Addressing Spirituality in Health Care:Perspectives from 35 Years of Research and Practice

Kenneth I. PargamentDepartment of Psychology

Bowling Green State Universitykpargam@bgsu.edu

Grand Rounds Presentation to Institute for Spirituality and HealthSeptember 30, 2010

My thanks to the John Templeton Foundation and Fetzer Institute for their support of this research

Message 1:There are good reasons to address

spirituality in health care

Message 1:There are good reasons to address

spirituality in health care(or)

People interested in spirituality and health are as sane as anyone else

Why Consider Spirituality and Health?

Spirituality can be part of the solution to problems

Spiritual Meditation among Patients with Vascular Headaches

(Wachholtz & Pargament, 2005)

83 college students with vascular headaches according to criteria of the International Headache Society (1988)

Random assignment to four groups Spiritual Meditation (e.g., “God is peace,” “God is joy” ) Internally Focused Secular Meditation (“I am content,” “I am joyful”) Externally Focused Secular Meditation (“Grass is green,” “Sand is soft”) Progressive Muscle Relaxation

Practice technique 20 minutes per day for four weeks Assess changes in headache frequency, pain tolerance, affect,

headache control efficacy

Headache Occurrence Prior to and during the Intervention

Time

21

Hea

dach

es15

14

13

12

11

10

9

8

GROUP

Spiritual Meditation

Internal Secular

External Meditation

Relaxation

Diary Analyses of Headache Occurrence by Group and Time

Time Period

Day 26-30

Day 21-25

Day 16-20

Day 11-15

Day 6-10

Day 1-5

Hea

dach

es2.2

2.0

1.8

1.6

1.4

1.2

1.0

.8

.6

GROUP

Spiritual Meditation

Internal Secular

External Meditation

Relaxation

Pain Tolerance by Group and Time

TIME

21

Pain

Tol

eran

ce (s

econ

ds)

120

110

100

90

80

70

60

50

40

30

GROUP

Spiritual Meditation

Internal Secular

External Meditation

Relaxation

Migraine Specific Quality of Life by Group and Time

Time

21

MSQ

L83

82

81

80

79

78

77

76

75

GROUP

Spiritual Meditation

Internal Secular

External Meditation

Relaxation

Why Consider Spirituality and Health?

Spirituality can be part of the solution to problems

Spirituality can be part of the problem itself

Divine Struggles “I’m suffering, really suffering. My illness is

tearing me down, and I’m angry at God for not rescuing me, I mean really setting me free from my mental bondage. I have been dealing with these issues for ten years now and I am only 24 years old. I don’t understand why he keeps lifting me up, just to let me come crashing down again” (undergraduate dealing with bipolar illness).

Assessing Religious Struggles:Illustrative Items from RCOPE

I wonder if God has abandoned me (Divine). I feel angry at God (Divine). I feel abandoned by people in my church (Interpersonal). I disagree with family and friends about spiritual matters

(Interpersonal). I feel confused about my faith (Intrapsychic). I act inconsistently with my religious beliefs

(Intrapsychic).

Correlates of Religious Strugglesamong Hindus

(Tarakeshwar et al., 2003)

Depression r = .40 Life Satisfaction r = -.40Marital Satisfaction r = -.27

Correlates of Religious Struggles among Jews

(Rosmarin, 2008)

Depression r = .34Anxiety r = .27Worry r = .15

Religious Coping among Medically Ill Elderly Patients: A Two-Year Longitudinal Study

(Pargament, Koenig, Tarakeshwar, & Hahn, 2001, 2004)

596 hospitalized patients over 55 Duke University Medical Center Durham VA Medical Center 1996-1997 Two year follow-up 176 deceased

Measures Number of Active Diagnoses Subjective Health Severity of Illness Scale (ASA) Activities of Daily Living (ADL) Mini-Mental State Exam (MSE) Depressed Mood Quality of Life Positive Religious Coping and Religious Struggle Global Religious Measures (Church Attendance, Private

Religiousness, Religious Importance) Demographics

Consequences of Religious Struggles Struggles with the divine predicted increases in

depressed mood, declines in physical functional status, declines in quality of life after controls

Chronicity of religious struggles is added risk factor

Struggles with the divine predicted 22-33% greater risk of mortality after controls

Specific Religious Struggle Predictors of Mortality

“Wondered whether God had abandoned me” (RR = 1.28)

“Questioned God’s love for me” (R = 1.22) “Decided the devil made this happen” (R = 1.19)

Why Consider Spirituality and Health?

Spirituality can be part of the solution to problems Spirituality can be part of the problem itself

People want spiritually sensitive health care

Spiritual Needs of PatientsLindgren and Coursey (1995) 65% of people with serious mental illness would

like to talk about spiritual concerns with therapists 35% talk to their therapists about spiritual concerns

Why Consider Spirituality and Health?

Spirituality can be part of the solution to problems Spirituality can be part of the problem itself People want spiritually sensitive health care

Spiritually sensitive care is ethical care

Ethical Principles of Psychologists and Code of Conduct (APA , 2002)

“Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups” (p. 1064).

Message 2:Studying spirituality and health is

challenging work

Message 2:Studying spirituality and health is

challenging work(or)

This is not a field for the faint-hearted

The Challenges of StudyingSpirituality and Health

Emotionality

“God is Not Great: How Religion Poisons Everything”

(Hitchens, 2007) “Revelation: The Nightmare of the ‘Old’

Testament” “The ‘New‘ Testament Exceeds the Evil of the Old

One”

The Challenges of StudyingSpirituality and Health

Emotionality

Methodological problems

Footprints of Faith

The Challenges of StudyingSpirituality and Health

Emotionality Methodological problems

Skepticism in the academy

Message 3: Spirituality is as rich and complex a

dimension as any other dimension of life.

Message 3:Spirituality is as rich and complex a

dimension as any other dimension of life

(or) We are spiritual onions.

The Richness of Religion and Spirituality

Religion and spirituality as multi-dimensionalMulti-dimensional motivations

The religion rooted in social pressureThe religion rooted in guiltThe religion rooted in intrinsic spirituality

Multiple pathwaysDwelling vs. seeking

Multiple understandings of the sacredLarge gods vs. small gods

The Appropriate (but Unglamorous Question)

“How helpful or harmful are particular forms of religious expression for particular people dealing with particular situations in particular social contexts according to particular criteria of helpfulness and harmfulness” (Pargament, 2002).

The Richness of Religion and Spirituality

Religion and spirituality as multi-dimensional

Religion and spirituality as multi-level

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Message 4: Spirituality can be integrated into

health care.

Message 4:Spirituality can be integrated into

health care (or)

Truly holistic health care is bio-psycho-social-spiritual.

Addressing Spirituality in Health Care

Good clinical skillsListening with interestA willingness to ask questionsA non-judgmental attitudeAn openness to being taught

Self-awarenessWillingness to engage in interdisciplinary care

Effectiveness of Chaplaincy(Bayer et al., 2007)

Randomized clinical trial of 166 CABG patientsHalf assigned to chaplaincy intervention (5 visits –

44 minutes total time) and half to control Intervention group shows significantly greater

increases in positive religious coping and significantly greater decreases in negative religious coping (spiritual struggles)

No differences on anxiety and depression

Winding Road: GoalsArticulate and normalize religious struggles Facilitate development of personal spiritual

identityBroaden and deepen understanding of sacredBroaden coping resources Facilitate acceptance of struggles

Winding Road: Illustrative Activities

Write and share spiritual autobiography Share religious strugglesCreate religious genogramVisualize ideal older spiritual self Share a sacred object with the group Surrender ritualWrite a group-lament to God

Winding Road: Quantitative ResultsDecline in Religious Struggles < p. 01Decline in Negative Affect < p. 05Decline in Psychological Distress < p. 01Decrease in Stigmatization < p. 05Increase in Positive Affect < p. 05Increase in Behavioral Control < p. 05Increase in Emotional Control < p. 05Increase in Religious Value-Behavior

Congruence < p. 05Increase in Acceptance from God < p. 05

Winding Road: Qualitative Findings

Growth and Transformation“I had a lot of rash emotions coming into this experience. It’s definitely calmed me down a little bit. I look at my struggles as more of a positive. It is a learning and growing experience. I’ve matured in my view of the struggle – that it doesn’t have to be resolved right now. But I got a lot of new ideas, that I can come back to in the future if I need to. I’ve been able to get a lot of my struggle sorted out and get a clearer idea of what’s going on. Now it’s not always pestering me. I was able to detangle it a little bit… Now it’s not so much of a struggle as an evolution.”

Stress is a natural part of development.

Without stress we would not grow.

Stress can happen at any time.

Stress can take many forms.

Stress is part of life!

Stress in the Army Can Take on Many Forms:

Family: relationships with family member

Social: problems with friends

Emotional: depression, combat operational stress

Physical: intense PT, regular drill, weight guidelines

You might also experience Spiritual Stress, or

Struggles of the Human Spirit.

Greater Purpose

Some soldiers believe in a greater power or purpose in the universe.

They may trust that their struggles have a larger meaning.

Soldiers who believe in a greater power might also feel confident that their situation is under control.Example: Study of US soldiers in Kosovo

Greater Purpose (see 1:45)

During her deployment, Sergeant Chen has not had as much contact with her husband and children as she would like. She often feels very distant from them and wonders if they miss her. It doesn't seem fair that she has to be separated from her family.

Think of at least two ways Sergeant Chen could make sense of her loneliness and type them in the space provided.

1) Growth Experience 5) An Imperfect World2) Developing Gratitude 6) Recognizing Human Destructiveness3) Time of Testing 7) Greater Purpose4) Remembering the Mission 8) Ultimate Justice