Twenty years have passed since spirituality and the perspective of God as a source of social support emerged from my dissertation research.1 In this research, older African American cancer survivors conceptualized spirituality as a personal relationship with God and the beliefs that maintain that relationship.2 Among these older African Americans, "religion" was the umbrella term used to describe participation in church activities, beliefs about God, and the perceived support derived from their relationship with God, family, and friends. Since my dissertation research, I have had the opportunity to engage in nearly 200 interviews with African Americans to better understand how these practices and beliefs are used in response to life-threatening illness. These interviews have brought clarity to the nature of religious beliefs and practices as complex and dynamic, yet distinct and interwoven concepts. Over the years, it has been extremely rewarding to advance my own scholarship in the area of spirituality, theology, and health and to also witness the increased frequency of scholarly contributions of others to this field. However, along with this growth of scholarship in the field of spirituality are inconsistencies and frequently a lack of clarity with concepts related to religion and spirituality used in scholarly writings. In this reflection, I will use exemplars from my research with African American cancer survivors to make the distinction between religion and spirituality and argue why these concepts should not be used interchangeably.

Among scholars, religion has been distinguished from spirituality, although this remains a controversial area.3 Generally, religion is an adherence to a set of beliefs, values, rituals, and symbols and participation in activities of organized religious institutions.3 Religiosity or religious involvement is another concept used among scholars to refer to beliefs and practices related to organized religious institutions.3 Spirituality, on the other hand, has been conceptualized to occur on a more personal level and apart from affiliations with organized religious institutions. Conceptualizations of spirituality may include a search for answers to questions about life, a relationship to God, and making meaning of individual human experience through dimensions of connectedness: within oneself; to others and the environment; or, to God or other higher power.4

Distinctions between religion and spirituality as practiced among African American cancer survivors have not been as clear as those proposed among scholars. Among older African Americans, the term religion, also known as religious experience, was used to capture the entirety of their beliefs in God, their covenant with this Deity, and the benefits derived from their beliefs. This religious experience generally included beliefs centered around church attendance, religious practices, and religious doctrine that guided relationships with others. A strong belief system among older African Americans has been attributed to a religious culture and life history where the church was the central institution in the community, and attendance at worship and other church services was strongly encouraged, if not mandatory.5 Attendance at church services exposed participants at an early age to practices of praying, reading and reciting scriptures, and singing of hymns. These religious practices reinforced beliefs, expectations for godly behaviors in society, and permitted expressions of worries, needs, and desires to God, family, and others in their social networks.6-8

During a cancer diagnosis and treatment, African Americans might find comfort in engaging in religious practices of singing religious songs, reading scriptures, and praying. During one interview, an older African American man spoke of a religious practice of singing hymns that was helpful to him during his illness:

One particular song that was very helpful to me because of one of the verses in it, and it goes to say that "many dangers[horizontal ellipsis] and He [God] brought me through all of that[horizontal ellipsis]." And that song, it really helped me to get through many dangers, toils, and snares-And the name of the song is "Amazing Grace"-and in fact "Amazing Grace" is one of the old[horizontal ellipsis] Negro gospel songs.

Engaging in the religious practice of reading scriptures has enabled participants to overcome fears and anxieties. One older African American woman described how reading and thinking about a verse from the Holy Bible helped her to overcome her fears when she needed surgery:

My favorite scripture is Psalms 46 and 1. God is my refuge and strength. A very present help in trouble.

Because I do believe that all the things that has happened to me-the source is from God. I can't do anything on my own, and He's my strength, He's my refuge, He keeps me.

Spirituality, on the other hand, is a language that has emerged over the years to refer to the religious experience of younger African Americans, a religious experience similar to older generations of African Americans in many ways. For example, the formative years of both generations consisted of affiliations with religious institutions where regular attendance at worship services and involvement in other religious activities were the norm. Moreover, the use of religious practices (singing or listening to hymns, reading scriptures, or praying) to express individual beliefs as well as to cope with stressful life events was consistent among both older and younger age groups.8,9 However, in contrast to older generations, younger generations of African Americans believe that a relationship with God and hence one's spirituality can and does exist apart from one's affiliation with an organized religious institution and church attendance. Church membership and attendance are not necessary to be spiritual or have a relationship with God. Therefore, spirituality as dimensions of connectedness to God, self, and others is a relevant concept for both age groups. Through a connectedness to God, cancer patients might have access to the powers associated with this Deity, resulting in the strength and courage needed to endure prescribed cancer treatments. Spirituality might promote a positive sense of self as a child of God, resulting in the cancer patient feeling loved and cared for. Further, a child of God has access to an omnipresent Deity with continual access to a trusted and caring confidante. Finally, spirituality promotes a positive outlook on life that might enable the cancer patient to engage in social relationships where social support is given and received.

African Americans frequently rely on the text of the 23rd Psalms as a reminder of their relationship with God and His ability to guide and protect them during life-threatening illness such as cancer. One 70-year-old man described his relationship with God as likened to that of a sheep to his shepherd:

Knowing that He [God] is my shepherd and He [God] is watching over me, keeping me safe, you know, and He [God] will always be there for me as long as I keep my hands in His hands. That's how faith keeps me-it just keeps me leveled off[horizontal ellipsis] and regardless of what happens in my life, I fall back on my faith. I feel that the Lord is my shepherd, and I don't have to want[horizontal ellipsis] all I have to do is look to Him, and that's the way I live.

Among African Americans today, the conceptualization of spirituality is largely due to the nature in which the religious culture of this population has historically embraced and transmitted a set of beliefs and practices that have extended the church-beliefs taught throughout the community in churches, homes, and public and private schools. Regardless of religious affiliation or involvement in religious institutions, African Americans were encouraged to rely on their religious beliefs and practices to cope with life's stressors.

In conclusion, religion, religious involvement, and religiosity are concepts intended to capture a system of collective beliefs, values, rituals, and practices associated with organized religious institutions. Spirituality occurs on a personal, individual level apart from affiliations with organized religious institutions. Therefore, scholars should not assume that religiosity and religious involvement are indicators for spirituality or religious beliefs that may be deeply personal. Similarly, scholars should not assume that the absence of affiliation with organized religious institutions implies that cancer patients are not spiritual.

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