Spirituality and the MMPI-2

Spirituality and the MMPI-2 䊲 Douglas A. MacDonald University of Detroit Mercy 䊲 Daniel Holland University of Arkansas at Little Rock The present investigation was an exploratory examination of the relation of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) Clinical scales to spirituality operationalized in terms of self-reported religious involvement and scores on a multidimensional measure called the Expressions of Spirituality Inventory (ESI; MacDonald, 1997, 2000). MANOVA and correlational results indicate that the MMPI-2 Clinical scales generate patterns of findings consistent with available research on spirituality and health. In particular, persons reporting involvement in organized religion obtained significantly lower MMPI-2 Clinical scale scores and were found to be less likely to obtain a clinically significant score (i.e., t-scores ⬎64) on any of the MMPI-2 scales. Further, with the exception of Masculine-Feminine and Hypomania, all MMPI-2 scales were found to associate appreciably with ESI dimension scores. The study concludes with a brief discussion of the meaning and implications of the findings for future research aimed at investigating the relation of spirituality to health. © 2003 Wiley Periodicals, Inc. J Clin Psychol 59: 399–410, 2003. Keywords: spirituality; psychopathology; psychometric; MMPI-2 In recent years, spirituality has been gaining recognition as a legitimate and important aspect of human functioning which demonstrates a reliable relation to health and wellbeing (e.g., Gartner, 1996; George, Larson, Koenig, & McCullough, 2000; Richards & Bergin, 1997; Seybold & Hill, 2001). Nevertheless, and despite the growing body of The authors would like to thank Dr. Cornelius J. Holland, Dr. Catherine Tsagarakis, and Dr. Jeffrey Kuentzel as well as the anonymous reviewers for their helpful suggestions and Bob Dario, Joel Gagnier, Kris Gene, and Andrew Taylor for their assistance during data collection. Correspondence concerning this article should be addressed to: D.A. MacDonald, Department of Psychology, University of Detroit Mercy, 8200 West Outer Drive, Detroit, MI 48219–0900; e-mail: macdonda@udmercy.edu. JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 59(4), 399–410 (2003) © 2003 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.10047 400 Journal of Clinical Psychology, April 2003 professional literature advocating its inclusion in clinical practice (e.g., Miller, 1999; Richards & Bergin, 1997, 2000; Shafranske, 1996) as well as the recent change of conventional diagnostic nomenclature to incorporate problems of a religious or spiritual nature [e.g., see Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV); American Psychiatric Association, 1994], there is minimal evidence indicating that spirituality is receiving attention by practicing physicians and psychologists. For instance, recent surveys of physician practices (Chibnall & Brooks, 2001) and test usage by psychologists (Camara, Nathan, & Puente, 2000) suggest that religion and spirituality are not being addressed in clinical work. If spirituality is indeed robustly related to health, then why are there virtually no indications of its inclusion in professional work? Though the answer to this question is complex and involves ethical and professional considerations (e.g., possible imposition of personal values on client, difficulties adding measures to already extensive comprehensive testing batteries; see Camara et al., 2000; Chibnall & Brooks, 2001; also see Sloan, Bagiella, & Powell, 1999, for discussion of ethics in context of medicine), one likely contributing factor relates to the lack of a coherent body of clinical knowledge. That is, at present, there is no identifiable corpus of information that establishes the place of spirituality within the nomological net of clinical constructs in a manner which makes spirituality salient to practitioners. For example, in the area of psychological assessment, there have been only a few studies published examining the relation of spirituality to commonly used instruments [e.g., Minnesota Multiphasic Personality Inventory-2 (MMPI-2); Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989; Rorschach, 1942; Thematic Apperception Test (TAT); Murray, 1938]. In the case of the MMPI-2, there are only two extant and marginally informative investigations involving spirituality in which the measure is employed (Plante, Manuel, & Tandez, 1996; Tloczynski, Knoll, & Fitch, 1997). Since clinical test usage has remained highly stable over the past several decades (Camara et al., 2000), it seems reasonable to contend that spirituality may find greater recognition by practitioners if empirical data exposing its relation to and/or impact on conventional clinical instruments were generated. In this vein, the purpose of this study was to investigate the relation of spirituality to one of the more dominant measures in clinical assessment, the MMPI-2. In particular, the present study aimed to determine how the MMPI-2 Clinical scales, both collectively and individually, relate to spirituality. Spirituality Operationalized Although spirituality is generally touted as having a robust connection to psychological functioning, closer inspection of the literature indicates that there are several points of ambiguity regarding its definition which raise questions about the accuracy of such assertions. For example, as has been noted by some (e.g., Zinnbauer et al., 1997), spirituality has only recently become a construct which is seen as different than religion and religiousness. In line with this, while it has been the trend for researchers to use the terms religion and spirituality as synonyms, at least one recent review of the spirituality-health literature has explicitly acknowledged that evidence supporting the association with psychological functioning is mostly related to measures of religion (and especially religious behavior) and not spirituality, per se (e.g., George et al., 2000), thus casting into doubt the practice of equating the two constructs and the viability of generalizing the findings from one to the other. As a further illustration, efforts to identify measures of spirituality which aim to minimize or exclude religion have revealed the existence of over 100 self-report instruments Spirituality and MMPI-2 401 (MacDonald, Kuentzel, & Friedman, 1999; MacDonald, LeClair, Holland, Alter, & Friedman, 1995). Inspection of these instruments and the research in which they have found use, however, indicates that there is little agreement as to what constitutes the main features and dimensions of spirituality and, by extension, little basis on which to draw cogent comparisons between tests to develop a cumulative body of knowledge (MacDonald, 2000). To address problems with measurement, the present investigation employed two different operationalizations of spirituality. First, in response to the fact that religious behavior (e.g., church attendance) has been found to be a highly reliable predictor of health and well-being (e.g., Gartner, 1996; George et al., 2000), we elected to include self-reported religious involvement as one general measure of spirituality. As our second measure, we chose to employ the recently developed Expressions of Spirituality Inventory (ESI; MacDonald, 1997, 2000). The ESI is a 98-item, self-report instrument designed to assess a five-dimensional, descriptive measurement model that was specifically devised to serve as a structural framework for organizing scientific definitions of spirituality. The five dimensions themselves, Cognitive Orientation Towards Spirituality (COS), Experiential/Phenomenological Dimension (EPD), Existential Well-Being (EWB), Paranormal Beliefs (PAR), and Religiousness (REL), embody common factors uncovered and replicated in a series of factor analyses completed with data obtained from over 1,400 participants on approximately 18 measures of spiritual constructs. Given this, the dimensions may be thought of “as encompassing five broad and somewhat intercorrelated content areas which reflect the expressive modalities of spirituality that form core descriptive components of the construct” (MacDonald, 2000, p. 187) at least insofar as it is represented in existing psychometric measures. (To get a better idea as to the nature and scope of the ESI, the reader is referred to the Method section and to Table 1, which provides sample items and a partial listing of tests which have been found to empirically contribute/relate to each dimension.) Research Expectations Even though the MMPI-2 has not been utilized in many studies concerning spirituality, the older MMPI (Hathaway & McKinley, 1951) has been employed in a fair number of investigations. Much of this research, however, has yielded inconsistent findings. For example, some studies suggested that MMPI Clinical scale scores vary as a function of religious affiliation and religiosity (Bohrnstedt, Borgatta, & Evans, 1968) while others did not (e.g., DeVries, 1966). Similar patterns of discrepant findings also are found involving mystical experience (e.g., Fite, 1981; Hood, 1975). Thus, there is little reliable information involving the MMPI and spirituality on which to generate meaningful hypotheses for the MMPI-2. Notwithstanding these difficulties, and considering the wider body of literature which indicates that spirituality (particularly when defined in terms of religious practice) is positively related to general well-being and inversely associated with affective disorders (especially depression) and antisocial behavior (Gartner, 1996; George et al., 2000), some research expectations could be formulated. In general, it was expected that the MMPI-2 Clinical scales would be (a) significantly lower for persons reporting involvement in organized religion relative to persons who have a religious affiliation but do not report any involvement, and (b) significantly related to spirituality as measured by the ESI. More specifically, it was expected that MMPI-2 402 Journal of Clinical Psychology, April 2003 Table 1 Expressions of Spirituality Inventory: Dimension Definitions, Sample Items and Partial Listings of Empirically Related Scales as Found in Correlational and Factor Analyses Cognitive Orientation Towards Spirituality: Belief in the existence of spirituality and perception of spirituality having relevance to identity and daily functioning Sample Items: Spirituality gives life focus and direction; I am a spiritual person. Related Scales: Spiritual Orientation Inventory—All subscales save Transcendent Dimension (Elkins, Hedstrom, Hughes, Leaf, & Saunders, 1988); Spiritual Assessment Scale—Innerness subscale (Howden, 1992); Spiritual Well-Being Questionnaire—Subjective Spiritual Well-Being subscale (Moberg, 1984). Experiential/Phenomenological Dimension: Experiences of a spiritual nature Sample Items: I have had an experience in which I seemed to transcend space and time; I have had an experience in which the world seemed perfect. Related Scales: Mystical Experiences Scale (M-Scale; Hood, 1975); Peak Experiences Scale (PS; Mathes, Zevon, Roter, & Joerger, 1982), Ego Permissiveness Inventory Peak Experience and Dissociated Experience subscales (Taft, 1969); Spiritual Orientation Inventory-Transcendent Dimension. Existential Well-Being: Comfort with one’s self and confidence in one’s ability to handle basic existential issues Sample Items: I seldom feel tense about things; I am not comfortable with myself (⫺) Related Scales: Ego Grasping Orientation (Knoblauch & Falconer, 1986), Spirituality Self-Assessment Scale (Whitfield, 1984), Spiritual Well-Being Scale–Existential Well-Being subscale (Paloutzian & Ellison, 1982); Spirituality Assessment Scale; Spiritual Well-Being Questionnaire–Self-Satisfaction subscale. Paranormal Beliefs: Belief in parapsychological phenomena, spiritualism, and witchcraft Sample Items: I believe witchcraft is real; It is possible to communicate with the dead. Related Scales: Paranormal Beliefs Scale (Tobacyk & Milford, 1983); Ego Permissiveness Inventory–Belief in the Supernatural subscale; Assessment Schedule for Altered States of Consciousness–Parapsychological Beliefs and Esoterics subscales (vanQuekelberghe, Altstotter-Gleich, & Hertweck, 1991). Religiousness: Intrinsic religious orientation and religious practice Sample Items: I feel a sense of closeness to a higher power; I practice some form of prayer. Related Scales: Intrinsic Religious Motivation Scale (Hoge, 1972); East–West Questionnaire–Man and the Spiritual subscales (Gilgen & Cho, 1979); Spiritual Well-Being Scale–Religious Well-Being subscale; Religious Orientation Scale–Intrinsic Religious Orientation subscale (Allport & Ross, 1967). Note. (⫺) ⫽ reverse scored. ESI items taken from MacDonald (1997). Used with permission of the author. For a complete listing of empirically correlated scales, the reader is referred to MacDonald (2000). Depression and Psychopathic Deviate scales would be significantly linked to spirituality such that lower scores will be associated with involvement in religion and increased ESI scores. Method Participants The sample consisted of 266 self-selected undergraduate psychology students from a mid-sized university in Southwestern Ontario, Canada. The sample (77 males and 189 females) had a mean age of 21.04 years (SD ⫽ 4.31, range ⫽ 17–51). Students who participated were informed both orally and in writing about the general purpose of the study. Thereafter, students who volunteered did so subsequent to providing written Spirituality and MMPI-2 403 consent. All participants received credit which applied towards their final psychology course grades.1 Measures ESI. The ESI contains 40 items on COS (i.e., beliefs about the relevance of spirituality to identity and day-to-day functioning), 19 items on EPD (i.e., spiritual experience), 9 items on EWB (i.e., comfort with one’s self and confidence in one’s ability to handle basic existential issues such as finding meaning and purpose in life), 13 items on PAR (i.e., belief in parapsychological phenomena, spiritualism, and witchcraft), and 17 items on REL (i.e., intrinsic religious orientation and religious behavior such as meditation and attendance to religious services). The ESI employs a 0 (Strongly Disagree) to 4 (Strongly Agree) response scale which respondents utilize to rate the extent to which they agree with the items. Dimension scores are obtained by summing relevant item responses. Examination of the psychometric properties of ESI indicates that the dimension scores demonstrate good reliability (e.g., scale reliabilities via alpha range from .85 for EWB to .97 for COS), satisfactory convergent and discriminant validity, and adequate factorial validity. In terms of factorial validity, oblique rotation has revealed that COS and REL are highly intercorrelated, but nonetheless appear to be unique constructs. There are indications that the instrument scores also are appropriately sensitive to external variables including religious affiliation (e.g., general differences have been found between persons reporting no religion and any religious affiliation, but no consistent differences between persons of differing religious affiliations have been observed), religious involvement, and reported spiritual experience (MacDonald, 2000). Table 1 presents sample items for each of the ESI dimensions as well as information regarding empirical correlates. MMPI-2. The MMPI-2 is a 567-item, paper-and-pencil measure of psychopathology which uses a true–false response format. The inventory is made up of a number of scale sets, the most fundamental of which is the ten basic Clinical scales: Hypochondriasis (Hs), Depression (D), Conversion-Hysteria (Hy), Psychopathic Deviance (Pd), Masculinity-Femininity (Mf ), Paranoia (Pa), Psychasthenia (Pt), Schizophrenia (Sc), Hypomania (Ma), and Social Introversion (Si). Research examining the psychometric properties of the MMPI-2 Clinical scales has generally indicated that they have satisfactory reliability and generally adequate validity (Butcher et al., 1989; Greene, 1991). 1 The use of a sample of undergraduate students may be seen as serious limitation of this investigation since any obtained findings may not prove generalizable to other (more relevant) populations (e.g., clinical, geriatric, religiously/spiritually developed persons). It may be argued, however, that the use of a sample drawn from a specialized population is not necessarily any superior to a student sample in terms of its impact on the internal or external validity of a study, at least within the context of the analysis of individual (as opposed to group) differences. For example, if it is assumed that spirituality has a positive relationship to health (inverse relation to psychopathology), then it appears reasonable to expect that scores on measures of spirituality will be lower with more markedly restricted ranges for a clinical sample than for a nonclinical sample (or, in the case of a spiritually developed sample, scores on measures of pathology will be lower with a restricted range). If such a restriction of score variance occurs, the extent to which basic (parametric, linear) statistical assumptions (e.g., homoscedasticity) are met by the data becomes questionable, and by extension, the quality and validity of correlational analyses are thrown into doubt (e.g., at minimum, correlations would be attenuated; at maximum, any linear statistic could be rendered uninterpretable). Within this line of thought, though the use of a sample drawn from the general population would be the most ideal in terms of capturing the largest amount of score variability (and covariability) across measures of both pathology and spirituality (and thereby best ensuring that statistical assumptions are fulfilled), the use of any nonclinical sample, including those drawn from an undergraduate student population, may be seen as facilitating the correlational study of spirituality–pathology relations due to the greater breadth of score variability such samples generate. 404 Journal of Clinical Psychology, April 2003 Survey Form. A brief survey form was included which asked participants to provide information about their age, sex, religious affiliation, and religious involvement (e.g., “Are you currently active in your religion?”). Procedure The instruments were administered as a part of a larger test battery used in a related investigation (MacDonald, 1997).2 Results Before initiating any analyses, MMPI-2 validity scale scores were examined as per the recommendations of Butcher, Graham, and Ben-Porath (1995) to determine if any invalid or questionable scores profiles existed. If participant scores did not meet any one of several validity criteria, they were excluded from analyses (e.g., to be included, a participant had to have ⬍30 missing-item responses, L and K scale T-scores ⬍80, F scale raw score ⬍30, VRIN T-score ⬍80, and TRIN raw score ⬎5 and ⬍13). This process resulted in the elimination of 27 participants, leaving a sample size of 239 (65 males and 174 females). The mean age of the revised sample was 21.16 years (SD ⫽ 4.51, range ⫽ 18–51). Two-hundred six participants reported affiliation with an organized religion, and of these, 94 indicated they were actively involved with their religion, 110 stated they were not involved, and 2 did not provide a response about religious involvement. Religious Involvement and MMPI-2 Clinical Scales A MANOVA was completed examining all ten MMPI-2 Clinical scales as a function of religious involvement (i.e., Involved, n ⫽ 94, and Not Involved, n ⫽ 110). Individuals who did not report having a religious affiliation as well as those who did not respond to the item concerning religious involvement were excluded from the analysis. Using Wilks’ criterion, a significant multivariate F was obtained, F(10,193) ⫽ 1.92, p ⬍ .05, h 2 ⫽ .09. Univariate ANOVAs (see Table 2) generated significant findings for MMPI-2 D, F(1,202) ⫽ 6.03, p ⬍ .02; Pd, F(1,202) ⫽ 6.66, p ⬍ .02; Pa, F(1,202) ⫽ 6.90, p ⬍ .01; Pt, F(1,202) ⫽ 4.85, p ⬍ .03; and Sc, F(1,202) ⫽ 4.77, p ⬍ .04. In all cases, the Involved group obtained the lower mean T-score. Though these results provide some indication as to how the MMPI-2 may change as a function of spirituality, it may be argued that they are of questionable import because (a) estimates of effect size are small (e.g., h 2 ranges from .00–.03), (b) the mean T-scores for both groups presented in Table 2 fall below the accepted level for clinical significance (i.e., T-score ⬎ 64), and (c) even for significant findings, there is less than a 5-point difference in mean T-scores across groups. By association, the results may be seen as not having any relevance to the type of populations for which the MMPI-2 is typically used (i.e., persons demonstrating significant levels of pathology). To address this concern at least partly, MMPI-2 scale scores were examined and participants placed into one of two groups based upon the presence or absence of one or 2 ESI and survey form data have been utilized in other articles. In MacDonald (2000), the ESI and survey form data included in the present investigation were part of a much larger data set used to develop and validate the ESI proper. In Taylor and MacDonald (1999), data regarding religious involvement were a small section of a sizable data set generated to examine the relation of religion to a measure of the five-factor model of personality. 405 Spirituality and MMPI-2 Table 2 Univariate ANOVA Results for MMPI-2 Clinical Scales as a Function of Religious Involvement Religious Involvement Involved (n ⫽ 94) MMPI-2 Scale Hypochondriasis Depression Hysteria Psychopathic Deviate Masculine–Feminine Paranoia Psychasthenia Schizophrenia Hypomania Social Introversion Not Involved (n ⫽ 110) Mean SD Mean SD F h2 51.79 49.05 51.06 50.72 52.79 51.39 53.23 55.77 57.15 48.90 10.20 10.31 11.70 9.64 11.47 10.91 10.74 11.31 10.61 9.73 53.98 52.95 51.41 54.41 53.54 56.07 56.93 59.68 60.06 51.08 11.97 12.13 11.21 10.59 9.79 14.02 12.88 13.87 11.52 11.58 1.95 6.01* 0.05 6.66* 0.25 6.90** 4.85* 4.77* 3.49 2.07 .01 .03 .00 .03 .00 .03 .02 .02 .02 .01 Note. For MMPI-2, T scores used in analyses. For all analyses, df ⫽ 1, 202. *p ⬍ .05, **p ⬍ .01. more clinically significant MMPI-2 score elevations.3 For the “No-Clinically-SignificantScore-Elevations” group (n ⫽ 72), none of the MMPI-2 Clinical scale T-scores equaled or exceeded 65. Conversely, for the “One-or-More-Clinically-Significant-Score-Elevations” group (n ⫽ 132), at least one MMPI-2 clinical scale score was observed to be 65 or greater. This variable was cross tabulated with religious involvement and the resulting contingency table (see Table 3) used as the basis for a test of independence. A significant finding was obtained (x 2 ⫽ 5.29, p ⬍ .05) indicating that the two variables are related. MMPI-2 Clinical Scales and ESI Dimensions Table 4 presents zero-order, partial, and multiple correlations between the MMPI-2 Clinical scales and the five ESI dimensions using data from the entire sample (N ⫽ 239). Partial correlations represent the association of each ESI dimension to each MMPI-2 scale while controlling for the remaining four ESI dimensions. Multiple correlations represent the association of the combined ESI dimensions with each MMPI-2 scale (last column in Table 4) and the relation between the combined MMPI-2 scales with each ESI dimension individually (last row in Table 4). Examination of the multiple correlations for the ESI reveals coefficients ranging in magnitude from .23 for MMPI-2 Mf to .65 for MMPI-2 D. With the exception of the multiple correlations involving MMPI-2 Mf and Ma, all coefficients are significant at p ⬍ .001. Multiple correlations for the MMPI-2 across each of the ESI dimensions range 3 Efforts also were made to categorize participants based upon their highest clinically significant MMPI-2 scale score, thereby generating ten groups (one corresponding to each of the MMPI-2 Clinical scales). However, while we were able to assign participants to all groups, there were insufficient numbers of participants in each group to allow for any meaningful statistical analyses. 406 Journal of Clinical Psychology, April 2003 Table 3 Contingency Table Showing Expected and Observed Frequencies of Participants Across Both Religious Involvement and MMPI-2 Clinical Scale Significance Variables Religious Involvement MMPI-2 Scale Elevation No Clinically Significant Scale Elevations (n ⫽ 72) Expected Observed One or More Clinically Significant Scale Elevations (n ⫽ 132) Expected Observed Involved (n ⫽ 94) Not Involved (n ⫽ 110) 33.2 41 38.8 31 60.8 53 71.2 79 Note. x 2 (df ⫽ 1) ⫽ 5.29, p ⬍ .05. in magnitude from .28 for ESI COS to .69 for ESI EWB. The coefficients for EPD, EWB, and PAR are significant at the p ⬍ .001 level. Considering next the zero-order correlations, inspection of the table reveals a differential pattern of significant coefficients between the MMPI-2 scales and each of the ESI dimensions. EWB obtained the most conspicuous array of findings, having produced significant negative correlations ( ps ⬍ .001) with MMPI-2 Hs (r ⫽ ⫺.33), D (r ⫽ ⫺.64), Hy (r ⫽ ⫺.27), Pd (r ⫽ ⫺.45), Pa (r ⫽ ⫺.47), Pt (r ⫽ ⫺.54), Sc (r ⫽ ⫺.48), and Table 4 Zero Order, Partial and Multiple Correlations Between ESI Dimensions and MMPI-2 Clinical Scales ESI Dimensions MMPI-2 Scales Hypochondriasis Depression Conversion Hysteria Psychopathic Deviate Masculine–Feminine Paranoia Psychasthenia Schizophrenia Hypomania Social Introversion Multiple r COS EPD .07 (⫺.00) ⫺.11 (.03) .09 (.06) ⫺.09 (.10) ⫺.11 (⫺.16) .00 (.05) ⫺.04 (.10) ⫺.01 (⫺.01) .02 (.01) ⫺.15 (⫺.00) .28 .16 (.11) ⫺.10 (⫺.09) .18 (.12) ⫺.01 (⫺.04) ⫺.03 (.10) .10 (.02) ⫺.04 (⫺.09) .14 (.11) .18 (.13) ⫺.26 (⫺.21) .41 EWB PAR ⫺.33 (⫺.33) .16 (.07) ⫺.65 (⫺.64) .01 (⫺.02) ⫺.27 (⫺.27) .14 (.05) ⫺.46 (⫺.44) .14 (.11) .08 (.08) ⫺.16 (⫺.15) ⫺.47 (⫺.46) .24 (.19) ⫺.54 (⫺.53) .10 (.07) ⫺.48 (⫺.47) .19 (.11) ⫺.06 (⫺.03) .18 (.11) ⫺.45 (⫺.47) ⫺.13 (⫺.09) .69 .38 REL Multiple r .05 (.04) ⫺.12 (⫺.03) .02 (⫺.04) ⫺.21 (⫺.19) ⫺.01 (.10) ⫺.07 (⫺.05) ⫺.10 (⫺.08) ⫺.06 (⫺.02) ⫺.07 (⫺.09) ⫺.09 (.04) .30 .38 .65 .33 .50 .23 .52 .55 .51 .25 .53 Note. N ⫽ 239. Correlations based on MMPI-2 T scores. Zero-order and partial correlations of magnitude .21 or greater significant at p ⬍ .001. For ESI, COS ⫽ Cognitive Orientation Towards Spirituality, EPD ⫽ Experiential/Phenomenological Dimension, EWB ⫽ Existential Well-Being, PAR ⫽ Paranormal Beliefs, REL ⫽ Religiosity. For each ESI variable, zero-order and partial correlations (in parentheses) are provided. Partial correlations for each ESI dimension were calculated after controlling for the remaining four ESI dimensions. For partial correlations, df ⫽ 233. 407 Spirituality and MMPI-2 Si (r ⫽ ⫺.45). The EPD produced a significant negative correlation with Si (r ⫽ ⫺.26, p ⬍ .001). PAR obtained a significant positive correlation with MMPI-2 Pa (r ⫽ .24, p ⬍ .001). REL generated one significant negative correlation with MMPI-2 Pd (r ⫽ ⫺.21, p ⬍ .001). COS did not generate any significant coefficients. Examination of partial correlations reveals minimal change in the pattern of significant relations between the ESI dimensions and the MMPI-2 scales with two exceptions—the levels of significance for partial correlations between ESI PAR and MMPI-2 Pa and ESI REL and MMPI-2 Pd fell below p ⬍ .001 after controlling for the other ESI dimensions. Finally, using the MMPI-2 grouping variable described earlier, a MANOVA was completed examining the five ESI dimensions as a function of these groups. Using Wilks’s criterion, a significant multivariate result was obtained, F(5,233) ⫽ 4.67, p ⬍ .001, h 2 ⫽ .09. Univariate ANOVAs calculated for each of the ESI dimensions separately (see Table 5) produced only one significant finding involving ESI EWB, F(1,237) ⫽17.38, p ⬍ .001, h 2 ⫽ .07. The group consisting of participants with no clinically significant MMPI-2 score elevations produced the lower mean score. Discussion Consistent with expectation and existing research (George et al., 2000), the findings of the present investigation indicate that the MMPI-2 Clinical scales are related to spirituality. In particular, when used collectively, MMPI-2 Clinical scale scores were found to significantly differ as a function of religious involvement and to generate moderate associations to spirituality as measured by the ESI. When treated individually, not only did the MMPI-2 D and Pd scales produce the expected significant findings in analyses involving both religious involvement and the ESI but MMPI-2 Pa, Pt, and Sc also generated notable results across both operationalizations of spirituality employed and all of the remaining Clinical scales, save Mf and Ma, obtained significant correlations with at least one ESI dimension. Finally, the general presence of clinically significant levels of Table 5 Univariate ANOVA Results for ESI Dimensions as a Function of Presence/Absence of Significant MMPI-2 Scale Elevation Presence/Absence of One or More Elevated MMPI-2 Scaled Scores At Least One Elevated Score (n ⫽ 158) ESI Dimension COS EPD EWB PAR REL No Elevated Scores (n ⫽ 81) Mean SD Mean SD F h2 87.55 33.10 21.34 28.20 38.92 31.48 14.12 6.66 11.79 15.46 89.91 30.01 24.86 27.90 41.28 34.44 12.87 5.12 12.02 16.54 0.28 2.71 17.38* 0.03 1.20 .00 .01 .07 .00 .01 Note. For MMPI-2 scale score, T score ⱕ 65 was used as cutoff. For ESI, COS ⫽ Cognitive Orientation Towards Spirituality, EPD ⫽ Experiential/Phenomenological Dimension, EWB ⫽ Existential Well-Being, PAR ⫽ Paranormal Beliefs, REL ⫽ Religiousness. For all analyses, df ⫽ 1,237, *p ⬍ .001. 408 Journal of Clinical Psychology, April 2003 pathology as reflected in one or more elevated MMPI-2 Clinical scale scores was found to be related to religious involvement and to be predictive of ESI scores, especially those for ESI EWB. While the results of this study are in line with extant research and suggest that spirituality/religion may play a role in facilitating and/or maintaining health, it is important to exercise caution in interpreting the relation as a simple causal one. Analysis of the available empirical literature has led to the proposal of three mediating mechanisms potentially responsible for the link between religion and health. In particular, religion is associated with increased healthy behaviors, social support, and an enhanced sense of meaning or coherence, three factors known to have a direct impact on levels of psychopathology and psychological distress (George et al., 2000). Moreover, despite the significant results obtained, the clinical relevance of the observed relation between MMPI-2 Clinical scales and spirituality appears equivocal as reflected in small absolute mean differences between religious involvement groups and meager effect sizes in ANOVA results. As such, though it may be tempting to treat elevations on MMPI-2 scales as potential indicators of deficiencies/problems in spirituality or vice versa, clinicians need to be wary of doing so because our findings are only really supportive of a general, and largely modest, association between psychopathology and spiritual functioning. Notwithstanding these limitations, our findings may be interpreted as clearly suggesting that the MMPI-2 holds potential for exploring the relation of psychopathology to spirituality. 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