714665

research-article2017
JHNXXX10.1177/0898010117714665Spirituality and Depression / Penman

243

jhn
Qualitative Research

Finding Paradise Within

How Spirituality Protects Palliative Care Clients Journal of Holistic Nursing
American Holistic Nurses Association
and Caregivers From Depression Volume 36 Number 3
September 2018 243­–254
© The Author(s) 2017
10.1177/0898010117714665
Joy Penman, PhD, RN journals.sagepub.com/home/jhn
Monash University, Australia

The aims of this article are to explore the experience of depression among palliative care clients and
caregivers, describe the strategies they use in coping with depression, and clarify the role of spirituality
in preventing and/or overcoming depression. This article discusses an aspect of the findings of a larger
doctoral study that explored the nature of spirituality and spiritual engagement from the viewpoint of
individuals with life-limiting conditions and their caregivers. van Manen’s phenomenology was used in
the study. The data generated from the doctoral study were subjected to secondary analysis to uncover
the experience of depression. The methodology underpinning the secondary analysis was phenomenol-
ogy also by van Manen. Fourteen clients and caregivers from across regional and rural South Australia
informed the study. Data collection involved in-depth nonstructured home-based interviews that were
audiotaped and transcribed verbatim. The findings highlighted relate to participants succumbing to
depression, but having spiritual beliefs and practices helped them cope. One of the most insightful
understanding was the role spirituality played in protecting individuals from depression, encapsulated
in the theme “finding paradise within.” Spirituality, understood from a religious or secular perspective,
must be embedded in palliative care as it assisted in preventing and overcoming depression.

Keywords: depression; palliative care clients; caregivers; spirituality

Introduction and spiritual needs of clients and caregivers (Penman

Palliative care in Australia has come a long way
with its developments in the areas of focus, approach,
assessment, and care interventions. Central to contem-
porary palliative care is not only the client but the fam-
ily as well. Home-based care and culturally competent
care are emphasized. It uses also a partnership approach
with broad multidisciplinary linkages to improve the
quality and safety of services (Michelson & Steinhorn,
2007; World Health Organization, 2014). Systematic
psychosocial assessments are conducted (R. Harding &
Higginson, 2003), and distressing symptoms are better
controlled (Blinderman & Billings, 2015). More
recently, advance care planning has been implemented
to ensure patients receive their desired end-of-life care
(McCune, 2016).
Despite these improvements, however, attention
is still needed to address the psychosocial, emotional,
& Ellis, 2015; Steinhauser et al., 2008). These clients
and caregivers (referring to informal carers, who can
be spouses, family members, and/or close friends) do
experience sadness, a normal part of the dying experi-
ence, but it has been estimated that 25% of oncology
patients will experience severe depressive symptoms,
especially for those with advanced disease and greater
pain and disability (Chochinov, 2006; K. G. Wilson,
Lander, & Chochinov, 2000). Compounding the
problem is poor detection and undertreatment of
depression (Irving & Lloyd-Williams, 2010). Other
issues that need addressing include difficulty in
assessing clients, reluctance in discussing emotional
Author’s Note: Please address correspondence to Joy Penman,
PhD, RN, Monash University, Rainforest Walk, Clayton, Victoria
3800, Australia; e-mail: joy.penman@monash.edu.
244  Journal of Holistic Nursing / Vol. 36, No. 3, September 2018
issues, and avoidance in having to deal with these
concerns on the part of health professionals. Thus,
depression may be overlooked, which in turn may
magnify suffering, reduce quality of life, and compro-
mise health outcomes (Chochinov, Wilson, Enns, &
Lander, 1997; Warmenhoven et al., 2012).
In-patient treatment may be required for high-
risk clients with depression (Steen, 2016), while
counseling and psychotherapy, which may address
issues like self-esteem, self-efficacy, relationships,
and problem solving, are provided for mild to moder-
ate cases. If recalcitrant, medications and intense
therapies are resorted to, and families are educated
and involved. Cognitive behavior therapy has been
used extensively in many cases (Steen, 2016).
However, spirituality has not been included in the
list of recovery interventions for depression.
This article focuses on depression experienced
by palliative care clients and caregivers identified
from the author’s doctoral study, and the strategies
that the same clients and caregivers used to prevent
and/or overcome depression. There is a need to
understand depression for health professionals to
assist clients and caregivers in managing it appropri-
ately. It is imperative to be cognizant and knowledge-
able about depression, find ways to address it, and
inform other health professionals how this common
but poorly addressed mental health condition is
managed in clinical settings.
Background
Palliative care has been defined by the World
Health Organization (2014) as an approach that is
beneficial and advantageous for clients and caregivers
as it prevents and relieves suffering through high-
quality assessment and treatment of all possible prob-
lems. This definition highlights the many needs of
palliative care clients, as well as the caregivers who also
experience the dying process albeit vicariously. The
needs are all encompassing, categorized as physical,
mental, psychosocial, emotional, and spiritual. Despite
the physical challenges, clients and caregivers need to
be psychologically healthy, free from loneliness, anxi-
ety, fear, and depression. However, unlike physical
needs such as pain and/or dyspnea, these intangible
needs are neither well understood nor researched. If
left inadequately addressed, these may manifest as
worry, nervousness, fatigue, mood fluctuations, hope-
lessness, to a full-blown affective disorder.
In particular, depression is characterized by low
mood; lack of pleasure, hope, or interest; lack of appe-
tite and sleep disturbances; and feelings of hopeless-
ness and helplessness (Athanasos, 2013; R. L. Wilson
& Riley, 2014). Individuals express low self-esteem and
fatigue for an extended period of time (Procter, Baker,
Grocke, & Ferguson, 2014). It is far more than being
sad; it dominates one’s life and profoundly affects daily
functioning. Genetic, biological, and environmental
factors are possibly involved in the etiology (Blows,
2016). Screening individuals at risk is undertaken by
interviews, depression rating scales, and mood chart-
ing. The management of depression consists of phar-
macological (antidepressants) and nonpharmacological
treatments (psychological interventions). Psychological
interventions, in either individual or group format,
have been reported to be effective (Henderson, 2011).
In exploring contemporary psychological inter-
ventions for depression, many therapies have been
investigated. Behavior therapy, for instance, teaches
people with depression how to engage in satisfying
activities, and targets which behavior(s) to modify
(Palmer, 2013), while cognitive behavior therapy
benefits individuals by recognizing and altering
depressing patterns of thinking and behavior (Moyle,
2013). Interpersonal therapy works by increasing
confidence, sense of acceptance, and empathy,
hence encouraging personal growth (O’Brien,
Maude, & Muir-Cochrane, 2013), while mindful-
ness draws individuals to the present moment.
Other depression interventions are acceptance/
commitment therapy, which assists individuals to
cease from overthinking traumatic events; art ther-
apy, which enables better management of stress,
personal relationships, and self-expression; and
music therapy, which purports to cause physical and
emotional change, and allows for self-expression
also (Black Dog Institute, 2016). The so-called nar-
rative therapy provides opportunities for individuals
to change their stories, while the application of
positive psychology principles boosts people’s resolve
to pursue meaningful lives (Black Dog Institute,
2016; Seligman, 2002). Self-help groups and online
therapies enhance problem-solving skills that are
helpful for depression (Henderson, 2011).
It is important to stress, however, that spiritual-
ity is not in the list of routine interventions for
depression. And yet, there is evidence showing its
role in inhibiting and/or managing depression
(Desrosiers & Miller, 2007). This is also to say that

attending to the spiritual needs of clients with
depressive symptoms can improve health and well-
being. Other authors corroborate and acknowledge
the role of spirituality in clients’ life as a possible
avenue to attain better mental health outcomes
(Fow, 2010; Gilbert, 2007; Yi et al., 2006).
People’s understanding of spirituality is broad
and diverse, and their expression and engagement
with spiritual matters are equally complex; they are
highly individualized. The literature emphasizes four
main concepts: meaning and purpose in life
(MacKinlay, 2006), belief in God/Supreme Being
with or without religion (Buck, 2006), the concept
of transcending the self (Buck, 2006), and connect-
edness (Harrington, 2006; Wiklund, 2008).
Spirituality is related to all aspects of life, including
physical and mental health. It is a potent internal
resource that features in the lives of some individu-
als, especially those in crisis, including clients and
caregivers confronting life-limiting conditions.
Other writers disagree and argue that spirituality
is not the answer when it comes to achieving satis-
factory health outcomes (Eckersley, 2007). While
spirituality may facilitate social support, clarify
meaning and purpose, and provide a moral code,
similar benefits can also be derived from other
sources, such as positive affect, social networks, and
emotional and psychological support. Baetz and
Toews (2009), Lawler-Row (2010), and Schultz,
Tallman, and Altmaier (2010) suspect that there are
specific mechanisms at work that might explain the
influence of spirituality on health. This research
article attempted to clarify further the mediating
effects of spirituality on depression by drawing from
the experiences of the participants.
Methodology
In 2013, the author completed her doctoral
study titled “The Phenomenon of Spirituality:
Palliative Care Clients’ and Caregivers’ Experiences
in Engaging With Spiritual Matters” that explored
the nature and essence of spirituality and spiritual
engagement from the perspective of palliative care
clients and their caregivers (Cayetano-Penman,
2012). van Manen’s phenomenology was used in the
study to uncover the themes depicting the meaning
of spirituality and engaging in spiritual issues. The
focus of this article is depression, an emotion the
participants experienced intensely during the course
Spirituality and Depression / Penman   245
of their illness (or their loved ones’ illness). While
identifying with depression, some study participants
would also narrate their individual ways of address-
ing it. This aspect of the findings of the larger study
was mentioned in the doctoral thesis, but was not
explored completely.
Secondary data analysis of existing nonidentifi-
able data was undertaken by expanding the phenom-
enological reflection to include the subjective
experience of depression. Underlining the analysis
was inductive reasoning, which involved multiple
premises that were true, and combined to reach a
specific conclusion. The essential questions asked
were, “What is the experience of depression like for
palliative care clients and their caregivers?” and
“What strategies helped them prevent and/or over-
come depression?”
Research Orientation
The technique of reusing qualitative data to
answer a question of a secondary enquiry has been
used in social and health research (Heaton, 2008;
Long-Sutehall, Sque, &Addington-Hall, 2010). In
seeking out further data, new knowledge, category,
and/or concept is developed and expanded, which is
different from what was primarily intended. However,
this technique is only possible if the primary data set
is sufficiently robust to answer the question(s) of the
secondary research (Heaton, 2008).
The interview data of the doctoral study, col-
lected from 2008 to 2010, were assessed to be suf-
ficient in terms of quality and potential to answer
the questions of a secondary research. The data
provided appropriate depth, detail, and suitability to
explicate the lived experience of depression and
strategies of addressing the same. Phenomenology
was the methodology underpinning the secondary
analysis because it was during this analytical inter-
pretation that the concept of depression was identi-
fied and explored.
In analyzing the data, several steps were under-
taken. First was turning to the phenomenon of depres-
sion, searching for evidences in the texts to obtain an
exhaustive and deeper description of the experience
(van Manen, 2014). Second was investigating the lived
experience as it related to the clients and caregivers.
Third was reflecting on the theme(s) that emerged, and
fourth was stepping back and examining the total pic-
ture, how each part contributed to the whole.
246  Journal of Holistic Nursing / Vol. 36, No. 3, September 2018
Research Participants
Fourteen palliative care clients and caregivers
from regional and rural South Australia were inter-
viewed (Penman, Oliver, & Harrington, 2009;
Penman, Oliver, & Harrington, 2013). Four partici-
pants were clients, while 10 were caregivers. Ten
were females, four were males. They possessed the
following characteristics: diagnosed with a terminal
illness, or have cared for or was caring presently for
a loved one with a terminal illness; 18 years or older;
spoke the English language fluently; residing in
regional or rural South Australia; and consented to
participate in the study. Recruitment was mainly
through palliative care teams of regional hospitals
and health services, though some were invited per-
sonally. Interested individuals were contacted to
arrange for face-to-face interviews (Cayetano-
Penman, 2012).
Data Collection and Analysis
Data collection involved in-depth nonstructured
home-based interviews. Interviews were recorded
and transcribed verbatim. van Manen’s (1997)
“wholistic” and “selective” approaches were used to
search for themes that characterized the phenome-
non. “Wholistic” method involved examining the
whole text and identifying its fundamental meaning.
“Selective” referred to reading the text several times,
determining the significant words, phrases, and sen-
tences, and highlighting them to signify the themes.
NVivo was also used to assist in identifying the
themes (QSR International, 2013).
Secondary analysis of existing transcripts was
performed to capture the interviewees’ experience of
depression. Sorting of data was undertaken (Heaton,
2008) so that the analysis could be directed specifi-
cally on depression. Notes and observations from the
researcher’s journal were considered as sources of
data also and, hence, analyzed accordingly.
Ethics
The university’s human research ethics commit-
tee approved the conduct of the study. Ethics
approval was also sought from participating hospi-
tals and health services with palliative care teams
(Penman et al., 2009). Informed consent was
obtained before interviews commenced. Codes were
used instead of names. The research procedures
observed strictly the guidelines outlined by the eth-
ics committee.
Trustworthiness
Trustworthiness of the research was assured by
meeting several criteria (T. Harding & Whitehead,
2016). Credibility was established by using open-
ended questions and verifying responses of the par-
ticipants. Auditability was ensured by presenting a
clear and logical research procedure with sufficient
information on the research process. Fittingness was
achieved by adequately describing the significance
and context of the study for the readers to relate
with their own research and/or practice (T. Harding
& Whitehead, 2016).
This researcher attempted to acknowledge her
personal beliefs, assumptions, preunderstandings,
and prejudices about the phenomenon of spirituality
before embarking on her doctoral study (Cayetano-
Penman, 2012). The researcher drew on these pre-
understandings, made them explicit, held them at a
distance, and dislodged them, as suggested by van
Manen (1997). This way the researcher’s interpreta-
tion of the phenomenon was clarified and distin-
guished from that of her study participants.
Findings
Description of Participants
Of the 14 participants interviewed, seven were
Caucasians and seven were Asians (Cayetano-
Penman, 2012; Penman et al., 2009). The mean age
was 59 years, the youngest was 34 and the oldest
was 77. All were residents of regional or rural South
Australia. Four were palliative care clients at various
stages of illness. There were four caregivers who
were caring for their loved one at the time of study,
while six were former caregivers. Nine reported they
were Catholics, and five stated they were Protestants.
Cancer was the primary diagnosis for the clients and
the caregivers’ loved ones.
The Phenomenon of Depression
The participants expressed various emotions,
including depression (Cayetano-Penman, 2012;
Penman, 2012). Though none of them were clinically
diagnosed with major depression, the term(s) and

phrase(s) “depressed” or “feeling depressed” (cited 21
times) and related term(s) and phrase(s) such as “feel-
ing low,” “feeling down,” “could not enjoy life,” “much
uncertainty,” “in total darkness,” “knocked us to the
ground,” “resigned [to die],” and “down and out” were
mentioned. These descriptors, highlighted from the
texts, were taken as self-reported depression.
The starting point for analyzing the experience
of depression was using van Manen’s (2014) “exis-
tentials,” referring to the fundamental lifeworld that
consisted of lived space, lived body, lived time, and
lived human relation. These “existentials” were used
in guiding the reflections for descriptive analysis.
Lived Space
The lived space according to van Manen (2014)
was the “felt” space of the phenomenon that affected
the way people felt about the phenomenon. In apply-
ing this concept to the study, the lived space in rela-
tion to depression was interpreted to mean the
manifestations and impact of depression. For exam-
ple, following the diagnosis of leukemia, Frederick
was unhappy because he could not plan his life. The
lived space had come to mean the rollercoaster feel-
ing of being overwhelmed with emotion and disbe-
lief of the disease and its suddenness, and anguish
and despair for caregivers like Eleazar and Hilary.
Following the diagnosis of leukemia, all emotions
were heightened. . . . For 9 months now I feel
depressed as I could not plan my life, I could not
enjoy life . . . (Frederick)
It [the cancer] came too sudden. There was never
anything wrong with her. My wife went for tests
every year, she had no breast cancer, and the cancer
did not show early enough for doctors to be able to
treat it aggressively. I was overwhelmed with emo-
tion and disbelief about the suddenness of the dis-
ease . . . even till now . . . (Eleazar)
You know this suffocating feeling when the air is
sucked out of the room, that’s how it felt when the
doctor said, “We cannot do anything anymore.” . . .
We just sank into depression. (Hilary)
However, for some research participants like pallia-
tive care clients Barbara and Nathan, the lived space
was being able to transcend depression through spir-
ituality and complementary therapy.
Spirituality and Depression / Penman   247
I try not to get depressed with cancer. . . . My spir-
ituality makes me feel powerful as it gives me
strength and courage to persevere in life. (Penman,
2012; Penman & Ellis, 2015). (Barbara)
For when I am down and out, I do reiki. It’s a ther-
apy that involves channeling the energy of the uni-
verse to me for healing. (Nathan)
Similarly, the caregivers expressed the same attempt
at managing depression by having a sacred place as
in experiencing God’s presence for Barbara, Gina,
and Isabelle, and a space for ritual and tradition
where Catherine, Eleazar, Hilary, and Leah prac-
ticed their dearly held religious beliefs.
My spiritual beliefs helped me cope. . . . I found this
paradise within myself. You need to find this peace
within yourself. (Hilary)
To overcome feeling low, I committed to caring for
my husband who was very sick. . . . My religion also
played a big role in my coping. (Isabelle)
Lived Body
The lived body referred to the phenomenologi-
cal fact that the individual experiencing the phe-
nomenon was physically in the world (van Manen,
2014). The lived body was revealed through the
bodily presence described by the participants as
they experienced the phenomenon of depression.
Frederick, who was suffering not only from leuke-
mia but hepatitis also, knew this experience only
too well. The illness came and went all the time,
anything from sweating to fatigue, to infections,
and assaults to the body that came intermittently.
He narrated also the physical symptoms brought
about by depression, “Feeling sick and run down to
the point of being self-centered as I am only con-
cerned about how I am feeling at the time” and
“losing sleep and weight,” and the mental turmoil
such as shock, denial, frustration, and fear. In the
same light, however, Frederick revealed that his
spirituality was sustaining him. His faith was help-
ing him cope with his condition. It kept him coher-
ent, focused, and happy at the same time. Frederick
was hoping for a cure.
If you did not have faith, it will be very difficult . . .
you will be unhappy because the illness will take you
down and all over the place. (Frederick)
248  Journal of Holistic Nursing / Vol. 36, No. 3, September 2018
The lived body of the experience of depression for
Barbara, another palliative client, was manifested
through constant complaints of pain. However, like
Frederick, she was quick to share what she does
when feeling afraid or depressed. She retreated to
her beautiful calming garden and/or surrounded
herself with friends over cups of tea and cakes.
When palliative caregivers bodily experience
depression, anxiety went with it also. The experience
was described as stressful, overpowering, and devas-
tating, catapulting them into a fight and flight mode.
The caregivers described their experiences as fol-
lows:
There was much uncertainty as she [her niece diag-
nosed with cancer] could not know what to expect,
. . . and we all seemed to be in total darkness. (Ana)
I felt crushed and pained for my dear mom. . . . I
desperately want her to get well. This was the start
of mobilizing all the services available to provide her
care and support. (Jonathan)
I felt physically exhausted because of the travel
required for treatments, and full-time care. I suffered
for a long time while caring for my husband. (Kelly)
It was hard. . . . The oncologist had a look at the
x-rays and said, “Go home, it’s palliative care, there’s
nothing we can do.” Those exact words just knocked
us to the ground. They [the oncology team] gave my
husband 3 to 12 months to live. . . . I was confused
and lost. I was depressed for a long time. . . .
However, instead of being discouraged, we thought
that there is hope, we could hunt for the cure, giv-
ing a positive spin to cancer. (Maria)
Lived Time
Lived time meant subjective time—the experi-
ence of time when the phenomenon was occurring
(van Manen, 2014). In applying the notion of lived
time to depression, the ways in which the partici-
pants experienced lived time included a discrete
time that was described as utterly dismal because of
the realities of impending death, distressing symp-
toms, seeking further treatments to extend life, and
wanting answers to questions. Palliative care clients
Diana and Nathan narrated their experiences:
Following my diagnosis of cancer of the kidney,
which had metastasized to the liver, I was told by my
oncologist to “just enjoy life.” What does that mean?
I was not satisfied with this advice, so I sought a
second opinion about my condition. I argued I don’t
have the symptoms . . . another oncologist suggested
to remove the cancer which will give me some
chance and time . . . (Diana)
The experience is difficult to describe. It seems like
having a bone pointed at me. I spend all my time
and energy towards finding a cure, remedy or some
way to reverse the cancer. (Nathan)
Lived time encompassed the past, present, and
future dimensions making up an individual’s tempo-
ral existence (van Manen, 2014). Amid depression,
there were hopeful times too as research partici-
pants recounted. For instance, Maria performed
Reiki on her husband, client Barbara went on a pil-
grimage, while caregivers Ana and Catherine prayed
for a miraculous cure for their loved ones. Below are
illuminating statements:
But I experienced a joyful time away from “cancer”
during my visit to Medjugorje [where apparitions
have been reported in the Shrine of the “Queen of
Peace”]. (Medjugorje Place of Prayer and
Reconciliation, n.d.) (Barbara)
Experiencing God living in us even in bad times
helps . . . and being there at the right time when
needed by father. (Gina)
We had church fellowship, prayers and communion.
We get this love and support from family and
friends. We prayed. . . . There was no time or reason
to be depressed. (Leah)
We found a relaxing and comforting time in between
cancer treatments and remedies. This was intimate
and special, specifically finding opportunities for
rest and happiness, which could be as simple as hav-
ing dinner with friends or holidaying somewhere.
(Maria)
Lived Human Relation
This “existential” pertained to the relationship
maintained with others in the “shared interpersonal
space” (van Manen, 2014). This concept was inter-
preted in this study to relate to the connection made
as the palliative care clients and caregivers dealt
with depression as a consequence of a terminal

illness. The relationships focused on intimate (fam-
ily and friends) to less intimate (pastor, church
members, compatriots) connections. These human
interactions and relationships are best illustrated by
palliative care clients Barbara and Diana and by car-
egiver Leah.
You need friends to affirm and encourage you and
spur you on a bit . . . but you need to change your
outlook and your heart. (Barbara)
Friends distract you for a while, we talk, then cry,
then talk some more. We draw on happy memories
and imagine a time when there will be no more
death and sickness. (Diana)
We [husband and I] learnt to live one day at a time,
to enjoy the time we had, to call upon the Lord, and
rise above feelings of despair and find peace. (Leah)
Strategies to Cope With
Depression
While identifying with the feeling of depression,
some study participants would also narrate their
individual ways of addressing it. The strategies used
by palliative care clients and their caregivers to cope
with depression were embedded in their stories.
Three themes emerged: “finding paradise within,”
“it’s like building community” and the “God and reli-
gion factors”.
“Finding Paradise Within.”  The theme “finding para-
dise within” encompassed the social, emotional, psy-
chological, mental, and spiritual aspects of addressing
the experience of depression, highlighting the rela-
tionship of the client or caregiver with himself or
herself. Paradise was understood to mean “peace,”
“heaven,” and/or “delight,” depicting the clients’ and
caregivers’ resolve to transcend the suffering cur-
rently being experienced.
The participants described this intrapersonal
connection with oneself, devising ways to help their
coping, trusting in one’s self and resources, finding
inner peace and acceptance, and acknowledging also
that life would go on. They kept themselves occu-
pied, joined clubs and support groups, renewed their
outlook, and sought meaning for life, death, and suf-
fering. A case in point was Nathan and Maria’s
indulgence with alternative therapies they claimed
to be useful for healing and peace.
Spirituality and Depression / Penman   249
“It’s Like Building Community.” The theme on com-
munity building referred to the “people who comforted,
encouraged and supported” the clients and/or caregiv-
ers. The essence of the theme comprised interpersonal
relationships that involved deep and meaningful con-
nections between individuals (client, caregiver(s),
friend(s), nurse(s), health professional(s), compatriots,
and even strangers). The participants were bonded with
others, and the relationship was described in various
ways from “friends calling in,” “praying and talking,
reminiscing, holding hands,” to “visiting” and “singing
Christian songs.” This horizontal relationship provided
a means of dealing with depression, a comfort to go
through the challenges with the knowledge that they
were supported. It was recommitting their lives to oth-
ers (without forgetting their loved one), seeking help
from family and friends, availing of counseling, main-
taining and forming new relationships, and disclosing
innermost thoughts and fears. In short, love and com-
passion were manifested, which helped alleviate
depression.
The “God and Religion Factors.”  This theme touched
on faith in God or “higher power or mother nature”
as well as commitment to religion. The participants
prayed to God, put their trust in God, went through
the depression with God, and overcame suffering
because God was their present help. He was their
hope. This was referred to as transpersonal relation-
ship, with or without religion. Though there was
some blurring in understanding of God and religion,
both were perceived to assuage depression.
Discussion
The themes that were acquired through the
study of participants’ transcripts of their lived experi-
ences enlightened the researcher about their strate-
gies for depression. The findings would be compared
and contrasted with other related studies. The impli-
cations for nurses (and possibly other health profes-
sionals) would conclude the discussion.
The Reality of Depression
In this study, depression appeared to be an inte-
gral part of the dying experience for some partici-
pants. Depression and anxiety disorders are indeed
common among cancer patients, greatly diminishing
their quality of life (K. G. Wilson et al., 2007).
250  Journal of Holistic Nursing / Vol. 36, No. 3, September 2018
Combination diagnoses are common and all types of
depression occurred (Mitchell et al., 2011).
Depression was describable, palpable, and very
real. A glimpse of the nature and essence of depres-
sion for these participants was achieved using van
Manen’s “existentials,” providing the thinking and
feeling during depression, its bodily manifestations,
the experience of time while feeling depressed, and
the interpersonal relationships that were shared dur-
ing the process. However, while these findings were
not surprising, there was no complete hermeneutic
phenomenological explanation that would ade-
quately cover the intricacies of depression. It
remained incomplete, inviting further insights to
extend the understanding. The disclosure of the
majority of the participants about how they dealt
with depression was most beneficial.
The Link Between Spirituality and
Depression
In understanding the lived experience of spiritual-
ity, its relevance in preventing and/or overcoming
depression could be elucidated. Note that some par-
ticipants could have been involved in spiritual matters
even before the crisis. The individuals’ beliefs about
spirituality determined how they engaged in these
matters. It appeared that spirituality propelled indi-
viduals into positive actions that would help them in
their present circumstance of confronting death and
dying. Both clients and caregivers, viewed spirituality
as a human value, while engaging in spiritual matters
or spiritual engagement referred to some action,
which extended also in protecting themselves against
depression. Those participants adhering to the “belief
in God” prayed to God to lift the depression, while
those who viewed spirituality as being associated with
“coping” with death and dying applied spirituality to
cope also with depression. Those participants who
understood spirituality from the perspective of “rela-
tionships” engaged in spirituality by enhancing feel-
ings and promoting practices that communicated
love, compassion, kindness, and contentment, which
helped deflect depression. The others who under-
stood spirituality to be part of “religion” held religious
beliefs and participated in religious activities to dimin-
ish depression. Despite impending death, the partici-
pants remained positive as they drew strength from
others, and they lived from day to day with hope and
optimism, and less depression.
The three themes that emerged exemplified spir-
ituality as a means of preventing and/or overcoming
depression. These themes were extracted from
Hilary’s personal description of her experience with
coping.
It’s like building a community—when you are in a
predicament it seems that you are standing on holy
ground, and the people all around are ministering to
you and your loved one. . . . My spiritual beliefs
helped me cope. . . . I found this paradise within
myself.
Spirituality-Mediated
Antidepressant Effects
Biological, biopsychosocial, and behavioral
mechanisms have been employed to explain the link
between spirituality and better health outcomes.
The plausible biological mechanisms relating to
neurohormones and immune responses (Campbell,
Yoon & Johnstone, 2010; Ironson & Hayward, 2008)
have been investigated, but these are beyond the
scope of this research. Behavioral mechanisms might
have an impact also on spirituality and good health.
Martin et al. (2010) promoted that the client’s view
of God and spirituality influence health, illness,
healing, and care-seeking behavior.
The interconnections of the mind, spirit, and
body that could explain the relationship between
spirituality and health could also illuminate how
spirituality works in depression. Clarke (2010)
argued that what affected the body affected the
mind and the spirit. Another theory relevant to this
study was motivational theory, which might be
applied to overcome depression (Reeve, 2001).
Promoting a constructive rather than a destructive
reaction to death and dying could achieve a more
positive outcome as a result of change in perspective
and direction. Transformation could have occurred
when Barbara was “[wiping] off the cancer out of
[her] thoughts . . . I do not dwell on it nor am I in
denial of it, but I have changed my state of mind,”
and Maria found hope in “finding a cure.”
The biopsychosocial effect of spirituality could
explain the mechanism by which it influenced health
(Katerndahl, 2008), and depression specifically. The
participants, in applying their spiritual beliefs and
practices, consciously or unconsciously, used the
principles underpinning the psychological and

support interventions that were routinely used in
treating depression.
Spirituality, understood from religious or secular
perspective, proved helpful in preventing and/or
overcoming depression. For palliative care client
Barbara, it gave her a new perspective, helped her
look at death in the face, and diverted her attention.
It also made her stronger and more accepting. For
Diana, spirituality assured her she was not alone,
while for Nathan, it represented a comforting space
and opportunity for rest, healing, and bonding. It
reduced anxiety for caregiver Gina because of the
belief that God is in control even during those
depressing times. Spirituality drew people together,
according to Hilary. It gave rise to positive emotions
of compassion for Isabelle and hope for Maria.
Depression is assisted because individuals did not
sink in despair, instead they reported about feelings
of love, hope, compassion, and contentment.
Helpful from literature were studies on spirituality
that showed its potential to inhibit and manage depres-
sion. The symptoms of depression were reduced and
positive mental effects and positive feelings were elic-
ited consequently. Chaudhry (2008) alluded to feelings
of contentment and satisfaction, and to positive emo-
tions of kindness, compassion, and hope, concepts that
resonated very closely with the findings of this study.
Positive associations have been reported by Baetz and
Bowen (2008), who concluded that their study partici-
pants, who were both religious and spiritual, experi-
enced better psychological well-being and used positive
coping strategies. Koenig, Pearce, Nelson, and Erkanli
(2016) similarly argued from their randomized con-
trolled study that prayer may be beneficial for depres-
sion and anxiety in addition to medications. “Resilience
and connectedness” were ways of achieving a high
quality of life despite personal challenges (Denz-
Penhey & Campbell Murdoch, 2008). These might
also explain why spirituality was found advantageous in
many other critical situations, such as healing from
sexual abuse (Sutton, McLeland, Weaks, Cogswell, &
Miphouvieng, 2007) and successful ageing (Lowis,
Edwards, & Burton, 2009; Ng et al., 2009).
The Implications for Nurses and
Other Health Professionals
This study provided an overwhelming positive
nature of the experience of spirituality in relation to
depression. It highlighted the beneficial aspects of spir-
Spirituality and Depression / Penman   251
ituality in preventing and/or overcoming depression.
Education of nurses should include accommodating
spirituality in clinical practice. Increasing its emphasis
on the nursing curricula is important. In fact, Saguil,
Fitzpatrick, and Clark (2011) reported that familiarity
with spirituality as part of residency education curricu-
lum may help break down barriers to addressing spir-
itual issues with patients. The Nursing and Midwifery
Board of Australia (2006) directs nurses to gain com-
petency in facilitating a spiritual environment that
promotes safety and security.
Thus, another implication of this study would be
for nurses to give attention to their clients’ spiritual
beliefs and practices. Nurses are in the best position
to help clients and caregivers find their sense of spir-
ituality as they are in greatest contact with them.
Early recognition of symptoms and early interven-
tion are most effective when dealing with depression
(Moyle, 2013). Nurses could conduct assessments
to ascertain mood and/or anxiety disturbances, for
example, Quality of Life Scale (Burckhardt &
Anderson, 2003), Geriatric Depression Scale, and
the Cornell Scale for Depression (Kørner et al.,
2006), Life Orientation Test (Carver, Scheier, &
Segerstrom, 2010), and the Hamilton Rating Scales
for Depression (Gonzalez, Shreck, & Batchelder,
2013), and intervene accordingly.
Following assessment, clients’ ways of coping are
to be explored and recovery in case of depression is
planned. More important is helping clients identify
their strengths and resources and illuminating strate-
gies and solutions to address depression. Nurses may
assist clients and caregivers by providing reassurance
and support and relieving suffering (Cayetano-
Penman, 2012; Sherman, 2001). They may encour-
age clients to find the “paradise” from within, and
draw on their spirituality.
In all these adaptive tasks, nurses need to be
vigilant and intervene accordingly, from helping cli-
ents obtain a new positive outlook, to providing
comfort and care. Involving family and significant
others is part of the psychological intervention as
many gained strength from interpersonal relation-
ships. The linkages and referrals by health profes-
sionals are important, but these need to be
appropriate, coordinated, and timely. Finally, direct-
ing clients and caregivers to various resources that
have already been developed, such as CareSearch:
Palliative Care Knowledge Network, Palliative Care
Victoria, Palliative Care Network New South Wales,
252  Journal of Holistic Nursing / Vol. 36, No. 3, September 2018
and Beyond Blue online resource, could assist them
in learning more about depression.
Conclusion
With a significant life event and change as death
and dying, depression could almost always be sus-
pected. However, it is often poorly recognized and
treated causing grief and suffering. The alleviation
of depression has been identified as a need of dying
people and their caregivers. Its management must be
an integral part of palliative care.
Spirituality was portrayed by some clients and
caregivers as helping in their coping with their
depression in this study. It appeared that spirituality
played a role in depression and its impact was note-
worthy. The theme “finding paradise within” eluci-
dated how spirituality was used to address depression
from the perspectives of individuals facing death and
dying. This theme seemed to encapsulate the par-
ticipants’ resolve at transcending the social, emo-
tional, psychological, mental, and spiritual pain of
their circumstances; drawing strength from the self
and others; being accepting of what life had to offer;
and trusting God to see them through.
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Dr Joy Penman holds master’s degrees in Nursing and Pharmacy
and PhD in Nursing. Joy has over thirty years teaching experi-
ence and many years nursing experience in various health care
services. She has extensive experience in research and commu-
nity engagement. She is well published, and has presented her
work at national and international conferences.