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Spirituality and Health: Developing a Shared Vocabulary
Spirituality and Health: Developing a Shared Vocabulary
B.M. Mount, W. Lawlor, E.J. Cassell, for McGill Programs in Integrated Whole Person Care Working Group (Address for reprints. B.M. Mount, McGill Programs for Integrated Whole Person Care, 546 Fine Ave. W., Montreal QC H2W 1S6.)
Abstract
The spiritual domain is an important determinant of subjective well-being, and thus, of quality of life and health-care outcomes. While medicine has a shared vocabulary for the discussion of clinical and research issues relating to body and mind, the language of spirituality is often an obstacle to communication rather than an aid to understanding. This barrier impedes the integration of the spiritual domain in clinical assessment, therapeutics, research, and teaching. The objective of this collaborative effort was to write clear, succinct statements concerning basic concepts relevant to spirituality and health, that are respectful of divergent world views, and useful in discussing clinical, research, and teaching initiatives. They are offered as a point of departure to be used as a catalyst lot dialogue and clarification. The authors suggest that religious adherence is an uncertain indicator of personal spirituality, and thus, they distinguish between spirituality and religion.
This article has been peer-reviewed.
Clinical Encounters
How often the patient's clinical course is coloured by enigmatic features due to factors that we cannot measure.
C.D. had been an elite athlete and business executive in a life filled with conspicuous achievement. Days before dying with metastatic cancer at the age of 30 years, he said goodbye to his doctor, commenting, "This last year has been the best year of my life." When asked about how a year filled with such apparent agony could be considered "the best year," C.D. confided that he had experienced a new awareness of the spiritual dimension of human existence.1
Mrs. C., a widow in her 70s, had pain due to breast carcinoma metastatic to bone. It had failed to respond to treatment as expected, and escalating morphine doses produced sedation without pain relief. A conversation with her puzzled physician shed light on her plight. "When were you last well"? "Do you mean physically"? "No, I mean in yourself" "Doctor, I've never been well a day in my life." "Really! Well, if we are body, mind, and spirit, where do you think the problem has been...? "I've been sick in mind and spirit every day of my life." Her anguish persisted until death.1
C.H. was a professional musician in her late 40s, who became bedridden with osteomyelitis of the spine. Although in physical distress, her attitude stayed positive. Her physician was intrigued, On her medical record was the designation "no religion," She felt estranged from organized religion, and had not attended church since she was 14 years old. But when asked what spirituality meant to her, her response was illuminating. "The spiritual part of my life is more important to me than the physical part. There is some kind of guiding force. I hate to use a word such as God, Buddha, or Mithra. It is all those things and more. It encompasses closeness to the earth and an interconnectedness of all things... It is everywhere, but for me, it is particularly present in superb music superbly performed. That is a religious experience... It is a positive force, a healing force."
TABLE 1
MCGILL PROGRAMS IN INTEGRATED
WHOLE PERSON CARE WORKING GROUP
Patricia Boston, department of oncology, McGill University, Montreal, Canada
Mary Brooksbank, Royal Adelaide Hospital and Mary Potter Hospice, Adelaide, South Australia
Ira Byock, Palliative Care Service, Missoula, and Robert Wood Johnson Foundation Program on End of Life Care, Missoula, U.S.A.
Eric J. Cassell, department of public health, Weill Medical College, Cornell University, New York, U.S.A.
Nessa Coyle, Memorial Sloan?Kettering Cancer Center, New York, U.S.A.
Douglas Graydon. Casey House Hospice, Toronto, Canada
Marian Jerry. World Health Organization Collaborating Center for Cancer Control, Canmore, Canada
Martin Jerry, World Health Organization Collaborating Center for Cancer Control, Canmore, Canada
Michael Kearney, Our Lady's Hospice and University College, Dublin, Ireland
William Lawlor, faculty of education, McGill University, Montreal, Canada
Barbara Monroe, St. Christopher's Hospice, London,U.K.
Balfour M. Mount, departments of medicine and oncology, McGill University, Montreal, Canada
John Seely, University of Ottawa, Ottawa, Canada
Porter Storey, Hospice at The Texas Medical Center, Houston, U.S.A.
Background
Medicine has a shared vocabulary that is used in discussions of clinical observations and research relating to body and mind.2,3 When factors that may be considered to be issues of the spirit are raised, however, there is no equivalent shared vocabulary to facilitate communication.
A shared language of spirituality would enable two ends that are important in improving health care. First, it would capture dimensions of the patient's experience of illness that physicians are missing - those shades of meaning, anguish, or triumph out of suffering that influence the capacity to celebrate what is still possible in life. Second, it would facilitate discussion with colleagues across socio-cultural and religious boundaries; building on each other's work in the interdisciplinary team; writing of constructive progress notes in patients' charts: and the design of effective care plans.
TABLE 2
CONSULTANTS
David Barnard, center for bioethics, health, and law, University of Pittsburgh, U.S.A.
Kathleen Foley, Memorial Sloan-Kettering Cancer Center, New York, U.S.A.
Nancy S. Jackson, McGill University, Montreal, Canada
Martin Jeffery, Kingston, Canada
Joseph F. O'Donnell, Dartmouth Medical School, Hanover, U.S.A.
Dame Cicely Saunders, St. Christopher's Hospice, London,U.K.
Goal
Our goal was to develop clear, succinct statements of basic concepts concerning spirituality, religion, and health that are respectful of divergent world views, and useful in discussing clinical, research, and teaching initiatives.
Method
The McGill Programs in Integrated Whole Person Care's working group (Table 1) was formed in September 1999. An initial meeting (Boston, Brooksbank, Cassell, Lawlor, and Mount) resulted in a draft document that was circulated to McGill colleagues and international collaborators who were identified because of their clinical experience and interest in these issues. The disciplines represented included medicine, nursing, pastoral care, education, psychology, social work, and theology.
A cyclic process that involved repeated amendment by work-group members, and consultation with patients, their families, professional and volunteer caregivers, and other colleagues (Table 2) followed, resulting in the identification of common ground.
Results
The statement of basic concepts is shown in Table 3.
Discussion
There is an increasing awareness of the need to consider a spiritual dimension of health care. Cassell,4 Byock,5 Kearney,6,7 and Kearney and Mount8 have explored the multi?dimensional nature of suffering, and the physician's role in responding to the patient's spiritual needs. But what is the "spiritual" dimension of care? Parker Palmer writes, "We need to shake off the narrow notion that 'spiritual' questions are always about angels or ethers or must include the word God. Spiritual questions are the kind that (our patients), and we, ask every day of our lives as we yearn to connect with the largeness of life: "Does my life have meaning and purpose"? "How can I rise above my fears"? "How do I deal with suffering"? "How does one maintain hope"? "What about death"?9
Is the spiritual domain relevant to the physician's mandate as healer? Not from the perspective of the biomedical model. where health is defined as the absence of disease, that is, physiologic integrity. Yet the World Health Organization defines health as not merely the absence of disease or infirmity. but as the presence of physical, mental, and emotional well-being.10 Recent studies have clarified that emotional well-being,11 I life satisfaction,12 quality of life.13 and a sense of being healthy may be experienced even in chronic and life-threatening illness.14 For example, Kagawa-Singer found that 17 of 50 (33 per cent) cancer patients who were aware of their diagnosis considered themselves "fairly healthy," while the remaining 33 (66 per cent), including 12 who died during the study, consider themselves "very healthy." 15
TABLE 3
BASIC CONCEPTS
Spirit, from the Latin "spiritus" or breath, refers to an animating or vital principle in humans. It may be equated to the terms "Spirit," "God." and "the Sacred"31 the intent being to express a notion that brings together both the immanent and the transcendent. Bonhoeffer observed, "God is the 'beyond' in the midst of our life."32
Spirituality refers to spirit, and the human capacity to respond to the sacred in the search for meaning in life.
Sacred refers to that which is deemed holy, consecrated, esteemed, or special by virtue of an association with ultimate reality, ultimate meaning, or God, however perceived by the individual.
Soul is often used as a synonym for spirit. For many, soul refers to that aspect of the individual that is thought to be immortal.
Faith may be understood as confidence, reliance, trust, or belief without need for proof.
Religion is a system of teachings and practices concerning the living of one's faith, generally in an experience of community with others who honour the same beliefs.
Religious refers to one's degree of adherence to a religion, in both belief and practice.
Suffering is a state of anguish or pain. It is subjective and personal. It is experienced by whole persons and is not merely somatic. It may arise in any aspect of the individual. Suffering occurs with a perceived threat to one's sense of personal integrity,33 and ends when the threat passes, or when integrity is restored in another way.34 Suffering may result from art awareness of a discrepancy between one's expectations of self or life, and present experience.35-38 It may be a catalyst to growth, as it calls us out of the familiar, and challenges us to adapt through opening to new realities.
Healing entails movement toward integration, integrity, and wholeness. It may or may not involve a return to physical health. It is possible to die "healed," in the sense of having moved toward a previously unattained sense of wholeness.
"Transcendence is a response of the self that enables an individual to rise to challenging and deeper levels of In ing and endurance. It involves development of new capacities, new forms of living, new insight into living."39 In the transcendent response, the person identifies with something greater and more enduring than the self, resulting in a sense of expanded purpose, meaning, and quality of life. "Transcendence is probably the most powerful way in which one is restored to wholeness after an injury to personhood. The sufferer is not isolated by pain but is brought closer to a transpersonal source of meaning and to the human community that shares that meaning. Such an experience need not involve religion in any formal sense; however, in its transpersonal dimension it is deeply spiritual33
Spiritual care refers to an interaction that has a capacity to "heal" by virtue of its impact on the sufferer's total lived experience. It does not necessarily involve religious belief or prescription for action. "The way care is given can reach the most hidden places and give space for unexpected development."40 The quality of presence the caregiver brings may transform the simplest act into spiritual care, whether or not that was the intended outcome.41,42 Such an interaction supports a sense of integrity and personal meaning.
How are we to understand such a sense of well-being in the presence of advanced illness? Cassell has observed, "Our intactness as persons, our coherence and integrity, come not from intactness of the body, but from the wholeness of the web of relationships with self and others."16 It is precisely this interconnectedness that is fundamental to the notion of spiritual care.
Patients may indicate that they have "no spiritual needs," by which they may mean that they have no affiliation with a religion or preoccupations that they would identify as being spiritual or religious. Many of these patients, however, would claim a need for support in the quest for meaning, purpose, and hope in their experience of illness.
In their review of the scientific literature pertaining to spirituality and health,17-21 Larson et at used one core criterion for "spirituality," "religion," and "religiousness": "The feelings, thoughts, experiences, and behaviours that arise from a search for the sacred." 22,23 Summarizing their results, Larson et al observe, "There is little consensus among researchers on what constitutes 'religion' or 'religiousness,' or 'religious commitment,' not to mention the more nebulous concept of spirituality."24
Failure to distinguish between spirituality and religion may lead to the assumption that religious adherence is a reliable indicator of spirituality. In general, the studies reviewed by Larson et al reflect the association between religious adherence and health, rather than spirituality and health, as the consensus report's title suggests. This is problematic since cultural and social factors that are unrelated to personal spirituality may influence religious adherence. These include the expectations of family or other members of the community.
Another difficulty with considering spirituality and religion as synonymous is that many people distinguish between the two concepts, and identify more closely with the former. For example, Hill et at23 cite Shafranske's finding25 that only 48 per cent of a sample of clinical and counselling psychologists found religion to be very important or fairly important in their lives, whereas 73 per cent rated spirituality as very or fairly important. Religion for many may provide the song, dance, ritual, poetry and metaphor needed to experience and express the spiritual. Yet for others, such as the osteomyelitis patient C.H., and these psychologists, a vibrant spirituality that may modify the experience of illness can occur outside traditional religion.
King et al have also recognized the need to distinguish between spirituality and religion. "A narrow use of the term religious has led to a failure to appreciate the broader, metaphysical understanding of the word spiritual and the presumption that if someone does not profess a recognized religious faith they have no spiritual discernment or need.”26,27 King et al make a further distinction in using the term “philosophical beliefs" to describe "a search for an existential meaning in a particular life experience, without reference to any external power or being."28
The problem in trying to find language to express the inner life has been described by Kabat-Zinn as "trying to put words to an inward experience which is ultimately beyond labels." He says, "Perhaps ultimately, spiritual simply means experiencing wholeness and interconnectedness directly, a seeing that individuality and the totality are interwoven, that nothing is separate or extraneous. If you see in this way, then everything becomes spiritual in its deepest sense. Doing science is spiritual. So is washing the dishes. It is the inner experience that counts. And you have to be there for it. All else is mere thinking."29
If inclusive language is so problematic, why not avoid it by focusing on communication skills and psychodynamics, and by viewing meditation exclusively as a means of provoking a relaxation response?30 The answer lies in the realization that people have transformative experiences that they regard as spiritual. They experience body, mind, and spirit (or soul) as interdependent, each modifying the experience of health and of living. Thus, competent health care should demand consideration of these domains. For example, a physician's understanding of the determinants of a cancer patient's pain influences the choice of therapy. Increasing the opioid dose for pain that is unrelieved because of mental and spiritual suffering will only lead to persistence of pain or somnolence, and reduced quality of life.
More precision in discussing matters of the spirit will lead to enhanced discernment in diagnostics and therapeutics. These statements about basic concepts relating to spirituality, religion, and health are offered as a point of departure, and a catalyst for dialogue and clarification.
Acknowledgment
This project was supported by funding from M. Flanders, The Nathan Cummings Foundation, Purdue Pharma (Canada), and The R. Howard Webster Foundation.
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Received December 12, 2001
Accepted April 8, 2002
Posted by editor on September 30, 2003 10:46 AM