Spiritual Care in the United States:

Understanding, Research and Practice

Harold G. Koenig, MD

Professor of Psychiatry and Associate Professor of Medicine

Duke University Medical Center

Distinguished Adjunct Professor, King Abdul Aziz University, Jeddah, Saudi Arabia

What is Spiritual Care? Who provides Spiritual Care? What is the basis for Spiritual Care? Why do it? How often do health professionals provide Spiritual Care in USA? How do health professionals in USA provide Spiritual Care? Open discussion

Overview 14:30-15:30

Further Reading:

Spirituality in Patient Care, Second Edition

Templeton Foundation Press, 2007 (reviewed in JAMA 2008; 299:1608-1609)

Spiritualitat in den Gesundheitsberufen: Ein proaxisorientierter Leitfaden Bearbeitet und mit enem Geleitwort von Rene Hefti

(Kohlhammer Press, 2012)

Part of care for the whole person: - physical body - emotional/psychological - social - spiritual

What is Spiritual Care?

Spiritual Care is NOT the same as providing medical or nursing care; that is provided by doctors and nurses

Spiritual Care is NOT the same as addressing the emotional and

psychological needs of patients; that is provided by mental health specialists (counselors, psychologists, psychiatrists)

Spiritual Care is NOT the same as addressing the social or family

needs of patients; that is provided by social workers

What Spiritual Care is Not:

Spiritual Care involves health professionals addressing that

aspect of the whole person that has to do with their relationship to the Transcendent and the spiritual needs that result from that relationship

Is Spiritual Care the same as providing “religious care”? Yes, broadly speaking. It is the only distinctive aspect of Spiritual Care that

separates and distinguishes it from the physical, psychological, and social aspects of care.

What is Spiritual Care?

Practically speaking, Spiritual Care involves: (1) Taking a spiritual history (talking with patients about

these issues) (2) Identifying spiritual needs (3) Ensuring that spiritual needs are met by someone (4) Providing healthcare in a spiritual way *Will say more about each of these later*

What is Involved in Spiritual Care?

Chaplains and other clergy (pastors or pastoral counselors), but also:

Medical doctors Nurses Social workers Counselors, psychologists, psychiatrists Other health professionals (physical/occupational therapy, etc.)

Who Provides Spiritual Care?

Why Provide Spiritual Care?

• Many patients are religious, and would like it addressed in their

health care (next)

• Many patients have spiritual needs related to illness that could

affect mental, social and physical health (next)

• Religious beliefs of patients affect healthcare decisions, and could

conflict with the medical care plan (discuss)

• Religious beliefs of health professionals (physicians/nurses) affect

their healthcare decisions; could conflict with patients’ beliefs (discuss)

• Religion influences support and care in the community (discuss)

Many Patients are Religious (and Most are Spiritual)

In the USA (general population; Gallup Polls Jan-Dec 2011):

- 40% are “very religious”

(religion important part of daily life, weekly or almost weekly attendance)

- 28% are “moderately religious” (religion important but not regular attenders, or religion not important but

are regular attenders)

- 32% are “non-religious”

(religion not important part of daily life and seldom or never attend

religious services)

When sick or stressed, many become religious and/or use it to cope

0

0.1-4.9

5.0-7.4

7.5-9.9

10

5.0%

5.0%

22.7%

27.3%

40.1%

Self-Rated Religious Coping

The Most Important Factor

Large Extent or More

Moderate to Large Extent

None

Responses by 337 consecutively admitted patients to Duke Hospital (Koenig 1998)

Small to Moderate

Religious Coping is Common in Response

to Stress

America’s Coping Response to Sept 11th:

1. Talking with others (98%)

2. Turning to religion (90%)

3. Checked safety of family/friends (75%)

4. Participating in group activities (60%)

5. Avoiding reminders (watching TV) (39%)

6. Making donations (36%)

Based on a random-digit dialing survey of the U.S. on Sept 14-16

New England Journal of Medicine 2001; 345:1507-1512

Many Patients Would Like it Addressed in their Health

Care by Medical Doctor (MD)

- MD should consider pt’s spiritual needs 77% - Want MD to ask about R/S 65% (33-84%)*

- MD should pray w pt if requested 64%

- Would like MD to pray with them 57% (33-78%)**

- [MDs who say pts would ever want prayer 37%

- R/S & medicine should be separate 28%

- MD should not ask 17%

- did MD every ask? 13% (9-20%)

* Based on 6 patient surveys, range depends on circumstances

**Based on 4 patient surveys

Many Patients Have Spiritual Needs Related to Illness

In a multi-site study by Harvard investigators, 230 patients

with advanced cancer were surveyed. Most (88%) considered

religious to be at least somewhat important. However, 47%

reported that their spiritual needs were minimally or not at all

supported by their religious community and 72% said their

spiritual needs were minimally or not at all supported by the

medical system (doctors, nurses or chaplains). Furthermore,

spiritual support provided by their medical team or religious

communities was associated with significantly higher quality of

life (p=0.0003) (Balboni et al, 2007).

Not Addressing Spiritual Needs is Expensive

Multi-site, prospective study of 345 patients with advanced cancer who were

followed to their death. They found that intensive, expensive, futile life-

prolonging care (mechanical ventilation or resuscitation in last week of life) was

significantly more common among those with high levels of religious coping

(Phelps et al, 2009, JAMA).

When these investigators examined who among those using religion to cope

were using more expensive health services, they found that this was primarily

among those whose spiritual needs were not being addressed by the medical

team. Among high religious copers whose spiritual needs were to a large extent

or completely supported (vs. not supported), the likelihood of receiving hospice

increased 5-fold (p<0.005) and of receiving aggressive care towards the end of

life decreased by 72% (range 21% to 96%) (p=0.02) (Balboni et al., 2010,

Journal of Clinical Oncology).

Religious or Spiritual Issues Also Important

for Patients in Europe

Religiousness of European Countries (EURODEP) (n=22,570, over age 65) (Braam)

Weekly Attend Orthodox Beliefs (0-12)

#1. Ireland 81% 9.0

#2. Italy 38% 6.9

#3. Spain 30% 5.8

#4. Netherlands 27% 4.7

#5. Belgium 27% 4.6

#6. Germany 18% 5.2

#7. UK 14% 6.4

#8. France 10% 4.4

#9. Finland 4% 6.2

#10. Sweden 4% 3.8

#11. Iceland 2% 6.4

Religious Coping in Europe (see Handbook of Religion and Health, 2nd ed., 2012)

Sweden 1% rely on R faith

0.2 times/week sought spiritual support (GI cancer)

Norway 43% no belief in God; 45% no comfort whatsoever (terminal CA)

Finland 4% attend services regularly; 70% religion not important

Denmark 63% believe in God; 3% attend services regularly (1981)

60 of 1,425 (4%) youth identified with religious groups

Of those over 50, 21% pray daily and 30% weekly (49% never)

United Kingdom 27% religion important (73% not)

Religious coping ranked 13th of 14 (just ahead of alcohol/drugs)

Terminally ill – 43% spiritual beliefs major part of life

France 30% religion important (all ages); 10% regular attenders

Netherlands 33% religion important (all ages); 35% of over 50 pray daily

Germany 41% religion important (all ages); 18% regular attenders

29% used religion “a lot” to cope (older persons w dentures)

57% used religion to cope (ALS patients)

Italy 71% religion important (all ages) (highest except Greeks, 71%)

Switzerland 42% religion important (all ages)

42% religion very important or essential for coping (schizophrenia)

Thus,

Spiritual Care is Important

in

the United States

and

Europe

Failure to Meet Spiritual Needs Could Affect

Mental and Physical Health

The Research (systematic review 1872-2010 of all quantitative research published in

peer reviewed academic scientific journals in the English language

listed in PsychInfo and Medline)

This research is documented in:

Handbook of Religion and Health, (Oxford University Press, 2001)

Handbook of Religion and Health, Second Edition (Oxford

University Press, 2012)

Research on Religion and Mental Health

Emotional disorders

Depression Suicide Substance use Positive emotions/virtues

Well-being and happiness Meaning, purpose, and hope Forgiveness, altruism, gratitude, compassion Social health

Social support

Social capital

Marital stability

Emotional Disorders

Religious involvement is related to: Less depression, faster recovery from depression 272 of 444 studies (61%) [67% of best] More depression (6%)

Depression (systematic review)

Religious involvement is related to: Less suicide and more negative attitudes toward suicide 106 of 141 studies (75%)

Suicide (systematic review)

Religious involvement is related to: Less alcohol use / abuse / dependence 240 of 278 studies (86%) [90% of best]

Alcohol Use/Abuse/Dependence (systematic review)

Drug Use/Abuse/Dependence (systematic review)

Religious involvement is related to: Less drug use / abuse / dependence 155 of 185 studies (84%) [86% of best] [95% of RCT or experimental studies]

Positive Emotions / Virtues

Religious involvement is related to: Greater well-being and happiness 256 of 326 studies (79%) [82% of best] Lower well-being or happiness (<1%)

Well-being and Happiness (systematic review)

Religious involvement is related to: Significantly greater meaning and purpose in life 42 of 45 studies (93%) [100% of best] Significantly greater hope

29 of 40 studies (73%) Significantly great optimism

26 of 32 studies (81%)

Meaning, Purpose, Hope, Optimism (systematic review)

Religious involvement is related to: Significantly more forgiveness 34 of 40 studies (85%) [70% of best] Significantly more altruism / volunteering 33 of 47 studies (70%) [75% of best]

Significantly more gratitude, compassion, kindness

8 of 8 studies (100%)

Positive Human Virtues / Character Traits (systematic review)

Social Health

Religious involvement is related to: Significantly greater social support 61 of 74 studies (82%) [93% of best]

Social Support (systematic review)

Religious involvement is related to: Significantly greater social capital 11 of 14 studies (79%)

Social Capital (systematic review)

Religion, Health Behaviors, and Disease

Prevention

Exercise Weight Sexual behavior Cigarette smoking Diet Cholesterol Seatbelt use Disease screening Treatment compliance

Religious involvement is related to: • More exercise/physical activity 25 of 37 studies (68%) [76% of best] • Less extra-marital sex, safer sexual practices (fewer partners) 82 of 95 studies (86%) [84% of best] • Lower weight (7 of 36 studies) (19%) Heavier weight (14 of 36 studies) (39%)

Health Behaviors (systematic review)

Religious involvement related to: • Less cigarette smoking, especially among the young 122 of 135 studies (90%) [90% of best] • Better diet 13 of 21 studies (62%)

• Lower cholesterol 12 of 23 studies (52%)

• More likely to wear seat belts 3 of 3 studies

Health Behaviors (cont)

Research on Religion and Physical Health

Heart disease

Hypertension

Immune function

Endocrine function

Cancer

Overall mortality

Religious involvement is related to: Significantly lower rates of coronary artery disease 12 of 19 studies (63%) [69% of best] Lower cardiovascular reactivity, greater heart rate variability, more positive cardiovascular functions 10 of 16 studies (63%) [62% of best]

Heart Disease (systematic review)

Religious involvement is related to: • Lower BP or lower rates of hypertension 36 of 63 studies (63%)

Hypertension (systematic review)

Religious involvement is related to: • Better immune function (higher lymphocyte counts, lower

inflammatory markers, etc.) 14 of 25 studies (56%) [60% of best] • Better endocrine function (cortisol, epi and norepinephrine) 23 of 31 studies (74%)

Immune and Endocrine Function (systematic review)

Religious involvement is related to: • Lower rates of cancer or better prognosis 17 of 28 studies (61%) [65% of best]

Cancer (systematic review)

Religious involvement is related to: • Lower mortality, longer survival 82 of 120 studies (68%) [66% of best] [76% of very best]

Overall Mortality (systematic review)

0

500

1000

1500

2000

2500

C NG (NG) M (P) P NA

C

NG

(NG)

M

(P)

P

NA

Number of studies includes some studies counted more than once (see Appendices of 1st and 2nd editions).

Prepared by Dr. Wolfgang v. Ungern-Sternberg

The Relationship between Religion and Health: All Studies

Belief in,

attachment to

God

Public prac, rit

Priv ate prac, rit

R commitment

R coping

Positiv e Emotions

Negativ e EmotionsMental Disorders

Social Connections

Ph

ysic

al H

ea

lth a

nd

Lo

ng

evity

Imm

une, E

ndocrine, C

ard

iovascula

r F

unctions

Theoretical Model of Causal Pathways

Genetics, Dev elopmental Experiences, Personality

Decisions, Lif esty le Choices, Health Behav iors

SOURCE

R experiences

Spirituality

faith

community

Psy chologicalTraits / Virtues

Forgiv enessHonestyCourageSelf -disciplineAltruismHumilityGratef ulnessPatienceDependability

Theolo

gic

al V

irtues:

faith

, hope, lo

ve

faith

community

*Model f or Western monotheistic religions (Christianity , Judaism, and Islam)

(c) Handbook of Religion & Health, 2nd ed

Thus,

Spiritual Care is Important for Medical Reasons,

Psychological Reasons, Social Reasons, and

Financial Reasons

How does a Healthcare Professional

Provide Spiritual Care?

Take a Spiritual History

1. Health professionals should take a screening spiritual history (2-4

minutes); this is not the same as a spiritual assessment (chaplain or

pastoral care specialist)

2. The purpose of the SH is to obtain information about religious

background, beliefs, and rituals that are relevant to their mental health

care

3. If patients indicate from the start that they are not religious or spiritual,

then questions should be re-directed to asking about what gives life

meaning & purpose and how this can be addressed in their care

A Brief Explanation Should Precede the

Spiritual History

1. Patients may become alarmed or anxious if a health professionals begins

talking about religious or spiritual issues

2. The health professional should be careful not to send an unintended

message to the patient that may be misinterpreted

3. Make it clear that such inquiry has nothing to do with the patient’s

diagnosis or the severity of their medical condition

4. Indicate that such inquiry is routine, required, and an attempt to be

sensitive to the spiritual needs that some patients may have

Physician Should Take

The Spiritual History

• Patient needs to feel comfortable talking with physician about spiritual

issues

• Patients’ medical decisions are influenced by their religious beliefs

• Patients’ compliance with medical treatments are influence by religious

beliefs

• Taking spiritual history enhances doctor-patient relationship & may itself

affect health outcomes

• Spiritual struggles, if undetected, can adversely affect health outcomes

Religious Struggle 444 hospitalized medical patients followed for 2 years

Wondered whether God had abandoned me

Felt punished by God for my lack of devotion

Wondered what I did for God to punish me

Questioned the God’s love for me

Wondered whether my church had abandoned me

Decided the Devil made this happen

Questioned the power of God

Each of 7 items below rated on a 0 to 3 scale, based on agreement. For every 1 point increase on religious struggle scale (range 0-21), there was a 6% increase in mortality, independent of physical and mental health (Arch Intern Med, 2001; 161: 1881-1885)

Contents of the Spiritual History

1. What is patient’s religious or spiritual (R/S) background (if any)

2. R/S beliefs used to cope with illness, or alternatively, that may be a

source of stress or distress

3. R/S beliefs that might conflict with medical (or psychiatric) care or might

influence medical decisions

4. Involvement in a R/S community and whether that community is

supportive

5. Spiritual needs that may be present and need to be addressed for health

reasons

See JAMA 2002; 288 (4):487-493

Medical Doctors Say It’s Important, but Don’t Do it

Attitudes

- SWB important part of health 96% (Ellis)

- should be aware of pt’s R/S beliefs 85% (Monroe)

- MD has right to inquire about R/S 89% (Maugans)

- should ask about R/S beliefs 35% (Monroe)

- has responsibility to ask R/S 52% (Maugans)

- usually/always appropriate to ask 55% (Curlin)

Practices

- often/always take a spiritual history 8% (7-10%)

Besides Taking a Spiritual History…

1. Support the religious/spiritual beliefs of the patient (verbally, non-verbally)

2. Ensure patient has resources to support their spirituality – refer patients

with spiritual needs to CHAPLAINS

3. Accommodate environment to meet spiritual needs of patient

4. Be willing to communicate with patients about spiritual issues

5. Prescribe religion to improve health (?)

6. Pray with patients if requested (?)

Refer to Professional Chaplains

1. Get to know your chaplains. Are they competent? If yes, then…

2. If any but the most simple of spiritual needs come up, always refer

3. Need to know the local pastoral care resources that are available, and

the degree to which they can be relied on

4. Before referral, explain to patients what a chaplain is and does (they

won’t know)

5. Explain why you think they should see a chaplain

The way health care is provided – by physicians, nurses, social workers, counselors, physical therapists, occupational therapists, dieticians, etc. – can be Spiritual (recognizing the Sacred nature of the person and the Holy obligation and privilege that health professionals have) What does this mean? - providing care with respect for the individual patient - inquiring about how patient wishes to be cared for - providing care in a kind and gentle manner - providing care in a competent manner - taking extra time with patients who really need it

This is not easy to do

Providing Care in a Spiritual Way

Limitations

1. Do not prescribe religion to non-religious patients

2. Do not force a spiritual history if patient not religious

3. Do not coerce patients in any way to believe or practice

4. Do not pray with a patient before taking a spiritual history and unless the patient asks

5. Do not spiritually counsel patients (always refer to trained professional chaplains or pastoral counselors)

6. Do not do any activity that is not patient-centered and patient-directed

Summary

• There is a solid rationale for addressing patients’

spiritual needs in clinical settings

• Many patients in the United States and Europe

are religious or spiritual, and have spiritual needs

that must be addressed

• Identify spiritual needs by taking a spiritual history

and explore the role that spiritual factors may play

in either (1) coping with the illness or (2)

contributing to the illness (spiritual struggles)

• Utilize trained professional chaplains or pastoral

counselors to address patients’ spiritual needs

1. Spirituality in Patient Care (Templeton Press, 2007) (clinician)

2. Healing Power of Faith (Simon & Schuster, 2001) (patient)

3. Medicine, Religion and Health (Templeton Press, 2008)

(patient/clinician)

4. Spirituality and Health Research: Methodology, Measurement,

Analyses, and Resources (Templeton Press, 2011) (researcher)

5. Handbook of Religion and Health (Oxford University Press, 2001;

and Second Edition, 2012) (clinician and researcher)

Further Reading

Summer Research Workshops Durham, North Carolina

5-day intensive research workshops focus on what we know about the relationship between

spirituality and health, applications, how to conduct research and develop an academic career

in this area. Leading spirituality-health researchers at Duke, UMSC, and elsewhere will give

presentations:

-Strengths and weaknesses of previous research

-Theological considerations and concerns

-Highest priority studies for future research

-Strengths and weaknesses of measures of religion/spirituality

-Designing different types of research projects

- Primer on statistical analysis of religious/spiritual variables

-Carrying out and managing a research project

-Writing a grant to NIH or private foundations

-Where to obtain funding for research in this area

-Writing a research paper for publication; getting it published

-Presenting research to professional and public audiences; working with the media

Scholarships are available for the financially destitute

If interested, contact Harold G. Koenig: Harold.Koenig@duke.edu

Open Discussion

till 15:30