Allowing spirituality into the healing process
It is fair to say these cautions are worthy of serious consideration and need to be addressed by any responsible model of integration. Certainly there is a need for added research on this subject. Koenig et al,11 for example, in rating the research done on the subject, rate only 18.5% of the studies a 10, 9, or 8 on a scale of 1 to 10 (10=excellent) and assert “we have only scratched the surface in acquiring knowledge about the influences of religion on health, the influences of health on religion, and the mechanisms by which these effects occur.” A review of studies attempting to link religiosity to physiological processes notes that the results are “suggestive,” but that additional research is needed that combines both stronger research methodology with more representative populations.29 Even proponents of integration are aware of the difficulties related to boundaries.30
Providers with an interest in the integration of medicine and spirituality are thus left with a dilemma. On the one hand there appear to be some very good reasons for integration: patient need and desire, the respect such an approach illustrates for the whole person, and strong clues that it does aid with coping, prevention, and recovery. On the other hand, there appear to be very real dangers with integration: a potential violation of boundaries, lack of training, lack of time, and potential misuse of the spiritual.
A model for integration
An appropriate response seems to be finding a model that encourages physicians to treat the patient as a whole person, addressing not only physical, but also social, emotional, and spiritual issues. This model should provide the physician with the ability to identify patients who are struggling with such issues, and the tools for addressing them in an appropriate manner. But this model should take into account the serious issues of time, boundaries, and respect for the deep and complex nature of spiritual and emotional issues.
In general the model should have the following components:
- Good active-listening skills and other tools that encourage the patient to share safely and freely about such issues, providing new self-awareness on the part of the patient, and in some cases spiritual relief.
- Identification of spiritual/emotional issues.
- Appropriate and effective referral of the patient to a “spiritual specialist,” one trained to deal with spiritual issues in a longer term, deeper manner.
- Ongoing communication with the patient and their specialist about this aspect of the person’s healing process.
The first step involves simply asking specific questions to develop a basic understanding of the patients’ spiritual culture. Various sets of questions have been developed to aid practitioners with this task.31-33 It is also a matter of practicing what many have called the “art of medicine.” It is being patient centered and entering into a true dialogue with patients that involves active-listening skills. Active listening is important, because most patients will not make direct statements regarding their feelings or issues. Usually their deep spiritual turmoil is expressed indirectly through body language, tone of voice, stories, and other subtle expressions. True dialogue allows physicians to pick up the clues patients are sending regarding spiritual issues, and to help their patients come to a clear awareness of those issues for themselves.
Once the discussion has begun, it is important to include some element of assessment. A hospital chaplain has developed an assessment tool that he uses to think about the spiritual health of those he visits and to structure his interventions with those patients.34 At Oregon Health and Science University we have adapted his approach by encouraging physicians to develop a set of 5 to 8 paired terms, such as anger and acceptance, which they believe reflect important spiritual issues (Table 3). Using these terms, a continuum is developed that can be used to help assess patients from a spiritual perspective.
A physician can use this continuum to think about the patient and to develop ideas for intervention. First, the physician places an “X” on each continuum of the chart, noting his or her perception of how the patient is functioning.
Second, the physician evaluates that position. Is this a logical place for the patient to be at this place, in this time? Severe anger might be appropriate when one first receives news of a terminal illness. It may not be as appropriate 6 months later.
Third, the physician picks the issue(s) they believe should be addressed through intervention. If a person is feeling helpless, what might be done to help them feel more empowered? The physician can ask what he or she can do. This is likely to be somewhat limited due to training, time, and other issues. The physician can also seek collaboration. Who can be brought into the healing mix, who might become a partner in helping healing happen?
