Journal of Behavioral Medicine

, Volume 36, Issue 2, pp 186–198 | Cite as

Posttraumatic growth in patients who survived cardiac surgery: the predictive and mediating roles of faith-based factors

  • Amy L. Ai
  • Daniel Hall
  • Kenneth Pargament
  • Terrence N. Tice


Despite the growing knowledge of posttraumatic growth, only a few studies have examined personal growth in the context of cardiac health. Similarly, longitudinal research is lacking on the implications of religion/spirituality for patients with advanced cardiac diseases. This paper aims to explore the effect of preoperative religious coping on long-term postoperative personal growth and potential mediation in this effect. Analyses capitalized on a preoperative survey and medical indices from the Society of Thoracic Surgeons’ National Database of patients undergoing cardiac surgery. Participants in the current follow-up study completed a mailed survey 30 months after surgery. Hierarchical regression analysis was performed to evaluate the extent to which preoperative use of religious coping predicted growth at follow-up, after controlling for key demographics, medical indices, mental health, and protective factors. Predictors of posttraumatic growth at follow-up were positive religious coping and a living status without a partner. Medical indices, optimistic expectations, social support, and other religious factors were unrelated to posttraumatic growth. Including religious factors diminished effects of gender, age, and race. Including perceived spiritual support completely eliminated the role of positive religious coping, indicating mediation. Preoperative positive religious coping may have a long-term effect on postoperative personal growth, explainable by higher spiritual connections as a part of significance-making. These results suggest that spirituality may play a favorable role in cardiac patients’ posttraumatic growth after surviving a life-altering operation. The elimination of demographic effects may help explain previously mixed findings concerning the association between these factors and personal growth.


Posttraumatic growth Cardiovascular diseases and surgery Religion, faith, and spiritual support Social support Optimism and hope 


  1. Affleck, G., Tennen, H., Croog, S., & Levine, S. (1987). Causal attribution, perceived benefits, and morbidity after a heart attack: An 8-year study. Journal of Consulting and Clinical Psychology, 55, 29–35.PubMedCrossRefGoogle Scholar
  2. Ai, L. A., Hopp, F., Tice, T. N., & Koenig, H. (2012). Enhanced existential relationship in light of eudaemonic tradition and religious coping of middle-aged and older cardiac patients. Journal of Health Psychology, 17.Google Scholar
  3. Ai, A. L., Ladd, K. L., Peterson, C., Cook, C., Shearer, M., & Koenig, H. G. (2010a). Long-term adjustment after surviving open-heart surgery: The effect of using prayer for coping replicated in a prospective design. The Gerontologists, 50, 798–809.CrossRefGoogle Scholar
  4. Ai, A. L., Pargament, K., Kronfol, Z., Tice, T. N., & Appel, H. (2010b). Pathways to postoperative hostility in cardiac patients: Mediation of coping, spiritual struggle, and interleukin-6. Journal of Health Psychology, 15, 186–195.PubMedCrossRefGoogle Scholar
  5. Ai, A. L., Park, C., Huang, B., Rodgers, W., & Tice, T. N. (2007). Psychosocial mediation of religious coping: A prospective study of short-term psychological distress after cardiac surgery. Personality and Social Psychology Bulletin, 33, 867–882.PubMedCrossRefGoogle Scholar
  6. Ai, A. L., Peterson, C., Bolling, S. F., & Koenig, H. (2002). Private prayer and the optimism of middle-aged and older patients awaiting cardiac surgery. The Gerontologist, 42, 70–81.PubMedCrossRefGoogle Scholar
  7. Ai, A. L., Rollman, B. L., & Berger, C. S. (2010c). Co-morbid mental health symptoms and heart diseases: Can health care and mental health care professionals collaboratively improve the assessment and management? Health and Social Work, 35, 27–38.PubMedCrossRefGoogle Scholar
  8. Ai, A. L., Tice, T. N., Lemieux, C., & Huang, B. (2011a). Modeling the meaning-laden paradox after 9/11: From deep connection and struggle to posttraumatic stress and growth. Archive for the Psychology of Religion, 33, 173–204.CrossRefGoogle Scholar
  9. Ai, A. L., Tice, T. N., Peterson, C., & Huang, B. (2005). Prayers, spiritual support, and positive attitudes in coping with the 9–11 national crisis. Journal of Personality, 73, 763–792.PubMedCrossRefGoogle Scholar
  10. Ai, A. L., Tice, T. N., Peterson, C., Huang, B., & Bolling, S. F. (2009a). Counteracting pathways of prayer coping to the short-term postoperative adjustment in middle-aged and older cardiac patients. In A. L. Ai & M. Ardelt (Eds.), Faith and well-being in late life: Linking theories with evidence in an interdisciplinary inquiry (pp. 113–142). Hauppaugue, NY: Nova Science Publishers.Google Scholar
  11. Ai, A. L., Wink, P., & Shearer, M. (2011b). Secular reverence predicts shorter hospital length of stay among middle-aged and older patients following open-heart surgery. Journal of Behavioral Medicine, 34, 532–541.PubMedCrossRefGoogle Scholar
  12. Ai, A. L., Wink, P., Tice, T. N., Bolling, S. F., Wasin, A., & Shearer, M. (2009b). Prayer and reverence in naturalistic, aesthetic, and socio-moral contexts predicted fewer complications following coronary artery bypass. Journal of Behavioral Medicine, 32, 570–581.PubMedCrossRefGoogle Scholar
  13. American Heart Association (2011). Heart Disease and Stroke Statistics–2012 Update: A Report from the American Heart Association. Retrieved from
  14. Andrew, M. J., Baker, R. A., Kneebone, A. C., & Knight, J. L. (2000). Mood state as a predictor of neuropsychological deficits following cardiac surgery. Journal of Psychosomatic Research, 48, 537–546.PubMedCrossRefGoogle Scholar
  15. Ano, G. G., & Vasconcelles, E. B. (2005). Religious coping and psychological adjustment to stress: A meta-analysis. Journal of Clinical Psychology, 61, 461–480.PubMedCrossRefGoogle Scholar
  16. Ardelt, M., & Koenig, C. S. (2009). Differential roles of religious orientation on subjective well-being and death attitudes in old age: Mediation of spiritual activities and purpose in life. In A. Ai & M. Ardelt (Eds.), The role of faith in the well-being of older adults: Linking theories with evidence in an interdisciplinary inquiry. Hauppauge, NY: Nova Science Publishers.Google Scholar
  17. Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182.Google Scholar
  18. Bellizzi, K. M. (2004). Expressions of generatively and posttraumatic growth in adult cancer survivors. International Journal of Aging and Human Development, 58, 267–287.PubMedCrossRefGoogle Scholar
  19. Bellizzi, K. M., Smith, A. W., Reeve, B. B., Alfano, C. M., Bernstein, L., Meeske, K., et al. (2010). Posttraumatic growth and health-related quality of life in a racially diverse cohort of breast cancer survivors. Journal of Health Psychology, 15, 615–626.PubMedCrossRefGoogle Scholar
  20. Boudrez, H., & De Backer, G. (2001). Psychological status and the role of coping style after coronary artery bypass graft surgery. Results of a prospective study. Quality of Life Research, 10, 37–47.PubMedCrossRefGoogle Scholar
  21. Bozo, Ö., Gündoğdu, E., & Büyükaşik-Çolak, C. (2009). The moderating role of different sources of perceived social support on the dispositional optimism-posttraumatic growth relationship in postoperative breast cancer patients. Journal of Health Psychology, 14, 1009–1020.PubMedCrossRefGoogle Scholar
  22. Cadell, S., Regehr, C., & Hemsworth, D. (2003). Factors contributing to posttraumatic growth: A proposed structural equation model. American Journal of Orthopsychiatry, 73, 279–287.PubMedCrossRefGoogle Scholar
  23. Calhoun, L. G., & Tedeschi, R. G. (1998). Posttraumatic growth: Future directions. In R. G. Tedeschi, C. L. Park, & L. G. Calhoun (Eds.), Posttraumatic growth: Positive changes in the aftermath of crisis (pp. 215–238). Mahwah, NJ: Lawrence Erlbaum Associates.Google Scholar
  24. Calhoun, L. G., & Tedeschi, R. G. (2006). Handbook of posttraumatic growth: Research and practice. Mahwah, NH: Erlbaum.Google Scholar
  25. Carroll, D., Phillips, A. C., Hunt, K., & Der, G. (2007). Symptoms of depression and cardiovascular reactions to acute psychological stress: Evidence from a population study. Biological Psychology, 75, 68–74.PubMedCrossRefGoogle Scholar
  26. Chatters, L. M., Levin, J. S., & Taylor, R. J. (1992). Antecedents and dimensions of religious involvement among older Black adults. Journal of Gerontology: Social Sciences, 47B, S269–S278.Google Scholar
  27. Contrada, R. J., Goyal, T. M., Cather, C., Rafalson, L., Idler, E. L., & Krause, T. (2004). Psychosocial factors in outcomes of heart surgery: The impact of religious involvement and depressive symptoms. Health Psychology, 23, 227–238.PubMedCrossRefGoogle Scholar
  28. Davis, C. G., Nolen-Hoeksema, S., & Larson, J. (1998). Making sense of loss and benefiting from the experience: Two construals of meaning. Journal of Personality and Social Psychology, 75, 561–574.PubMedCrossRefGoogle Scholar
  29. Duits, A. A., Boeke, S., Taamms, M. A., Passchier, J., & Erdman, R. A. M. (1997). Prediction of quality of life after coronary artery bypass graft surgery: A review and evaluation of multiple, recent studies. Psychosomatic Medicine, 59, 257–268.PubMedGoogle Scholar
  30. Hefferon, K., Grealy, M., & Mutrie, M. (2009). Posttraumatic growth and life threatening physical illness: A systematic review of the qualitative literature. British Journal of Health Psychology, 14, 343–378.PubMedCrossRefGoogle Scholar
  31. Helgeson, V. S., Reynolds, K. A., Tomish, P. L., de Jonge, P., Rob, H. S., & van den Brink, R. H. S. (2006). A meta-analytic review of benefit finding and growth. Journal of Consulting and Clinical Psychology, 73, 797–816. Special Issue: Benefit-finding.CrossRefGoogle Scholar
  32. Janoff-Bulman, R. (2004). Posttraumatic growth: Three explanatory models. Psychological Inquiry, 15, 30–34.Google Scholar
  33. Joseph, S., & Linley, P. A. (2005). Positive adjustment to threatening events: An organismic valuing theory of growth through adversity. Review of General Psychology, 9, 262–280.CrossRefGoogle Scholar
  34. Kahneman, D., Diener, E., & Swchwarz, N. (Eds.). (1999). Well-being: The foundations of hedonic psychology (pp. 3–25). New York: Russel Sage Found.Google Scholar
  35. Lechner, S. C., & Weaver, K. E. (2009). Lessons learned about benefit finding among individuals with cancer or HIV/AIDS. In C. Park, et al. (Eds.), Medical illness and positive life change: Can crisis lead to personal transformation?. Washington, DC: American Psychological Association.Google Scholar
  36. Lepore, S., & Kernan, W. D. (2009). Positive life change and the social context of illness: An expanded social-cognitive processing model. In C. Park, et al. (Eds.), Medical illness and positive life change: Can crisis lead to personal transformation?. Washington, DC: American Psychological Association.Google Scholar
  37. Lichtman, J. H., Bigger, T., Jr., Blumenthal, J. A., Frasure-Smith, N., Kaufmann, P. G., Lespérance, F., et al. (2008). Depression and coronary heart disease: Recommendations for screening, referral, and treatment: A science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Psychiatric Association. Circulation, 118, 1768–1775.Google Scholar
  38. Linley, P. A., & Joseph, S. (2004). Positive change following trauma and adversity: A review. Journal of Traumatic Stress, 17, 11–21.PubMedCrossRefGoogle Scholar
  39. Mallik, S., Krumholz, H. M., Lin, Z. Q., Stanislav, V., Kasl, S. V., Mattera, J. A., et al. (2005). Patients with depressive symptoms have lower health status benefits after coronary artery bypass surgery. Circulation, 111, 271–277.PubMedCrossRefGoogle Scholar
  40. Manne, S., Ostroff, J., Winkel, G., Goldstein, L., Fox, K., & Grana, G. (2004). Posttraumatic growth after breast cancer: Patient, partner, and couple perspectives. Psychosomatic Medicine, 66, 442–454.PubMedCrossRefGoogle Scholar
  41. Oxman, T. E., Freeman, D. H., & Manheimer, E. D. (1995). Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosomatic Medicine, 57, 5–15.PubMedGoogle Scholar
  42. Pargament, K. I. (1997). The psychology of religion and coping: Theory, research, practice. New York: Guilford.Google Scholar
  43. Pargament, K. I. (2011). Religion and coping: The current state of knowledge. In S. Folkman (Ed.), Oxford Handbook of stress, health, and coping (pp. 269–288). New York: Oxford University Press.Google Scholar
  44. Pargament, K. I., Ano, G. G., & Wachholtz, A. B. (2005a). The religious dimension of coping: Advances in theory, research, and practice. In R. F. Paloutzian & C. L. Park (Eds.), The handbook of the psychology of religion and spirituality (pp. 479–495). New York: Guilford.Google Scholar
  45. Pargament, K. I., Magyar, G., & Murray, N. (2005b). The sacred and the search for significance: Religion as a unique process. Journal of Social Issues, 61, 665–687.CrossRefGoogle Scholar
  46. Pargament, K. I., Smith, B. W., Koenig, H. G., & Perez, L. (1998). Patterns of positive and negative religious coping with major life stressors. Journal for the Scientific Study of Religion, 37, 710–724.CrossRefGoogle Scholar
  47. Park, C. (2009). Medical illness and positive life change: Can crisis lead to personal transformation?. Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  48. Park, C. L., Cohen, L. H., & Murch, R. L. (1996). Assessment and prediction of stress-related growth. Journal of Personality, 64, 71–104.PubMedCrossRefGoogle Scholar
  49. Park, C. L., Lechner, S. C., & Stanton, A. L. (2009). Dimensions of religion and spirituality in psychological adjustment in older adults living with congestive heart failure. In A. Ai & M. Ardelt (Eds.), The role of faith in the well-being of older adults: Linking theories with evidence in an interdisciplinary inquiry. Hauppauge, NY: Nova Science Publishers.Google Scholar
  50. Petrie, K. J., Buick, D. L., Weinman, J., & Booth, R. J. (1999). Positive effects of illness reported by myocardial infarction and breast cancer patients. Journal of Psychosomatic Research, 64, 537–543.CrossRefGoogle Scholar
  51. Petrie, K. J., & Corter, A. (2009). Illness perceptions and benefit finding among individuals with breast cancer, acoustic neuroma, or heart disease. In C. Park, et al. (Eds.), Medical illness and positive life change: Can crisis lead to personal transformation?. Washington, DC: American Psychological Association.Google Scholar
  52. Pignay-Demaria, V., Lesperance, F., Demaria, R. G., Frasure-Smith, N., & Perrault, L. P. (2003). Depression and anxiety and outcomes of coronary artery bypass surgery. Annals of Thoracic Surgery, 75, 314–321.PubMedCrossRefGoogle Scholar
  53. Prati, G., & Pietrantoni, L. (2009). Optimism, social support, and coping strategies as factors contributing to posttraumatic growth: A meta-analysis. Journal of Loss and Trauma: International Perspectives on Stress and Coping, 14, 364.CrossRefGoogle Scholar
  54. Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.CrossRefGoogle Scholar
  55. Rothenbacher, D., Hahmann, H., Wusten, B., Koenig, W., & Brenner, H. (2007). Symptoms of anxiety and depression in patients with stable coronary heart disease: Prognostic value and consideration of pathogenetic links. European Journal of Cardiovascular Prevention and Rehabilitation, 14, 547–554.PubMedCrossRefGoogle Scholar
  56. Rumsfeld, R. S., & Ho, P. M. (2005). Depression and cardiovascular disease: A call for recognition. Circulation, 111, 250–253.PubMedCrossRefGoogle Scholar
  57. Ryan, R. M., & Deci, E. L. (2001). On happiness and human potentials: A review of research on hedonic and eudaemonic well-being. Annual Review of Psychology, 52, 141–166.PubMedCrossRefGoogle Scholar
  58. Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57, 1069–1081.CrossRefGoogle Scholar
  59. Sawyer, A., Ayers, S., & Field, A. P. (2010). Posttraumatic growth and adjustment among individuals with cancer or HIV/AIDS: A meta-analysis. Clinical Psychology Review, 30, 436–447.PubMedCrossRefGoogle Scholar
  60. Scheier, M. F., & Carver, C. S. (1985). Optimism, coping, and health: Assessment and implications of generalized outcome expectancies. Health Psychology, 4, 219–247.PubMedCrossRefGoogle Scholar
  61. Scheier, M. F., & Carver, C. S. (1992). Effects of optimism on psychological and physical well-being: Theoretical overview and empirical update. Cognitive Therapy and Research, 16, 201–228.CrossRefGoogle Scholar
  62. Schroevers, M. J., & Teo, I. (2008). The report of posttraumatic growth in Malaysian cancer patients: Relationships with psychological distress and coping strategies. Psycho-Oncology, 17, 1239–1246.PubMedCrossRefGoogle Scholar
  63. Shaw, A., Joseph, S., & Linley, P. A. (2005). Religion, spirituality, and posttraumatic growth: A systematic review. Mental Health, Religion and Culture, 8, 1–11.CrossRefGoogle Scholar
  64. Sheikh, A. I. (2004). Posttraumatic growth in the context of heart disease. Journal of Clinical Psychology in Medical Settings, 11, 265–273.CrossRefGoogle Scholar
  65. Snyder, C. R., Harris, C., Anderson, J. R., Holleran, S. A., Irving, L. M., Sigmon, S. T., et al. (1991). The will and the ways: Development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60, 570–585.PubMedCrossRefGoogle Scholar
  66. Stanton, A. L., & Revenson, T. A. (2007). Adjustment to chronic disease: Progress and promise in research. In H. S. Friedman & R. C. Silver (Eds.), Foundations of health psychology (pp. 203–233). New York, NY: Oxford University Press.Google Scholar
  67. Stanton, A. L., Revenson, T. A., & Tennen, H. (2007). Health psychology: Psychological adjustment to chronic disease. Annual Review of Psychology, 58, 565–592.PubMedCrossRefGoogle Scholar
  68. Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15, 1–18.CrossRefGoogle Scholar
  69. Widows, M. R., Jacobsen, P. B., Booth-Jones, M., & Fields, K. K. (2005). Predictors of posttraumatic growth following bone marrow transplantation for cancer. Health Psychology, 24, 266–273.PubMedCrossRefGoogle Scholar
  70. Zimet, G. D., Powell, S. S., Farley, G. K., Werkman, S., & Berkoff, K. A. (1990). Psychometric characteristics of the multidimensional scale of perceived social support. Journal of Personality Assessment, 55, 610–617.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Amy L. Ai
    • 1
  • Daniel Hall
    • 2
  • Kenneth Pargament
    • 3
  • Terrence N. Tice
    • 4
  1. 1.Florida State UniversityTallahasseeUSA
  2. 2.VA Pittsburgh Healthcare SystemPittsburghUSA
  3. 3.Bowling Green State UniversityBowling GreenUSA
  4. 4.Iliff University of TheologyDenverUSA

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