What Benefits Might a Family Expect From Using Spiritual Coping Mechanisms When Providing Care for People With Schizophrenia? Literature Review

Abstract

Introduction

Caring for people with schizophrenia has consequences, one of which is stressors during care. Families as caregivers often using coping strategies that involve relationships with self, others, or the transcendent/God or nature and also may include religious/spiritual practices.

Objectives

This literature review aims to identify the benefit of using spiritual coping as used by a family schizophrenia caregiver. The variable is spiritual coping.

Methods

This literature review method used PRISMA methodology for systematic reviews. Search was conducted in March 2017, updated in August 2022 and submitted in April 2023 for the publication process, limited to English by using electronic databases: Scopus, ScienceDirect, Sage, ProQuest, and PubMed.

Results

Fifteen studies were included in this review. Two synthesized findings emerged: spiritual coping strategies used by family caregivers give positive effects for family.

Conclusion

When the stress or crisis phase is experienced while caring for people with schizophrenia, the family who acts as a caregiver reveals the meaning of life they have and that they feel hopelessness and helplessness. In an effort to overcome the family's burden as caregivers, they often use spiritual coping, which is important to increase the caregiver's wellbeing.

Introduction

There are various advantages to religion, some of which can offer people motivation to take action. The traditional responses that religion offers its followers to events include prayer, seeking spiritual guidance, and participating in religious ceremonies (Delaney, 2005; Pargament et al., 2014). By assisting caregivers in processing traumatic events, discovering meaning, coming up with hopeful expectations, and putting coping strategies into action, these religious schemas and hearth practices can enable positive coping outcomes (Pargament et al., 2014; Serfaty et al., 2020). Spiritual needs, such as finding purpose in life and hope, as well as spiritual or religious practices that can help them cope with stressful situations, are present in families caring for people with chronic illnesses like schizophrenia (Casaleiro et al., 2022a).

Schizophrenia is a persistent mental illness that endangers people, their families, and society as a whole (World Health Organization, 2019). In conjunction with the development of deinstitutionalization, patients move the responsibility for providing care to their family, particularly close relatives. The patient's experience of family care is influenced by the backdrop of spiritual suffering (Roze des Ordons et al., 2018). Even though nurses typically see spiritual care as important, it is rarely offered (Neathery et al., 2020). According to a study, encouraging spiritual coping is necessary to control maladaptive behavior (Robinson-Lane et al., 2021) furthermore it is crucial to include in the health services offered (Turner & Hodge, 2020).

Schizophrenia is a chronic mental disorder that affects 20 million people worldwide characterized by distortions in thinking, perception, emotion, language and behavior as well as an inability to make interpersonal relationships with other people in time, place and environment (Townsend & Morgan, 2018; Videbeck, 2020; WHO, 2019). Transference of patients with schizophrenia to home shifts the responsibility of care to relatives or people closest to the patient so that they need to making adaptations in their personal lives. The problems faced by families caring for family members who have schizophrenia at home, as well as community perceptions about schizophrenia, the rising cost of care and basic necessities, and challenges connecting socially with the community, all have an impact on the families. In addition, the stress that the caregiver feels when giving care at home is actually increased by the perceived burden by the caregiver (Fitrikasari et al., 2012).

Therefore, in order to manage the responsibilities and difficulties that come with caring for family members who have schizophrenia, caregivers need to have strong coping mechanisms. According to earlier studies findings, spiritual coping is one type of coping used by caregivers of schizophrenia patients. In order to maintain their spiritual wellbeing, caregivers can make benefits from spiritual coping by finding self-satisfaction, healthy relationships with other people, the environment, and God (Fisher, 2010). Indicators of spiritual wellbeing include self-esteem and the capacity to deal with issues as they arise. Additionally, earlier studies have shown that those who have a strong relationship with God have greater life satisfaction, less stress, and are psychologically healthier (Darvyri et al., 2014). Caregivers or families often develop coping strategies that involve relationships with self, others, or transcendence/God or nature and these may include religious/spiritual practices.

Several studies found, by comparing perceived physical or psychological responses between noncaregivers and caregivers, higher levels of distress, anxiety, sleep disturbances and depression as well as more psychosomatic disorders such as hypertension, cardiovascular disorders, and obesity among the caregivers. From previous studies’ results, it was also found that families who served as caregivers received more prescriptions for psychotropic drugs than the general population. Thus, it can be explained that families who serve as caregivers experience more psychological and physical health problems, which can interfere with their ability to provide care to people with schizophrenia. This in turn can increase the healthcare costs for care givers and the people they care for.

Burden on caregiver is considered as important indicator of caregiver health and has been defined as the stress that caregivers typically experience from their caregiving duties. These usually include physical, mental, financial, and social stresses that can affect health-related quality of life (HRQoL) (LoboPrabhu et al., 2006). Identifying these factors can help to ease the burden of caregiving and then will assist health professionals and policy makers in designing and funding effective interventions and educational programs. Many factors have been reported to influence the health condition of caregivers. Being a family as well as the main caregiver for family members of relatives with severe mental disorders often has an impact on quality of life, physical, and mental health. The use of coping strategies related to spirituality can improve physical and mental wellbeing.

Various factors can affect the health status of families who become caregivers of people with schizophrenia, one is the use of spirituality as a coping strategy. Spiritual coping (SC) can help families who serve as caregivers to better cope with stress and crises experienced by mobilizing beliefs and practices. Literature shows a growing body of research confirming the association between SC and better health outcomes in caregivers. Research also shows that families or caregivers who do not use spiritual coping strategies have a higher risk of depression and anxiety. The results of another study stated that the level of spiritual/religious coping was relatively high in caregivers of families with chronic illnesses. In addition, studies have found spiritual/religious coping makes for better adaptation, lower levels of parenting burden and less use of mental health services in spiritual groups or religious caregivers. Many people with schizophrenia rely on their family members for support and help with daily tasks. Because of this, caregivers may be more likely to have mental health issues like depression, anxiety, and caregiver stress (Saffari et al., 2018).

In this literature review, we aim to identify the benefits of using spiritual coping that is used by family caregivers with schizophrenia. The PCC framework (P = population; C = concept; C = context) was used to construct the research questions. The research questions are based on the population of families who directly care for people with schizophrenia. Due to the nature of the research topic, there were no specific focus interventions. An interesting explanation is the reason families use spiritual coping while caring for people with schizophrenia. The target outcomes are themes related to the benefits of using spiritual coping. The main research question was: “What are the benefits of using family spiritual coping in treating people with schizophrenia?”

Methods

The 2020 PRISMA checklist for systematic reviews and meta-analyses is followed when conducting a systematic review (Page et al., 2021). Reviewers can use the 15 criteria on the checklist to ensure transparent reporting. Articles were searched on Scopus, Sage, ScienceDirect, PubMed, and ProQuest as part of an extensive literature search for published studies. Additionally, the reference list of the articles that were retrieved was checked for other articles. Studies had to be written in English within the previous seven years (2017–2022) and submitted by April 2023. Regular keywords were combined with MeSH terms to ensure more relevant articles were displayed in search results. Table 1 summarizes the list of regular keywords and MeSH terms used in this search strategy.

Table 1.

Regular Keywords and MeSH Terms.

Regular keyword	MeSH terms
Spiritual coping	Religiosity Coping Spiritual Coping
Schizophrenia	Schizophrenic Disorders, Mental Disorders, Psychotic Disorders, Schizophrenia
Family	Family, Relatives, Family Life Cycles, Family Members

To combine keywords and search terms, Boolean connectors are employed. Figure 1 provides a summary of the search approach, as well as the boundaries and filters applied. The peer-reviewed, English-language articles about spiritual coping in families with schizophrenia that were chosen for review were published in the journals identified. For the review, only primary studies were chosen. Because systematic reviews are secondary research and there is no purpose in incorporating a secondary study into another secondary study, secondary studies such as scoping reviews, systematic reviews, and other literature reviews were thus eliminated. Student dissertations and theses, organizational reports, and government publications are excluded. The keywords that correspond to the MesH utilized are shown in Table 1.

Figure 1.

PRISMA flow diagram.

Results

The identified articles were filtered using inclusion and exclusion criteria after the aforementioned search approach was used. The selection of the studies involved no automation. Instead, two impartial reviewers conducted the process. Reviewers individually examined each document. For instance, independent reviewers made independent choices when applying inclusion and exclusion criteria, which were then compared for further processing. If the two reviewers disagreed, a third reviewer was asked to conduct a second, independent evaluation of the records or reports in question. The majority of the review's findings were taken into account.

Two independent reviewers used inclusion and exclusion criteria to omit the full text of the remaining 75 articles, of which 34 were eliminated because they were deemed irrelevant, lacked the required details, or had a focus unrelated to spiritual coping. In light of this, the two impartial reviewers decided to eliminate 34 papers at this time. Only 26 of the remaining 41 articles were deemed suitable for inclusion in this code by the independent reviewers. Of these, 11 were subsequently dropped for quality grounds. A third independent reviewer looked over the final 15 articles, after which the final 15 articles were presented. An overview of the search procedure is shown in Figure 1 (the PRISMA flowchart). A total of 231 study findings were discovered using a literature search, as shown in Figure 1 below, which displays the search results using the modified PRISMA flowchart 2009 (Moher et al., 2009). Fifteen papers were eventually chosen, and data were gathered and displayed in Table 1. Each component was evaluated to discover how using spiritual coping affected the situation. An integrated quantitative and qualitative research approach was used. The study sample size was in the middle, and the majority of the information was gathered by questionnaires.

Following the title screening, initially 20 citations were found in Sage, seven citations in Scopus, 25 in ScienceDirect, six in PubMed, and 165 in ProQuest. Eleven articles were automatically eliminated with the current tools, four articles were excluded for specific reasons, and seven because they were duplicates or reported the same research findings in different versions of the articles or across the five databases. Finally, two independent reviewers assessed the abstracts of 201 publications. They concurred that 126 records were omitted due to the fact that they did not satisfy all exclusion requirements, the majority of which were preprinted, they did not satisfy the requirements for peer review, and the remainder demanded full-text deletion, which was not possible in the free and subscription modes (Tables 2 and 3).

Table 2.

Inclusion and Exclusion Criteria.

Inclusion

Exclusion

Publication date: 2017–2022 to ensure up-to-date information was retrieved even if no systematic review had been conducted. Language: English only to avoid translation errors and associated costs. Population: Families and caregivers who care for people with mental disorders and/or chronic illnesses Country: Applicable globally due to the limited amount of research information conducted relating to topics in accordance with the theme. Age group: Families registered as caregivers of sufferers with a minimum age of 18 years. Setting: Hospital or community care. Research design: Qualitative, quantitative, are captured in the search. Type: Peer-reviewed to ensure only relevant and credible information was utilized. Subject: Family spiritual coping in caring for people with schizophrenia

Systematic reviews, meta-analyses, scoping reviews, literature reviews, integrative reviews, etc. Secondary studies were excluded because they do not contain primary information to inform the topic of interest. Secondary studies also contain information that is interpreted, which may be wrong. Gray literature, including government publications, organizational reports, and student theses and dissertations, was also not considered for inclusion to address any publication bias that might exist.

Table 3.

Results of Literature Study.

No	Title, author, years	Methode (desaign, sample, variable, instrument, analysis)	Results
1	The effect of family psychoeducational therapy on the spiritual well-being of the caregivers of the family member with schizophrenia in an area affected by a tidal flood (Budiarto & Hamid, 2019)	Desain: A quasi-experimental pretest–post-test with control group research design Subyek: 81 respondents Variabel: Spiritual wellbeing Instrumen: FACIT-SP version 4 questionnaire Analisis: Independent t-test	There are significant differences in the spiritual wellbeing of the caregivers of the schizophrenic family members
2	Religious coping among adults caring for family members with serious mental illness (Guo1 et al., 2017)	Desain: Cross-sectional Subyek: 436 respondent Variabel: Religious coping Instrumen: COPE, Family Experiences Interview Schedule (FEIS) Analisis: Pearson correlations	Religious coping was associated with a positive caregiving experience and greater religious support
3	Spiritual aspects of the family caregivers’ experiences when caring for a community-dwelling adult with severe mental illness: A systematic review of qualitative evidence (Casaleiro et al., 2022b)	Desain: Qualitative evidence Subyek: 467 family caregiver Variabel: Spiritual aspects Instrumen: Joanna Briggs Institute methodology Analisis: PRISMA	There were 26 studies included in all. Spiritual coping mechanisms employed by family caregivers and spiritual needs revealed by family caregivers were two synthesized findings that were found. Based on the observations of 467 caregivers from 14 different nations, these conclusions were made
4	Coping and spirituality among caregivers of patients with schizophrenia: A descriptive study from South India (Gojer et al., 2017)	Design: A descriptive study with a cross-sectional design Subjects: Population: Family caregivers associated with schizophrenia Sample: 92 patients and their caregivers Variables: Coping, spirituality Instruments: Positive and Negative Syndrome Scale (PANSS), Royal Free Interview for Spiritual and Religious Beliefs, General Health Questionnaire-12 (GHQ-12) Analysis: Multiple linear regression	72.7% of the participants believed that spiritual powers could influence events in daily life, 14.1% reported that religion helped to make difficulties more bearable and gave peace and comfort to the mind
5	Coping with caregiving stress among caregivers of patients with schizophrenia (Rao et al., 2020)	Design: Cross-sectional study Subjects: Population: 200 diagnosed schizophrenia sufferers based on DSM IV and their families Sample: Patients Schizophrenia diagnosed based on DSM IV and their family with criteria (1) aged 18–50 years; (2) at least 2 years old diagnosed with schizophrenia and living with his family; (3) sufferers clinically stable; (4) caring family is not sufferings physical or mental illness or being dependent on any type of drug certain drugs (tobacco)  Sampling technique: Purposive sampling Large sample: 100 respondents Variable: Coping Instrument: PANSS which is used to measure sequelae in patients, Global Assessment of Functioning Scale (GAF) to measure level function, Ways of Coping Questionnaire (WCQ) to measure coping, Brief Religious Coping Scale to measure religious coping, and General Health Questionnaire to measure psychological morbidity Analysis: Independent t-test and Mann-Whitney to test variable difference, Pearson's product-moment correlation and Spearman's rank correlation to test the relationship between strategies coping and other variables, Bonferroni's correction to test relationship of all variables	Based on the results of the study, it was found that caregivers with schizophrenia using a mix of adaptive coping strategies and maladaptive coping, including what is used is coping religious. The use of adaptive coping is associated with better outcomes better for the patient and the level of morbidity or distress lower psychological. The best family coping strategy widely used is a coping strategy by seeking support social, accept responsibility, plan problem solving, positive assessment. With the results of the analysis of caregivers, patients who work more often use coping strategies seeking social support (<.001), accepting responsibility, planning problem solving (<.001), and positive reassessment (<.001), while escape avoidance coping (<.001)
6	Strategies used by families to cope with chronic mental illnesses: Psychometric properties of the family crisis-oriented personal evaluation scale, Persepectives in Psyciatric care (Sari & Duman, 2020)	Design: Descriptive Subjects: Population: Caregivers who come from families with chronic mental disorders Sample: 153 caregivers who come from families with chronic mental disorders with data collection time from June 2017 to February 2019 with inclusion criteria (1) age above 18 years old; (2) willing to participate; (3) become the main caregiver for Besar sample: 153 caregivers Variable: Coping skills of caregivers with mental disorders chronic, psychometric trait crisis-oriented personal evaluation scale family (F-COPES) Instrument: Descriptive form of respondent caregiver's characteristics (age, gender, educational status, length of care, employment status, number of child); Descriptive form of patient characteristics (age, gender, status occupation, marital status, comorbidities); The family crisis-oriented personal evaluation scale (to measure effective coping strategies) used by the family) Analysis: Language validation, content validity, sample testing, psychometric testing, regression	The results showed that F-COPES was acceptable, so that This instrument can be used to assess coping behavior in children caregivers with people with chronic mental disorders and can also be used as a tool to assess caregiver coping skills. With the results of the analysis, namely the loading factor between 0.56 and 0.69 for the Social support subscale, between 0.43 and 0.74 for the Reframing subscale, between 0.53 and 0.74 for Spiritual. The model fit index is as follows: 2 = 176.369, df = 116, 2/ df = 1.52, RMSEA = 0.059, CFI = 0.90, IFI = 0.91, GFI = 0.88
7	The effect of family psychoeducational therapy on the spiritual well-being of the caregivers of the family member with schizophrenia in an area affected by a tidal flood (Budiarto and Hamid, 2019)	Desain: A Quasi-Experimental Pre-Posttest With Control Group Research Design Subyek: P population: 110 caregivers in the puskesmas area Pekalongan Sample: Caregivers who are in the area of Pekalongan Public Health Center with inclusion criteria (1) is a member of the nuclear family on duty directly caring for people with schizophrenia in their families; (2) aged 18 years and over; (3) lives at home with the patient; (4) can read, write and communicate well Sampling technique: Total sampling Large sample: 81 respondents with a distribution of 40 control groups 41 groups intervention Variable: Spiritual wellbeing Instrument: The functional assessment of chronic illness therapy-spiritual wellbeing (to assess spiritual wellbeing) Analysis: Independent t-test (to assess the psychoeducational effect between groups control and treatment)	There is a significant difference between the control group and the treatment after being given psychoeducation with the results of the analysis obtained P value .003
8	The mediating effect of family function and medication adherence between symptoms and mental disability among Chinese patients with schizophrenia: A cross-sectional study (Sun et al., 2019)	Design: A cross-sectional naturalistic design Subjects: The population of people with schizophrenia is 562 samples of patients schizophrenia with inclusion criteria (1) diagnosed with schizophrenia based on (ICD-10); (2) aged between 18 and 60 years; (3) suffered schizophrenia based on an assessment using the Assessment Schedule Disabilities World Health Organization II (WHO-DAS II); (4) those who are recovering based on the routine clinical assessment of a psychiatrist; and (5) patients who voluntarily participated in the study. Patients were excluded if they had other mental illnesses A sample of 499 schizophrenic patients. Sample size: 562 patients with schizophrenia Sampling technique: a cross-sectional naturalistic design Variables: Psychotic symptoms, family function, medication adherence, and disability. Instruments: General Information Data (demographic and clinical information, namely, age, gender, educational status, income status, status marital status, employment status, age of onset, number of previous hospitalizations, psychotic symptoms). PANSS (to assess the patient's positive and negative symptoms, as well as general aspects), WHO-DAS II (to assess disability over a 30-day period), Family APGAR Index (APGAR) (to assess family functioning), and Morisky Medication Adherence Scale (MMAS-8) (to assess patient compliance) Analysis: Descriptive analysis (to draw descriptive data and clinical data), maximum-likelihood, Pearson's correlations, Structural equation modeling, Bootstrapping method	This study illustrates that family function has a positive correlation with medication adherence in patients with mental disorders.  The results of the analysis show that the mediating effect of family function and significant medication adherence (Z = 0.314, CI = 0.180–0.598); and direct effect also significant (Z = 2.375, CI = 0.042−0.440)
9	Coping strategies of family caregivers of patients with schizophrenia in Iran: A cross-sectional survey (Rahmani et al., 2019)	Design: Descriptive correlational study Subjects: Population: All family members who care for people with schizophrenia from 2015 to 2016 Sample Some members families caring for schizophrenia sufferers in accordance with the inclusion criteria that have been set. The sampling technique is homogeneous purposive sampling based on the criteria (1) 18 years of age and over and without mental disorders; (2) the main family (parents, husband/wife, children) who are in charge of caring for patients with the condition is that there is no mental disorder as evidenced by a diagnosis from a health worker; (3) at least has at least 1 year of experience in caring for patients. Sample size is 225 families who care for people with schizophrenia using a predetermined formula Variables: Family Coping, Family Burden Instrument: Family Coping Questionnaire (FCQ) and the Zarit Burden Interview (ZBI), a family caregivers’ demographic and clinical characteristics form consisting of age, gender, education, employment status, relationship status with the patient, duration of caring for the patient, whether he lost his job due to responsibility treat people with schizophrenia. Analysis: Kolmogorov-Smirnov is used to test the distribution of data based on variables, Pearson correlation coefficient is used to assess the relationship between the scores of coping strategies used by families and the burden felt by families, Independent sample t-test is used to test differences in the average coping scores with variables; Demographic categories including age, gender, employment status, perceived income adequacy, duration of care and job loss due to illness care responsibilities, one-way analysis of variance (ANOVA) was used to examine differences between mean coping scores and demographic variables. Simple linear regression was performed to examine demographic characteristics (predictor variable) and coping strategies (as variable).	Based on the results of the study, it was found that the coping strategies that the most widely used by families is emotional focus coping with the most widely used strategy is avoidance, family caregiver with more male gender using problem focus coping, there is a significant relationship between age and the coping strategies used (problem focus coping), education is also positively and significantly related with the coping strategies used (the higher the education of the family caregiver, the easier it is to get a job so that it will be easier to provide support). The results of the regression model analysis showed that adaptive coping strategies were significantly related to several demographic characteristics including age, education level, gender, employment status, job loss due to caregiving responsibilities, perceived income adequacy, duration of illness, duration of care and caregiver burden (P < .05).
10	The effect of a brief cognitive behavioural stress management programme on mental status, coping with stress attitude and caregiver burden while caring for schizophrenic patients (Ata and Doğan, 2018)	Design: Pretest/post-test control group model Subjects: Population: Family members who care for people with schizophrenia from January 1, 2012 to January 1, 2013 Samples of family members who care for people with schizophrenia with inclusion criteria (1) are over 18 years old; (2) live in the city center; (3) can communicate and cooperative; (4) does not have a disease disorder that can disqualify participation in the study (5) at least takes care of the patient for 3 months; (6) is directly responsible for caring for the patient; (7) is not currently caring for a sick family member other than the patient; (8) agrees to participate; (9) recorded in community health administration; Sampling technique: Sample size was calculated based on PASS (Power Analysis and Sample Size) 11 Statistical Software (NCSS LLC, Kaysville, Utah, USA) using margin of error = 5%, confidence level = 95% and response distribution = 50%, and based on the calculations and found to be 40 respondents from each group (total 80) Variables: Stress, coping, and family burden Instruments: Demographic data (age, gender, marital status, number of children, educational status, length of care, period of illness, frequency of hospitalization), Zarit Caregiver Burden Scale to measure difficult experiences of care givers, Scale of Evaluation of Coping Attitude (COPE) to evaluate the coping used by caregivers when dealing with stress, General Health Questionnaire-28 (GHQ), Stress Self-Assessment Checklist (SIS) to measure a person's stress indicators Analysis: Chi-square tests to compare characteristics respondents in the control group, Wilcoxon test and Mann-Whitney U test, independent sample t-test, and paired t-test	It was found that BCBSMP is effective in reducing signs and symptoms stress that arises in the caregiver, as well as being able to identify situations that can cause stress, help change the mind negative with one other thing that is positive, time management, improve problem solving (coping) and assertive skills and reduce emotional cognitive and stress symptoms that appear. With the results of the analysis, there is a statistically significant decrease in ZCBS the study group scores were compared with the control group (P = .006) Before the program, the caregivers’ GHQ scores in the control and study groups were not statistically different. After the program, GHQ scores decreased significantly in the study group compared to control group, and the difference between the mean scores was statistically significant (P < .001)
11	Coping strategies of caregivers towards aggressive behaviors of persons with severe mental illness (Madathumkovilakath et al., 2018)	Desaign: Non experimental descriptive cross-sectional study Subjects: Population: Patients and caregivers for patients with mental disorders; Samples of patients and caregivers for patients with mental disorders according to the inclusion criteria (1) aged 18 years and over; (2) able to read in Malay and exclusion (1) caregiver with a substance use disorder and known to have a physical illness Chronic or psychiatric illness; Sampling technique consecutive sampling; Sample size 270 patients and caregivers Variables: Aggressive behavior and coping strategies Instrument: Modified overt aggression scale (MOAS) to measure aggressive behavior in patients, Revised Ways of Coping scale to assess the coping used Analysis: Pearson correlation was used to test the relationship between aggressive behavior and the coping used	The results of this study indicate that adaptive coping strategies widely used is planned problem solving, seeking support social with a percentage of 40% each and only 4.4% caregiver who use avoidance coping strategies
12	The effectiveness of a knowledge translation cognitive- educational intervention for family members of persons coping with severe mental illness (Weiss et al., 2018)	Design: Quasi-experimental research design with control Subject: Population: Parents, siblings, or spouse of a family members with diagnosed severe mental disorders by health workers; Sample: parents, siblings, or spouse of a family member with mental illness weight diagnosed by health personnel with criteria (1) more than 85% participate in group activities; (2) family members from people with mental disorders; (3) are on the waiting list of the course program (Keshet) Sample size: 38 respondents Variables: Family attitude toward people with mental disorders, function family, family burden, family coping Instruments: Personal data such as gender, age, years of education, country of birth, religion, and questions related to illness mental health in the family, such as the number of years family members have suffered from mental disorders, relationships with sick family members, participation of family members in therapy activities and household activities, Caregiver attitude questionnaire consisting of: knowledge, belief, and action (used to measure family attitudes toward people with mental disorders), Family Functioning Questionnaire (FF) (to measure the positive quality of family functioning), Burden Assessment Scale (BAS) (to measure the objective and subjective consequences of providing care sustainability for mentally ill family members, MILE (to measure coping) Analysis: MANOVA (to analyze the relationship between family functions, attitudes and family burden, Pearson's analysis (to measure the relationship between variables)	Attitudes about caregivers’ knowledge of how to encourage cognitive modification in mentally ill family members significantly more positive after participating in the intervention program (Keshet). In addition, there is a tendency toward significant changes in relation to attitudes toward the implementation of actions which are actually. However, attitudes regarding the emotional aspect of family coping. A closer look at the findings revealed that regarding attitudes related to participants’ emotions, related scores for hope and self-motivation were both high before and after the intervention. In other words, parents feel highly motivated and hopeful both before and after the intervention.
13	The effects of psychoeducational family intervention on coping strategies of relatives of patients with bipolar I disorder  (Sampogna et al., 2018)	Design:Experimental group Subjects: Population: Sample: Patients and their families with bipolar disorder according to the inclusion criteria (1) aged 18 to 65 years; (2) diagnosed with BDI; (3) living with at least one family member. Inclusion criteria for family (1) aged 18 to 70 years; (2) not being physically or mentally ill Sampling technique: Consecutive sampling; Sample size: 123 patients and 139 families Variables: Psychoeducation and coping strategies Instrument: Family Coping Questionnaire (to measure strategy family coping), Brief Psychiatric Rating Scale depressive-anxiety and manic hostility subscales Analysis: t-test, Spearman correlation (to analyze between coping strategies with individual characteristics), linear regression models (to test the efficacy of the intervention on coping strategies)	Based on the results of the study, it was found that the coping strategies that widely used is a problem-oriented coping strategy such as communication, involving family members in social activities and seeking information, while emotional coping strategies focus coping such as collusion, coercion, resignation and spiritual assistance, in addition it was found that family coping strategies related to family function
14	Caregivers of family members with chronic diseases: coping strategies used in everyday life (Miguel et al., 2018)	Desain: Descriptive study with qualitative-quantitative approach and cross-sectional design Subject: Population: Families who care for their family members who sick; Sample: Families who care for their sick family members with criteria (1) caring for family members who suffer from illness noncommunicable; (2) aged 18 years and over; Sampling technique: convenience sampling; Sample size: 30 family caregivers of members who are familiar with PTM Variable: Coping type Instruments: Sociodemographic questionnaire, Barthel index, Coping Mode Scale, and semistructured questionnaire Analysis: Descriptive statistics, ANOVA test for repeated, thematic content was analyzed using qualitative data	Based on the results of the study, it was found that the main way of coping used by families caring for chronic disease sufferers Infectiousness is the problem of focusing on coping and religious-fantastic thinking. Participants expressed “feelings about everyday problems,” refers to positive perceptions of feelings of caring beneficial, but also negative perceptions of changes in working life. Participants’ “coping strategy” is the achievement of “activities” fun, spirituality, and seeking informal social support that contribute to alleviating the problems experienced
15	Coping with caregiving stress among caregivers of patients with schizophrenia (Rao et al., 2020)	Design: Cross-sectional tudy Sample: Population: 200 diagnosed schizophrenia sufferers based on DSM IV and their families Sample: Sufferers schizophrenia diagnosed based on DSM IV and their families with criteria (1) aged 18 to 50 years; (2) at least 2 years diagnosed with schizophrenia and lives with his family; (3) sufferers clinically stable; (4) the caring family is not suffering physical or mental illness or being dependent on any type of drug certain drugs (tobacco); Sampling technique: Purposive sampling; Large sample: 100 respondents Variable: Coping Instrument: PANSS which is used to measure residual symptoms in sufferers, GAF to measure levels function, Ways of Coping Questionnaire (WCQ) to measure coping, Brief Religious Coping Scale to measure religious coping, and GHQ to measure psychological morbidity Analysis: Independent t test and Mann-Whitney to test difference variables, Pearson product-moment correlation and Spearman's rank correlation to test the relationship between strategies coping and other variables, Bonferroni correction to test relationship of all variables	Based on the research results, it was found that caregivers with schizophrenia uses mixed adaptive and strategic coping strategies maladaptive coping, including coping used religious. The use of adaptive coping is associated with different outcomes better for the patient and the level of morbidity or distress lower psychology. The most family coping strategies widely used is a coping strategy by seeking support social, accepting responsibility, planning problem solving, positive assessment. With the results of the analysis, patient caregivers who work more often use coping strategies seeking social support (<.001), accepting responsibility, planning problem solving (<.001), and positive reappraisal (<.001), while escape avoidance coping (<.001)

Note. ACIT-SP = the functional assessment of chronic illness therapy-spiritual well-being; COPE = coping orientation to problems experienced; DSM IV = diagnostic and statistical manual of mental disorders, 5th ed.; RMSEA = root-mean-square error of approximation; CFI = comparative fit index; IFI = incremental Fit Index; GFI = goodness-of-fit index; MANOVA = multivariate analysis of variance; PTM = penyakit tidak menular/non-communicable disease.

Based from the results of the literature study above, it was found that the benefits of using spiritual coping used by families were:

1. Increasing mental or physical wellbeing (Health Status) (Park et al., 2021);

2. Giving comfort to the mind, find hope (Gojer et al., 2017);

3. Build meaning, greater religious support and positive caregiving experience (Guo et al., 2017);

4. Coping was associated with a positive caregiving experience and greater religious support. Religious coping methods that used by family caregiver may be particularly relevant and adaptive for dealing with the stress of caring for a person with a mental illness (Guo et al., 2017);

5. Decreasing burden and stress of family (Casaleiro et al., 2022a);

6. Increasing spiritual wellness (Budiarto & Hamid, 2019);

7. Better patient outcomes and lower levels of morbidity or psychological distress (Rao et al., 2020).

Discussion

An important finding from this study is that family coping influences family health. Doornbos' Family Health Theory (2002) shows that coping mechanisms affect family health (Doornbos, 2007). Family caregivers experience burdens or stress or even difficult times that arise while caring for people with schizophrenia. To address this, caregivers mention switching to the use of spiritual/religious practices. The term “spirituality” refers to a person's connection, whether religious or not, to what they perceive to be a nonphysical reality (Jordan et al., 2020; Rosmarin et al., 2021). Religious coping is defined as “an attempt to understand and deal with the existence of a stressor or life event in a way that is related to the sacred being” (Pargament et al., 2011, p. 12). Higher levels of spirituality and religion (R/S) have been linked to better mental health (Park et al., 2021). Spiritual intelligence can be employed as a coping mechanism to control and deal with the stressor in stressful situations (Moafi et al., 2021). Many caregivers of people with major mental illness find that religion is a significant part of their coping mechanisms (Guo et al., 2017). To foster a high level of spiritual wellbeing in the family, families with schizophrenia family members use spiritual coping as one of their coping mechanisms. According to studies, religion and spirituality can improve mental health by fostering constructive religious coping, a sense of belonging and support, and constructive beliefs. Additionally, research demonstrates that religion and spirituality can harm mental health due to unfavorable religious coping mechanisms, misunderstandings and miscommunication, and unfavorable views (Weber & Pargament, 2014).

Based on the results of 25 main studies that looked at the spiritual aspect of the experience of caring for a family with mental health problems, they suggested that spiritual needs, such as hope and finding meaning in life, and spiritual or religious practices help cope with stressful situations. Spiritual coping strategies for families in charge of caring for people with schizophrenia are an important component that must be provided and facilitated by health workers. This is because the use of coping strategies related to spirituality can improve physical and mental wellbeing, so a spiritually specific approach is needed to promote coping strategies in families with schizophrenia. After controlling for nonreligious forms of coping, religious coping was linked to increased objective caregiving burden, increased care recipient demand, decreased mental health awareness, and decreased use of mental health services (Guo et al., 2017).

Based on the results of the study, it was found that religiosity and spirituality can help build meaning, and find hope (Smith Lee et al., 2020). In general, religion and spirituality have long been regarded as important social determinants of human health, and there is some of research to support this (Colenda & Blazer, 2022). Research results show that spirituality and religiosity can have a positive impact on various health outcomes (Launius et al., 2022; Roze des Ordons et al., 2018) and become one of the healing program to increase quality of life (Saiz et al., 2021). Based on past studies, the coping strategies commonly used by families in caring for people with mental disorders include spiritual coping (80%) (Robinson-Lane et al., 2021). Therefore it is also very important for nurses to provide spiritual care to families or individuals who have psychiatric mental health needs (Gall & Guirguis-Younger, 2012; Neathery et al., 2020). This is also explained in a study which states that a strong spiritual, religious or personal belief system has a positive influence on active and adaptive coping skills in schizophrenia patients during remission, thereby helping individuals to overcome disease-related stress (Das et al., 2018a). Other research also explains that higher levels of religiosity and spirituality are associated with better treatment adherence (Kandeger et al., 2018).

The most frequent forms of spiritual adaptation consist of integrating religious content to carry out cognitive restructuring, psychoeducation and motivation, involvement in religious activities such as behavioral activation, meditation, or prayer to assist cognitive restructuring, using religious values and coping strategies (de Abreu Costa & Moreira-Almeida, 2022). In another study it was mentioned that religion and religious coping methods may be very relevant and adaptive for dealing with the stress of caring for someone with mental illness. In general, families caring for schizophrenics reported high levels of religious involvement and frequently used and perceived helpful religious coping strategies (Clark & Emerson, 2021). Likewise, other studies have shown that families who care for people with schizophrenia often turn to religion and spirituality for support (Das et al., 2018b). As in a study of Hindu family members with schizophrenia, 90% of participants reported praying to God to solve problems and seeing religion as a source of comfort, strength, and guidance in coping with the demands of parenting.

Another study showed that family members of people with serious mental illness who had higher levels of personal religiosity (i.e., the importance of religion and finding comfort and strength from God) also reported higher levels of mastery, self-esteem, and self-care. The use of religious coping was associated with adaptive coping and with better patient outcomes and higher rates of morbidity or distress (Rao et al., 2020; Zerach & Levin, 2018). This is consistent with research showing that there are significant disparities in the spiritual health of family members who have schizophrenia among caregivers (Budiarto & Hamid, 2019; Rosmarin et al., 2021).

Overall, the study's findings support the idea that people who are facing challenging circumstances turn to religion for solace (Pargament, 2001). When one has exhausted one's own human capacity and when religion is “available and accessible,” many individuals are more likely to rely on it (Pargament et al., 1988). Instead of explicitly shielding caregivers from suffering poor results, religion may have a greater impact in this situation by promoting and enhancing happy emotions and experiences amid feelings of stress and load. In other words, religion might give carers the tools they require to discover meaning and purpose in challenging and trying circumstances (Pearce et al., 2002). For instance, a study of those who cared for cancer patients who had reached the end of their lives revealed that those who turned to religion for solace experienced both greater caregiving burden and greater caregiving satisfaction (Pearce et al., 2002).

Implication for Practice

Mental health nursing care should take into account the spiritual requirements and coping mechanisms of family caregivers of a relative suffering from a severe mental illness. When fostering coping mechanisms for the family caregivers of a member with serious mental illness, a spiritually sensitive approach should be adopted. Apart from that, there are also several applications in the field of education where holistic nursing care, starting from physical, psychological, social, and spiritual, is very important for students in the health or nursing field to master in order to be able to provide comprehensive nursing care, especially meeting spiritual needs with a professional care approach.

Practice implications: Spirituality should be taken into consideration based on the beliefs and requirements of each caregiver, as it may provide significant resources for overall wellbeing and a feeling of purpose.

Conclusion

Family spiritual coping can improve the spiritual wellbeing of caregivers of family members with schizophrenia. Therefore, nurses can provide assistance to families with schizophrenia by following up at least once a month by providing consulting services, health education, and collaborating with local religious leaders to provide spiritual services. Health workers can support and remind caregivers of family members with schizophrenia to optimize spiritual coping to find comfort in faith such as praying and remembering God.