The Role of Religious Coping in Understanding the Suicide Risk of Older Adults during COVID-19

Abstract

In the United States, racially diverse, homebound older adults have been among those most impacted by the COVID-19 pandemic. During times of disaster, persons impacted tend to turn to their faith to make sense of suffering. COVID-19 has been an unusual disaster, as physical distancing was required to keep those most susceptible safe. Due to the resulting social isolation and loneliness, suicidal behaviors and ideation (e.g., desire to die) have increased during the pandemic. Suicide desire is encapsulated by two states: thwarted belongingness (T.B., chronic loneliness and lack of reciprocal care) and perceived burdensomeness (P.B., belief that one is a burden to others and society) and has historically been inversely correlated with religiosity. Therefore, understanding how religious coping can contribute to the relationship between the impact of COVID-19 on T.B. and P.B. in homebound older adults is important in understanding their suicide risk. Our participants (ages 62–101) varied in suicidality. Increases in suicide desire over time were associated with higher levels of negative religious coping. Implications for treatment are provided, particularly the importance of fostering belongingness, buffering perceived burdensomeness with older adults, and promoting positive religious coping and support. Suggestions for future research are also provided.

1. Introduction

In 2019, around 54.1 million Americans were over 65 years old (U.S. Census Bureau 2020), making up 17% of the population. According to the Centers for Disease Control and Prevention (CDC), suicide ranks as the 15th highest cause of death among adults aged 55 and older in the United States. Older adults make up 47.2% of all suicides in the United States (CDC 2022a). Suicide disparities affect older adults considerably. For example, in a twenty-year review, suicide rates increased for males ages 75 and older, and older adult males were 3–4 times more likely to die by suicide (Garnett et al. 2022). Of note, suicide death by firearms continued to increase for men (Garnett et al. 2022). Men aged 75 and older have the highest suicide rate at 40.5 per 100,000 (CDC 2022a). Therefore, suicide among older adults is an imperative public health concern requiring additional research that explores the complexity of potential risk factors among older adults (Eades et al. 2019). During the COVID-19 pandemic, suicide rates and risk continued to increase among older adults (Wand et al. 2020), further establishing the crucial need to understand potential protective mechanisms for suicide desire in this population.

For older adults with chronic health issues, the pandemic has increased their risk for infection and mortality (Richardson et al. 2020). Although necessary to stop the spread of the virus, the social distance mandates in the United States during the pandemic might have a detrimental side effect on older adults. Social isolation is especially difficult for older individuals (Liu et al. 2020), increasing their risk of suicide and mortality (Luo and Hendryx 2022; Sarangi et al. 2021). Older adults have been found at higher risk for death during the pandemic (Reger et al. 2020), especially those with marginalized identities (Shannonhouse et al. 2020). The pandemic has been labeled the “perfect storm” (Reger et al. 2020) for suicide mortality. As the pandemic continues to have a strong impact in our world, affecting all aspects of life, bringing with it continued social isolation, social distancing, and quarantine, understanding the impact on mental health and suicidal ideation within vulnerable communities is crucial during this time (McElroy-Heltzel et al. 2022). It is thus imperative to better understand the mechanisms that can potentially aid in protecting older adults during stressful times, such as during a global pandemic, or conversely to understand those which can exacerbate the impact of stressors. Previous studies have shown a moderating effect between positive religious coping practices and well-being. For example, the daily use of religious coping to buffer the effects of stress on negative affect resulted in healthier metabolic functioning in an older adult sample (Whitehead and Bergeman 2020). Understanding how religious coping can moderate pandemic-related stress and suicidal behaviors (desire) is a valuable next step.

1.1. Interpersonal-Psychological Theory of Suicide and Older Adults

It is established that people have a fundamental need to belong. The interpersonal-psychological theory of suicidal behavior (IPTS), advanced by Joiner (2005), outlines that an individual will not die by suicide unless they have the desire and the ability to do so. The theory explains that when the need to belong and the ability to contribute to the overall prosperity of those around an individual are lacking (i.e., thwarted belongingness and perceived burdensomeness), suicide desire ensues. For older adults, Van Orden et al. (2008) found that suicide risk may be the result of thwarted belongingness (T.B., chronic loneliness and lack of reciprocal care) and perceived burdensomeness (P.B., a belief that one is a burden to friends and family, and society) combined with an acquired capability for suicide (Joiner 2005; Van Orden et al. 2010). Joiner (2005) explains that acquired capability is a heightened state of absence of fear and pain related to suicidal ideas and behaviors; this results in the idea of suicide becoming less frightening and the act of suicide becoming more likely.

Following the IPTS, both T.B. and P.B. must exist for someone to feel suicidal desire. When the need to belong is thwarted, negative well-being and mental health challenges arise, and individuals experience increased suicidal behaviors (Joiner 2005). T.B. is rooted in extreme social disconnection or isolation, and P.B. is identified by the perception of being a burden to others (Van Orden et al. 2010). T.B. and P.B. are dynamic, their impact can vary across time, context, and relationships (Van Orden et al. 2010). Older adults are vulnerable to loneliness and decreased belongingness as they experience the death of partners/friends, reduced mobility, functional impairment, or the need to move out of familiar environments (Segal et al. 2018). Moreover, social isolation has been identified as a significant risk factor for older adults’ suicidal behavior (Van Orden and Conwell 2011). Thwarted belongingness occurs when the need to belong is unmet and the individual feels isolated, increasing their desire for death (Van Orden et al. 2010). Van Orden and Conwell (2011) explain that when older adults experience social isolation, this is an indicator that the need to belong may be thwarted.

Social disconnection and social stresses may increase both T.B. and P.B. for some older adults, putting them at greater risk of suicide (Eades et al. 2019). Given the potential trend toward increasing T.B. and P.B. over time as we age, understanding the changes to how one perceives their belonging and burdensomeness during late adulthood is vital for mental health professionals to respond to suicide risk comprehensively.

1.2. Religious Coping

Religious Coping can be defined as “the use of cognitive and behavioral techniques in the face of stressful life events, which arise out of one’s religion or spirituality” (Tix and Frazier 1998, p. 411). Religious coping is neither “problem nor emotion-focused coping” (Krägeloh et al. 2012, p. 1118); rather, it involves the use of religious concepts and behaviors as a coping response to life stressors (Krägeloh et al. 2012). For example, this type of coping opens an individual to utilize religious resources such as pastoral counseling, church events, and programs (Hill and Pargament 2008).

The Brief Religious Coping Instrument (B-RCOPE; Pargament et al. 1998, 2011) is a multidimensional instrument that gathers information about an extremely expansive scope of adapting reactions that include the utilization of religious concepts and activities. Pargament’s (1997) religious coping theory explains that religious coping is grounded in the idea that individuals will use their understanding and experience of the sacred to make sense of and face life stressors (Pargament et al. 2011). Per Pargament, the term sacred refers to not only traditional notions of God and divinity of higher powers, but also to other aspects of life that are associated with the divine (Pargament and Mahoney 2005). The B-RCOPE has two dimensions: positive religious coping (i.e., Looking for a stronger connection with God) and negative religious coping (i.e., Questioning God’s love for me).

Studies on religious coping have found that both dimensions differentially affect how individuals cope with stressors (Ano and Vasconcelles 2005; Pargament 1997; Shannonhouse et al. 2020). Positive religious coping is considered adaptive and includes personal, internal cognitive coping efforts stemming from individuals’ constructive and collaborative relationship with God or their faith (Kim et al. 2015). In contrast, negative religious coping refers to a person’s tendency to struggle internally with faith, such as perceiving one’s relationship with God as unstable, plagued by guilt, and distant (Kim et al. 2015; Pargament et al. 1998).

An extended body of research has demonstrated links between healthy religiosity, better mental health, and an improved sense of well-being (Chen et al. 2020; Koenig et al. 2012; Paloutzian and Park 2013; Pargament et al. 2013). Specifically, religious practices have been associated with greater levels of meaning in life (Park et al. 2013), satisfaction with life (Abu-Raiya and Agbaria 2016), attachment security (Granqvist and Kirkpatrick 2013), self-control (e.g., McCullough and Willoughby 2009), comfort (Exline et al. 2000), and lower levels of depression and anxiety (Hood et al. 2009). Furthermore, as Pargament et al. (2000) stated, “it is not enough to know that the individual prays, attends church, or watches religious television. Measures of religious coping should specify how the individual is making use of religion to understand and deal with stressors” (p. 521). Understanding how older adults make sense of stressors via religious coping is an important next step in understanding the mechanism of suicide in this population.

This research attempts to better understand the role of religious coping in older adults and their experience with this style of coping during stressful times, such as a global pandemic. McElroy-Heltzel et al.’s (2018) study suggests that positive religious coping may be one mechanism for reducing suicide risk in an older adult population during COVID-19. Their results align with previous studies on suicide risk and religion during COVID-19 (Fitzpatrick et al. 2020), where religion was shown to be an important resource against suicidality in a diverse sample.

It has been demonstrated that religiosity can be a protective factor against suicidality in the general population (Jacob et al. 2018). Moreover, religion and spirituality (R/S) have been shown to be associated with greater physical and mental health (Abu-Raiya et al. 2015; Aten et al. 2019; Cummings and Pargament 2012; Gall and Guirguis-Younger 2013), fewer suicide attempts (Burshtein et al. 2016), and fewer suicide deaths (Barranco 2016; VanderWeele 2017).

However, many people also experience spiritual struggles—experiences of tension, strain, or conflict around religion or spirituality (Pargament 2011; Pargament and Exline 2021). In recent years, the term spiritual struggles has been used synonymously with negative religious coping. In a study of older adults being treated for depression, about 50% reported religious/spiritual struggles (Murphy et al. 2016). The relationship between spiritual struggles and suicide has also been noted in the literature (Raines et al. 2020). Even though religious/spiritual struggles are widespread and experienced by many people, some may be reluctant to talk about such struggles because they might see spiritual struggles as a morally charged challenge or fear judgmental or shaming responses from others (Exline and Grubbs 2011). In efforts to expand the literature on the protective qualities of religious coping against suicide desire, this study looked at the use of religious coping and suicide desire in older adults in the context of the pandemic.

1.3. COVID-19 and Older Adults

COVID-19 has challenged every aspect of life for almost three years. In the United States (U.S.), the COVID-19 pandemic has caused over 900,000 reported deaths as of April 2022, and adults 65–74 years old account for 22.6% of those deaths (CDC 2022b; Larkin 2022). Older adults are disproportionally high risk and at increased risk for severe COVID-19–associated illness and death (Christie et al. 2021). The colossal impact of COVID-19 in healthcare systems worldwide leads to significant losses of health and life, particularly for older adults who require intensive care (D’Adamo et al. 2020).

Older adults also experience loneliness and social isolation, increasing the risk to their mental and physical health (Sepúlveda-Loyola et al. 2020; Rodney et al. 2021). Evidence suggests that social disconnectedness is associated with great suicide risk later in life. Furthermore, during the pandemic precautions of social lockdown, older people may be especially vulnerable to suicide through a heightened sense of disconnectedness from society, physical distancing, and loss of usual social opportunities, increasing their risk of heightened anxiety and depression (Santini et al. 2020).

In this study, suicide desire is encapsulated by two states: thwarted belongingness (T.B., chronic loneliness and lack of reciprocal care) and perceived burdensomeness (P.B., belief that one is a burden to others and society) and has historically been inversely correlated with religiosity (Mason et al. 2018). Therefore, understanding the relationship between positive and negative religious coping and T.B. and P.B. in older adults that are isolated and homebound is essential to determine intentional mental health treatment plans that consider cultural factors within this population

2. Materials and Methods

2.1. Participants

Participants were older adults who received home-based services, ranging from age 62 to 101 years old. The first time point of longitudinal data was collected from 437 older adults taking part in a larger project. A subset (n = 209) completed the measure set for this study at a second timepoint. Those that did not participate at time two did so for various reasons, including death, medical concerns, and lack of response. These older adults had similar scores on study measures at time one, compared with those who remained in the study. Of the older adults who took part in both administrations and comprise our sample, the majority identified as female (n = 155, 74.2%), Black (n = 138, 66.0%; n = 46, 22.0% White; and n = 18, 8.6% more than one race), and heterosexual (n = 206, 98.6%). Most identified as Christian Protestant (n = 157, 78.5%), though other religious identities included Atheist (n = 3, 1.5%), Agnostic (n = 4, 2.0%), Jewish (n = 3, 1.5%), Muslim (n = 1, 0.5%), Catholic (n = 8, 4.0%), Orthodox (n = 1, 0.5%), and Mormon (n = 1, 0.5%). More than half of the sample were either widowed (n = 74, 35.4%), divorced/separated (n = 73, 34.9%), or single (n = 41, 19.6%), and reported living alone (n = 126, 63.0%). Roughly half of the participants identified that they attended a form of religious service or gathering either in-person (n = 4, 2.1%) or online (n = 97, 50.3%) during the pandemic. Data were analyzed using SPSS.

2.2. Procedure

This research followed a quantitative, prospective longitudinal cohort design. Community-dwelling older adults were recruited across six counties in a large metropolitan area in the southeastern region of the United States. Eligibility criteria included (a) being aged 60 and older, (b) receiving home-delivered meal services (HDM), and (c) having no diagnosis of dementia or cognitive impairment. Recruitment occurred through coordination with the local Area Agency on Aging (AAA), facilitating contact with the participants, and dementia or cognitive impairment screening. Following confirmation of eligibility, participants consented via phone.

Following the longitudinal design, data were first collected in Spring 2019, before the pandemic, through in-person interviews at the participants’ homes, after which they received USD 10 compensation for their participation. Then, following COVID-19 physical distancing policies, the same participants were targeted via phone interviews and Qualtrics software in Fall 2020, and participants were provided USD 20 compensation after the interview. Additionally, data collectors received training, weekly supervision, instruction on aging-specific language, and a safety protocol to enact in the presence of suicide desire. Study procedures were approved by an academic Institutional Review Board, the county aging services agencies that organize HDM, and county governments (i.e., Boards of Commissioners).

2.3. Measures

Suicide Desire. The Interpersonal Needs Questionnaire (INQ; Van Orden et al. 2010) was administered at both time points and used to measure suicide desire through two subscales: Perceived Burdensomeness (6 items) and Thwarted Belongingness (9 items). Each item is scored on a 7-point Likert-type scale, in which 1 represents “not true at all for me” and 7 represents “very true for me.” The scales have yielded internal consistencies of 0.84 and 0.94 with older adult samples (Lutz and Fiske 2017) and 0.81 (Hill et al. 2015) for Perceived Burdensomeness and Thwarted Belongingness, respectively. Sample items include: “These days, the people in my life would be better off if I were gone” (Perceived Burdensomeness) and “These days, I often feel like an outsider in social gatherings” (Thwarted Belongingness). In the present study, the INQ had good internal consistency (P.B. α = 0.90, T.B. α = 0.88).

Religious Coping. The Brief Religious Coping Instrument (B-RCOPE; Pargament et al. 2011) was surveyed at time two (T2) and used to measure how participants coped with the COVID-19 pandemic through two constructs: positive religious coping (7 items) and negative religious coping (7 items). Each item is scored on a 4-point Likert-type scale assessing action frequency, in which 1 represents “not at all” and 4 represents “a great deal.” Sample items include “How much or how frequently did you question God’s love for you?” (negative religious coping) and “How much or how frequently did you seek God’s love and care?” (positive religious coping). Over 30 studies encompassing 5835 participants, the Brief RCOPE manifested consistently strong reliabilities of both positive (median a = 0.92) and negative (median a = 0.81) coping, along with evidence of predictive and concurrent validity (Pargament et al. 2011). In the present study, the B-RCOPE had an internal consistency of α = 0.92 for positive religious coping and α = 0.66 for negative religious coping. After further analysis, removing a single item (i.e., How much or how frequently did you decide the devil made this happen) brought the negative religious coping internal consistency to α = 0.77. No mention was found in the literature regarding the applicability of this item regarding the personification of evil and older populations; however, further exploration may be warranted.

3. Results

Our participants (ages 62–101) varied in suicidality. As older adult participants’ suicide desire increased, so did their negative religious coping. A hierarchical regression analysis was conducted to assess suicide desire (i.e., perceived burdensomeness and thwarted belongingness) when examining the incremental addition of our variables in this order: (1) sex, (2) pre-COVID suicide desire, (3) positive and negative religious coping. Descriptive statistics and correlations are provided in

Table 1. Descriptive Statistics and Correlations (N = 209).

Variables	Mean	SD	Range	1	2	3	4	5
1. T1 Perceived Burdensomeness	9.60	6.82	6–42	—
2. T2 Perceived Burdensomeness	8.89	6.31	6–42	0.43 **	—
3. T1 Thwarted Belongingness	20.40	11.84	9–61	0.48 **	0.28 **	—
4. T2 Thwarted Belongingness	18.46	11.68	9–63	0.23 **	0.62 **	0.42 **	—
5. Positive R/S coping	20.91	7.17	7–28	0.16	0.14	0.02	0.04	—
6. Negative R/S coping	7.07	2.44	6–23	0.12	0.19 *	−0.02	0.22 *	0.21 *

* p < 0.01, ** p < 0.001.

. Negative religious coping was significantly correlated to P.B. (r = 0.19, p = 0.006) and T.B. (r = 0.22, p = 0.001). The hierarchical regression results with P.B. and T.B. as the outcomes are provided in

Table 2. Summary of hierarchical regression analysis for T2 Perceived Burdensomeness.

	Step 1			Step 2			Step 3
Variables	B	SE B	β	B	SE B	β	B	SE B	β
Intercept	9.89	0.86		6.29	0.94		2.93	1.60
Sex (1 = Female)	−1.35	0.99	−0.09	−1.64	0.90	−0.11	−1.91	0.91	−0.13
T1 Perceived Burdensomeness				0.40	0.06	0.43 **	0.37	0.06	0.40 **
Positive R/S coping							0.07	0.06	0.08
Negative R/S coping							0.32	0.16	0.12
Change in R2	0.01			0.19 **			0.03

Note: The Intercept scoring is for a male older adult. ** p < 0.001.

and

Table 3. Summary of hierarchical regression analysis for T2 Thwarted Belongingness.

	Step 1			Step 2			Step 3
Variables	B	SE B	β	B	SE B	β	B	SE B	β
Intercept	20.98	1.58		11.91	2.00		4.01	3.17
Sex (1 = Female)	−3.39	1.84	−0.13	−2.41	1.68	−0.09	−2.50	1.68	−0.09
T1 Thwarted Belongingness				0.41	0.06	0.41 **	0.41	0.06	0.42 **
Positive R/S coping							0.01	0.10	0.00
Negative R/S coping							1.09	0.30	0.23 **
Change in R2	0.02			0.17 **			0.05 *

Note: The Intercept scoring is for a male older adult. * p < 0.01, ** p < 0.001.

, respectively.

3.1. Predicting Perceived Burdensomeness in Older Adults

Hierarchical regression was conducted to examine the predictive relationship between sex, T1 P.B., positive R/S coping, negative R/S coping, and T2 P.B. In the first step of the hierarchical regression model, sex was the sole predictor. T1 P.B. was added to the model in the second step. In the third step, positive R/S and negative R/S coping were inputted into the hierarchical regression model. Sex was not a significant predictor of T2 P.B. (B = −1.35, β = −0.09) and only accounted for approximately 1% of its variance. While controlling for sex, T1 P.B. (B = 0.40, β = 0.43) was a significant predictor of T2 P.B. With every one-unit increase in T1 P.B., T2 P.B. increased by approximately 0.40 units. T1 P.B. added approximately 19% of variance to the model, and the change in R² was statistically significant between Step 1 and Step 2.

While controlling for sex and T1 P.B., positive R/S coping (B = 0.07, β = 0.08) and negative R/S coping (B = 0.32, β = 0.12) were not significant predictors in the hierarchical regression. Positive R/S coping and negative R/S coping added approximately 3% of variance to the model, and the change in R² was not statistically significant between Step 2 and Step 3.

3.2. Predicting Thwarted Belongingness in Older Adults

A second hierarchical regression was conducted to examine the predictive relationship between sex, T1 T.B., positive R/S coping, negative R/S coping, and T2 T.B. In the first step of the hierarchical regression model, sex was the sole predictor. In the second step, T1 T.B. was added to the model. In the third step, positive R/S and negative R/S coping were inputted into the hierarchical regression model. Sex was not a significant predictor of T2 T.B. (B = −3.39, β = −0.13) and only accounted for approximately 2% of its variance.

While controlling for sex, T1 T.B. (B = 0.41, β = 0.41) was a significant predictor of T2 T.B. With every one-unit increase in T1 T.B., T2 T.B. increased by approximately 0.41 units. T1 T.B. added approximately 17% of variance to the model, and the change in R² was statistically significant between step one and step two.

While controlling for sex and T1 T.B., positive R/S coping (B = 0.01, β = 0.00) was not a significant predictor of T2 T.B. However, negative R/S coping (B = 1.09, β = 0.23) was a significant predictor in the hierarchical regression, while controlling for sex and T1 T.B. With every one-unit increase in negative R/S coping, T2 T.B. increased by approximately 1.09 units. Positive R/S coping and negative R/S coping added approximately 5% of variance to the model, and the change in R² was statistically significant between Step 2 and Step 3.

4. Discussion

This study provides insightful information about how and when older adults struggle during the pandemic; there is emerging evidence that suggests that suicide desire has increased for older adults during the pandemic (Asthana et al. 2021; Wand et al. 2020), making it imperative for researchers to explore the impact of the pandemic on mental health for older adults.

At first glance, suicidal desire (P.B. and T.B. separately) during the pandemic does not appear vastly different in aggregate from the pre-COVID-19 levels of these constructs. However, the above analysis allows us to provide a more nuanced understanding of how religiosity in practice was related to individual changes in suicide desire throughout the pandemic. Specifically, for older adults we showed a degree of consistency across these constructs over time, and that increases in T.B. were associated with reports of more negative religious coping (assessed at Time 2).

First, the test-retest stability of both P.B. and T.B. were significant, albeit low. Time 1 P.B. and Time 1 T.B. were statistically significantly related to Time 2 P.B. and Time 2 T.B. This suggests that while there is some inertia in how these aspects of suicide desire are manifested in any individual, there is far more variability with other factors accounting for roughly 80% of the values at Time 2. Consistent with Jahn et al. (2015), this result is more supportive of treating these constructs as a state rather than trait variables. Clinically, such a finding is encouraging because there is reason to believe that altered socioenvironmental factors and mental health intervention can ameliorate these pathways of suicide desire. Suicidality is individually experienced and can change.

Second, while positive religious coping was not a significant predictor in either of our models, negative religious coping was a significant predictor for T.B. Religiousness, in general, has been noted as a protective factor against suicide (Mason et al. 2018), and positive religious coping has been shown in older adults to mitigate the risk of the likelihood of attempting suicide (Suresh et al. 2020). Here we demonstrate that the practice of negative religious coping behaviors may predict increased suicide risk. Religion acts as a means of belonging, connecting individuals to a community and a place in the cosmos (Pargament 2011). Our data suggest that a greater sense of thwarted belongingness increases when that connection is shaken. Research shows that religion can serve as a buffer against suicide. Furthermore, we suggest that when one’s connection to that belonging through faith is challenged, it exacerbates the general unbelonging, which has been shown predictive of suicide desire.

In a study of religious coping in Botswana, Shannonhouse et al. (2019) showed that negative religious coping served as a mediative pathway from the resource loss experienced due to drought to the presentation of current trauma symptoms. Interestingly, drought and COVID-19 could be classified as chronic disasters, which often feature cascading mental health consequences since their ongoing nature makes the resolution timeframe uncertain. Chronic disasters may result in more difficult recovery for survivors (Stain et al. 2011). Unfortunately, the current study implies that when the nature of such a chronic stressor does result in negative religious coping practices, recovery may include recapturing a sense of belongingness with one’s creator, which has ramifications for suicidality.

Also, we found no significant relationships between gender and either P.B. or T.B. Results show that female participants tend to score lower than males on P.B. (which is argued to be the stronger predictor of suicide); however, this is not a significant difference. Other studies show no significant gender differences for P.B. For example, Donker et al. (2014) found that higher levels of perceived burdensomeness (P.B.) were associated with increased suicidal ideation in both genders. In Cukrowicz et al.’s (2011) study on P.B. and its impact on suicide desire, the results did not support the hypothesis that perceived burdensomeness exerts a greater impact on suicide ideation in males than females.

4.1. Implications

For therapists and mental health providers supporting older adults during the pandemic, strategies from Joiner et al. (2009) for targeting perceptions of burdensomeness may be helpful. For example, they suggested collaborating with the individual to generate evidence (e.g., identifying social supports or future aspirations) that indicates the patient’s life is worth more than their death. Additionally, engaging in conversations about feelings of burdensomeness and what kind of support clients need should identify in what ways they are helpful to their loved ones and society.

Future research should also test these interventions with older adults. Some researchers have successfully treated geriatric depression with cognitive behavioral therapy (Areán et al. 2010; Pinquart et al. 2006; Teismann et al. 2018). Therefore, perceptions of the burden on others may also be treated successfully in collaborative therapy work.

Higher engagement in negative religious coping was a significant predictor of suicide desire during the pandemic when controlling for pre-pandemic suicide data. Negative religious coping has been negatively related to the quality of life and increased stress (Gardner et al. 2014). This study supports prior work that negative religious coping exacerbates negative psychological outcomes (Gardner et al. 2014; Pargament et al. 2011, 2013). It may be beneficial to study the absence of this coping practice further. One of the stressors during the pandemic for older adults was not being able to attend church service; this might have impacted religious practices in addition to impacting how connected and supported older adults felt during the pandemic.

For mental health practitioners serving the mental health needs of older adults struggling during the pandemic, assessing clients’ religious identity and their current religious coping practices is recommended where applicable. The lack of access to religious community and support might have impacted how individuals feel towards the “sacred” (Pargament et al. 2011). Pargament et al. (2013) argue that spiritual beliefs and practices, possibly including a secure bond with God and spiritual connectedness, can be a protective factor against physical and mental health problems. When applicable, engaging in religious and spiritual conversations and assessments with clients can provide a therapist with insightful information about coping and its effect on mental health.

The sensitive nature of religious struggles should also be considered here. While the pastor or spiritual care provider may be the most equipped to help someone struggling with their faith, there may be a social disincentive for someone to disclose such struggles with their faith leader. Conversely, attending to religious and spiritual concerns is often outside of the training and scope of competence for mental health professionals. However, as demonstrated by the above data, internal struggles with one’s religious worldview can spill over into constructs traditionally the domain of the counselor/psychologist—feelings of isolation and suicidal desire. Neglecting this aspect of a client’s worldview and coping is done at the clinician’s peril, as the downstream consequences suggested by the IPTS may be severe.

The authors recommend clinicians approach religious and spiritual struggles and practices with curiosity and openness. The clinician should use basic counseling skills to not impose the clinician’s beliefs or practices onto the client and to ask open-ended questions for a better understanding of the client’s experiences with the divine. In addition, attend to the clinician’s religious and spiritual struggles, experiences, and biases. Finally, more detailed recommendations can be found in Jones (2019), Pargament and Exline (2021), and Vieten et al. (2013) for recommendations on how to best support clients navigating spiritual and religious struggles.

4.2. Limitations

Although this study supports the importance of P.B., T.B., and religious coping in the desire for suicide in older adults, the study’s limitations must be considered. For instance, results might have limited generalizability since this was a community-based sample not representative of the population. Using a self-report survey instrument presents limitations as participants may have been biased or input untruthful responses. Future research is needed to investigate the complex relationship between P.B., T.B., religious coping, and suicide desire in depth. There was considerable attrition from Time 1 to Time 2 (52.2%), potentially compounding the self-report nature of this study. It may be that T1 participants who experienced stronger negative mental health symptoms during the pandemic were more reluctant to participate in the follow-up survey. If this shirker behavior did occur, then the relatively consistent aggregate values of T.B. and P.B. observed would underrepresent the prevalence of these constructs at T2 in the population.

The sample was relatively small and contained a disproportionate number of females and Christian Protestants; future work should include a more diverse sample regarding gender and religious denomination. Similarly, other religious coping measures could be more inclusive for participants who might not identify with God as coping. Furthermore, the item “How much or how frequently did you decide the devil made this happen” reduced the internal consistency of the negative religious coping construct with this population. Further research may consider the applicability of this item with older adults when conducting religious and spiritual research and determine which populations this item may not apply to or be appropriate for given individual culture’s personification of “evil.”

5. Conclusions

In summary, the presence of faith appears less important in the context of mental health struggles and suicidality than how one connects with the practice of that faith. Furthermore, it appears that the internal existential isolation associated with “losing one’s faith” or maladaptively using one’s faith can have ripple effects beyond religiosity. Losing one’s sense of belonging or existentially struggling with it is quite isolating, which can contribute to suicidal desire.