Addressing Spirituality in Healthcare
eSolutions: June 2014
Feature article: Addressing Spirituality in Healthcare
Grantee Feature: Adult and Child Mental Health Center: Supporting Wellness through HOPE
Quick Tips: 6 Steps to Address Spirituality in Healthcare
Featured resource: SAMHSA Wellness resources
“If spirituality in any form matters to the peer I'm working with, s/he will bring it up when ready. And I do what I do with any other area of recovery under discussion -- listen first, then get into dialogue about how spirituality can help with recovery. I've worked with Christians of every stripe, Buddhists, a Pagan, a Wiccan, a Muslim, and a good number who say they're spiritual but aren't into organized religion of any kind. Regardless, I've found that spirituality is very important to a lot of people. I work with them to try to have their spirituality, however it's expressed, work for them and not against them.”
The exponential growth of scientific knowledge relevant to medical practice over the past 150 years has led to an increased focus on such tools as evidence-based medicine and standardized brief interventions. Medical practice has become centered on the task of choosing treatments proven effective through rigorous study, which has left less room for what some call the “art of medicine” and for the inclusion of factors such as spirituality in clinical practice.
However, this does not mean that spirituality is not important. Almost every concept of personhood -- psychological, philosophical, or theological (spiritual) -- affirms that the person is a multifaceted reality that is much more than the physical body (S Kliewer, J Saultz, 2005). Integrating Spirituality into Treatment defines health as having three domains -- suffering, function, and coherence. Suffering is the absence of health, function describes ability (or lack thereof), and coherence relates to inner peace. When working with a client to achieve outcomes, one must address all three factors: the illness itself, its impact on functionality, and the spiritual or existential framework the person embraces.
This third component of health is profoundly woven into our current view of wellness. Many of SAMSHA’s Eight Dimensions of Wellness relate to the concept of coherence, including the emotional, the social, and above all, the spiritual. Spiritual wellness is related to the dimension having to do with “expanding our sense of purpose and meaning in life.”
In my small rural county in Oregon, we have been working to bring together a wide variety of providers and programs so as to address all of these important domains. A key element in this effort has been the introduction of behavioral health professionals into the system of care. Behaviorists are trained to incorporate interventions that address not only the client’s primary health needs, but other factors that can be either a barrier or a resource for recovery, including spirituality. There are many brief interventions that behaviorists can use to help people deal with problematic spiritual stances and to help them develop and access inner spiritual resources.
An example from a Patient-Centered Medical Home that drives home the importance of spirituality to recovery was a woman in her forties who had experienced a traumatic brain injury (TBI) and had mental health issues relating back to a traumatic childhood. She had some losses in cognitive function and a belief that she was not “up and active” or “producing.” For her, this was a deeply spiritual issue, and her spiritually-centered feelings of worthlessness hindered her ability to accept her health issues, work on recovery, and move forward in a positive and productive manner. Robbed of both energy and motivation, she was not actively participating in her own recovery. Her spiritual issues were at the center of a profound depression that sometimes left her unable to leave her bed.
Using the Patient Activation Measure (PAM), the behaviorist was able to ascertain that the woman was not motivated, and by asking open ended questions related to motivation, was able to determine that much of the woman’s inability to move toward recovery was rooted in the realm of “spirituality.” Using a brief screening tool, the HOPE questionnaire, the behaviorist was able to get a better understanding of the woman’s spiritual framework. The HOPE tool consists of four simple questions: H – What are your sources of hope, meaning, comfort, strength, peace, love and connection: O – Do you participate in an organized religion; P: What are your personal spirituality and practices; and E – How does your spirituality affect life issues, end of life issues, and your view of medical care?
Once it became clear that spirituality was impacting her motivation for participating in her treatment, the behaviorist was able to connect her with a therapist. Using a standard cognitive behavioral approach (CBT) and incorporating a spiritual focus, the therapist was able to help her let go of her negative cognitions and move forward in her treatment. Her outcomes included increased motivation (per the PAM), engagement in care, planning and working towards weight loss, and finishing and submitting her resume for jobs.
It is not always easy to incorporate spirituality into health care. But with the inclusion of behaviorists in integrated mental health and primary care, we are moving closer to an approach that addresses the whole person.
Anandarajah G, and Hight E. Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment. American Family Physician. 2001 Jan 1;63(1):81-89.
Hibbard JH, J Stockard J, Mahoney ER, Tusler M. Development of the Patient Activation Measure (PAM): conceptualizing and measuring activation in patients and consumers. Health Serv Res. 2004 Aug;39(4 Pt 1):1005-26.
Kliewer S, Saultz J, Healthcare and Spirituality, Radcliffe Medical Press, Oxford, UK, 2006
Miller WR (ed), Integrating Spirituality into Treatment, American Psychological Association, Washington, DC, 1999
“Over the years, my heart has been so touched by listening to stories about how spirituality and recovery are closely connected for many people. These stories have shaped my beliefs about spirituality more than any other experience I have had, and I am so grateful to people who have been willing to share.”
-Leslie Marie, University of Kansas
James A. Dilger, Team Leader and Clubhouse Director, Adult and Child Mental Health Center
Integrated primary care and behavioral health providers know how the areas of whole health and wellness affect each other. We also know that for many people, having a safe, encouraging, non-judgmental forum to express views, ask questions, and have a connection with others with similar desires and questions is critical for whole health recovery. For many clients, this connection is most important for the dimension of wellness of spirituality.
This dimension of wellness for many is often neglected - not necessarily conscious or intended neglect, but relegated to an individual part of the person’s recovery instead of through active attention. Providers do not address the spiritual dimension by simply checking off a box on an assessment form or identifying a particular religious group someone has/had an affiliation with at some time in their lives. Creating a forum for the expression of personal (and possibly vulnerable) beliefs is paramount in the recovery process.
The Adult and Child Mental Health Center, a SAMHSA Primary and Behavioral Health Care Integration (PBHCI) grantee, heard from clients who identified the importance of spirituality in their recovery, many who ranked their spiritual health as a higher priority than their physical or mental health. It became rather apparent that people were “missing” something from a medical model perspective. To address this gap, staff and clients worked together to find and review any existing spirituality curricula to address clients’ questions, concerns, and desires.
This led to the development of our spirituality group, the Heartfelt Opportunities for Personal Enhancement (HOPE) program. To support and drive the group experience, members and staff are flexible and open to developing our own “curriculum.” The group members identify core concerns, areas of interest for discussion, and create worksheets. The effort is a collaborative process between clients, peers, and other staff. This collaborative effort has established a level of ownership with the group, its existence, and the continued quality of “curriculum” presented.
Areas explored include the idea of life after death; the notion of eternal existence (or not); individual choices versus fate; quantifying the existence of sin, forgiveness, and grace; and how to deal with guilt.
There was no magic involved with establishing this group. The group is successful because the agency is supportive and understanding, acknowledges this dimension to healthy living, and because of the connection of people (clients, peers, and staff) to support and encourage each other. The balance of someone’s belief system and refraining from proselytizing is critical.
Members have reported that they appreciate being able to talk about their experiences and beliefs without having questions asked such as, “Are you taking your meds?” or “Do you need to see the psychiatrist?” The group has encouraged increased levels of trust and hope among clients and staff.
Many of us experience some sort of spirituality. Expressing, connecting to, and defining these feelings and experiences is an integral piece of people’s recovery journey. Our journey continues, developing and establishing relationships along the way, connecting to people as just that - people.
How does your center address spirituality? Share your story, email firstname.lastname@example.org.
Spiritual beliefs are tremendously personal, and spirituality means something different to everyone. Exploration of a person’s spirituality in healthcare can happen when beginning the process of gathering and sharing information, in a moment of crisis or loss, or as part of a long-term process of client engagement. Here are some ways to address spirituality appropriately within healthcare.
- Understand that spirituality can be an important component of every client's physical well-being and mental health. Respect a person's privacy regarding spiritual beliefs, and don't impose your own beliefs on others.
- Promote competencies of spiritual care that support respectful, non-judgmental attitudes.
- Use tools like the FICA Spiritual History Tool or the HOPE Questionnaire to gather information on a client’s spiritual beliefs. In primary care, address spirituality at each complete physical examination and continue addressing it at follow-up visits as appropriate.
Ask questions* to engage individuals in the spiritual aspect of their health, such as:
- Religious or spiritual issues often influence how patients deal or cope with [condition]. Some people find their spiritual beliefs to be very helpful, while others do not find them helpful or never real think about these things at all. I would be interested to understand how you feel about this?
- What part if any, do your spiritual beliefs play in how you have been dealing with [define disease]?
- Are there ways in which you have/can find a sense of meaning and peace through all of this?
- Is there anyone else you can talk to?
- Use active listening skills to find out how to incorporate this information into an individual’s self-management goals.
- Make referrals to chaplains, spiritual directors, or community resources as appropriate.
There are many ways to address spirituality as part of the whole health of the people you serve. Visit our Health and Wellness pages for further resources to support all dimensions of health.
* Sample questions from Kliewer SP, & Saultz J, Healthcare and Spirituality, Abingdon, England: Radcliffe Medical Press, 2006
SAMHSA’s Wellness web pages explain and explore all eight dimensions of wellness. Check them out for wellness-related training and educational materials (posters, brochures, fact sheets) to inform providers, consumers, and policymakers.
The Centers for Disease Control and Prevention (CDC) released six new funding opportunity announcements for chronic disease prevention and health promotion. CDC is concentrating resources on key risk factors and major diseases that contribute substantially to suffering, disability, and premature death among Americans.
Improving the Physical Health of Adults with Serious Mental Illness reviews key findings from the evaluation of the implementation of the SAMHSA Primary and Behavioral Health Care Integration (PBHCI) program, consumer outcomes, and program features associated with consumer-level processes and outcomes of care.
The CDC’s Division of Community Health has a variety of resources on addressing tobacco use, obesity, and other chronic conditions. Visit the media center for materials to promote healthy living, the Communities Putting Prevention to Work resource center provides tools to support environmental changes that address obesity and tobacco use, check out a recent webinar about its Community Transformation Grants program with awardee Los Angeles County Department of Public Health on strategies used to address tobacco cessation for individuals served in outpatient and inpatient settings.
The Agency for Healthcare Research and Quality released the National Healthcare Quality and Disparities Reports on the latest findings on quality of and access to healthcare; trends in effectiveness, timeliness, and efficiency of care; and assess patient safety and person-centeredness.
Behavioral health organizations interested in implementing screening for substance use for adolescents can apply to participate in the Reducing Adolescent Substance Abuse Initiative by July 11. Selected organizations will participate in a 2-year learning community to help providers systematically implement an SBIRT protocol to address substance use among adolescents (ages 15 – 22).
Individuals with behavioral health conditions experience much higher rates of preventable and treatable viral hepatitis than the general population, and viral hepatitis is frequently undetected for years. Join CIHS on July 9 to learn practices for the effective identification, treatment, and prevention of viral hepatitis. Topic areas will include: epidemiology, public health and psychological issues and concerns, strategies for outreach, and patient engagement in treatment.