SPS or on spiritual beliefs and
for the selected items were summed and total scores of 0.89 practices. The sample had a restricted age range with only
or above were considered indicative of current PTSD. Twenty- one participant older than age 50. However, when
eight (56%) of the participants had PTSD at the time of this participants were divided into two groups, less than 40 years
study. Participants who had PTSD had also experienced of age and 40 years of age and older, significant differences
significantly more frequent and severe abuse as measured by were found. Older participants rated the importance of their
the CTS than those who did not have PTSD at the time of spiritual beliefs before entering the shelter higher than
their participation (t = 3.04, p < .01). participants who were younger than age 40 (t = 2.34, p < .05).
Also women who identified a religious affiliation scored
Spirituality significantly higher on the SPS than did those without a
The SPS was used to measure spirituality in these sheltered religious affiliation (t = 2.52, p < .05). No other significant
battered women. The mean SPS score was 4.9 + 0.89 and differences were found between age or religious affiliation
the range was 2.7 to 6.0. All items had a mean rating of 4 or and SPS.
higher. The items rated most highly were (a) I frequently feel Neither measure of battering experience (CTS or severity
close to God or a “higher power” in prayer, during public of physical injury) was correlated with SPS score. However,
worship, or at important moments in my daily life (5.22 + participants who scored higher on the SPS (stronger or more
0.89); (b) forgiveness is an important part of my spirituality frequent spiritual beliefs or practices) experienced fewer and
(5.18 + 0.98); (c) my spirituality is a significant part of my less intense symptoms in the obsessive-compulsive (r = -.34,
life (5.08 + 1.19); and (d) my spirituality is especially p < .05), interpersonal sensitivity (r = -.31, p < .05), and
important to me because it answers many questions about hostility dimensions (r = -.37, p < .01) of the SCL-90 (see
the meaning of life (5.08 + 1.05). These women reported Table 3). Participants who scored higher on the SPS reported
significantly fewer repeated unpleasant thoughts, worries
about carelessness, and feelings of “going blank,” and less
Table 2. Psychological Distress (SCL-90) Scores of Sheltered
need to repeat actions such as touching, counting, or washing.
Battered Women Compared to Normative Data
Participants who scored higher on the SPS also reported
Sheltered Battered Women (N = 50) Normative Sample* (N = 480) feeling less critical of others and less annoyed, and they had
Measure Mean SD Mean t df p fewer outbursts of temper that they could not control.
Primary dimensions
Somatization 1.13 (0.87) 0.43 5.72 49 <.0005 Table 3. Correlations Between Specific SCL-90 items and
Obsessive-compulsive 1.49 (1.00) 0.44 7.39 49 <.0005 Spiritual Perspective Scale Score
Interpersonal sensitivity 1.29 (0.96) 0.35 6.92 49 <.0005
Symptom Dimension r p
Depression 1.69 (1.01) 0.46 8.61 49 <.0005
Anxiety 1.14 (0.91) 0.37 6.00 49 <.0005 Obsessive-compulsive
Hostility 0.68 (0.68) 0.33 3.65 49 <.01 Repeated unpleasant thoughts that won’t leave your mind -.33 .02
Phobic anxiety 0.88 (0.85) 0.19 5.77 49 <.0005 Worried about sloppiness or carelessness -.29 .04
Paranoid ideation 1.27 (0.87) 0.34 7.57 49 <.0005 Your mind going blank -.32 .01
Psychoticism 0.99 (0.81) 0.15 7.31 49 <.0005 Having to repeat the same actions such as touching, -.35 .01
counting, or washing
Global indices
Interpersonal sensitivity
PST 51.54 (22.16) 22.00 9.43 49 <.0005
Feeling critical of others -.34 .02
PSDI 2.00 (0.67) 1.37 6.62 49 <.0005
Hostility
GSI 1.20 (0.76) 0.36 7.79 49 <.0005 Feeling easily annoyed or irritated -.42 .002
*Derogatis, 1994 Temper outbursts that you could not control -.51 <.0005

276 Third Quarter 2000 Journal of Nursing Scholarship

 Spirituality

Discussion the SCL-90 were significantly inversely correlated with

SPS score (Table 3).
The ethnically diverse sheltered battered women in this study These inverse correlations indicate that spirituality may be
suffered significant psychological distress that was highly associated with greater internal resources that buffer feelings
correlated with the frequency and severity of battering they of irritation with oneself and others and calm the mind. For
had experienced. These findings are consistent with the findings example, one participant said [My spiritual beliefs] “help to
of others (Houskamp & Foy, 1991; Kemp, Rawling, & Green, keep me focused and put my life in perspective.” Another
1991; Saunders, 1994) and reinforce the need for nursing participant wrote, [I] “feel that God can hear me, can apologize
assessment of battering experience in abused women. for behavior, and then I can feel more at peace.” Another wrote
The incidence of PTSD in battered women in this study (56%) “I’ve had a peace of mind, and I’m not worried as much as I
is consistent with figures of 33% to 60% reported elsewhere was before.” Reed (1992) wrote that spirituality is associated
(Follingstad, Brennan, Hause, Polek, & Rutledge, 1991; with a sense of relatedness that may be experienced
Houskamp & Foy, 1991; Kemp, Rawling, & Green, 1991; intrapersonally (as connectedness with oneself), interpersonally
Saunders, 1994). The measure used in this study was originally (in the context of others and the natural environment), and
developed with women who were crime victims (Saunder, Arata, transpersonally (as a sense of relatedness to the unseen, God,
& Kilpatrick, 1990) and has not previously been reported in or a power greater than the self and ordinary resources).
the literature on battered women. In Saunder, Arata, and Through connectedness one is able to move beyond the
Kilpatrick’s original report, a 75% sensitivity rate for “structures of everyday existence” (Brewer, 1979). As one
identification of PTSD positive subjects was reported. Thus participant in this study wrote [My spiritual beliefs are] “my
the finding that 56% of the participants in the current study solid foundation, the meaning of life, my strength, it’s who I
had PTSD may be an underestimate. However, no diagnostic am, what makes me me.” Another said, “In times of stress
measure was concurrently used in this study. The sensitivity of [spiritual beliefs] offer comfort and solace.”
the measure with this population requires further study. Findings from this study are consistent with the Symptom
These distressed women overwhelmingly reported that their Management Model (UCSF School of Nursing Symptom
spirituality was helpful to them. Eighty-two percent (n = 41) of Management Faculty, 1994). They indicate that sheltered
the participants thought that forgiveness was an important part battered women’s symptom experience of distress was
of their spirituality. Eighty percent (n = 40) said they felt very influenced by the personal variable of spirituality. As one
close to God or a “higher power,” that their spiritual views participant wrote, [My spiritual beliefs] “reduce shame, fear,
had influenced their lives, and that their spirituality was a and feelings of helplessness.” However, whether spirituality
significant part of their lives. One participant wrote: [My after trauma altered battered women’s perception of battering
spiritual beliefs are] “my support, my source of guidance, my events or only their response to the events remains to be
foundation.” As one participant said in response to an open- determined.
ended question, “I believe if it weren’t for my [spiritual] beliefs What nursing interventions can be offered to address client
I would not have made it out of my situation.” Participants spirituality? Tuck, Pullen, and Lynn (1997) advocated spiritual
also reported using a variety of spiritual practices ranging from interventions of being with clients, doing for clients, encouraging
prayer and meditation to spiritual readings and church clients to look inward, and encouraging clients to look outward.
attendance. In a study of self-transcendence in women with AIDS, Coward
Consistent with the experience of other people exposed to (1995) suggested the following interventions: (a) prevent
life-threatening events, the women in this study reported greater emotional and environmental isolation, (b) assist in reaching
valuing of their spiritual beliefs after entry into the shelter out, and (c) educate for health promotion. Peri (1995), also in
compared to before. Astin, Lawrence, and Foy (1993) noted research with persons with AIDS, concluded that the role of
that strong religious beliefs among other factors was predictive nurses is not to solve the spiritual problems of clients but to
of PTSD symptoms in their sample (N = 53) of battered women. provide an environment where spirituality can be expressed.
Racklin (1999) also noted that in a community-based sample Toward that end she suggested (a) spiritual assessment, (b)
(N = 210) of adults the adverse effects of traumatic exposure identification of resources that have been a source of spiritual
were mitigated by a strong sense of coherence. If distressed by support, (c) offering compassionate presence and support, (d)
traumatic symptoms, however, turning toward spirituality open and honest communication, (e) listening, (f) fostering
reduced traumatic distress by reinforcing sense of coherence. caring relationships with significant other people in clients’ lives,
The mean SPS score for this study (4.89 + .89) was higher and (g) encouraging prayer and meditation.
than Reed (1987) reported for terminally ill adults (4.16 to
4.53), but lower than Tuck, Pullen, and Lynn (1997) reported
for mental health nurses (M = 5.33). However, all SPS items Conclusions
had a mean score of four or more. Although total SPS score
was not significantly correlated with less frequent and intense This study can provide a beginning understanding of the
distress (GSI) (r =-.27, p = .06), the relationship between the relationship between spiritual beliefs and distressing
two was in the expected direction and probably would be symptoms in sheltered battered women. The findings show
significant with a larger sample. Dimensions and items of that in this sample spirituality was a means of reducing

Journal of Nursing Scholarship Third Quarter 2000 277

Spirituality

distress through greater connection to oneself and powers Peri, T.C. (1995). Promoting spirituality in persons with acquired
immunodeficiency syndrome: A nursing intervention. Holistic Nurse
beyond oneself. Interventions successfully used in nursing
Practitioner, 10(1), 68-76.
care with other distressed women would seem appropriate Racklin, J.M. (1999). The roles of sense of coherence, spirituality, and religion
for enhancing spirituality in battered women. At a minimum, in responses to trauma (Doctoral dissertation, California School of Professional
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Reed, P.G. (1986). Developmental resources and depression in the elderly.
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Nursing Research, 35, 368-374.
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face tremendous demands with limited external resources. adults. Research in Nursing & Health, 10, 335-344.
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knowledge for nursing. Family and Community Health, 14(2), 14-25.
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Reed, P.G. (1992). An emerging paradigm for the investigation of spirituality
recently experienced battering. The participants in the in nursing. Research in Nursing & Health, 15, 349-357.
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a small sample of battered women. The PTSD measure in crime-related post-traumatic stress disorder scale for women within the
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