Reattaching the “S”
How often do you hear the following phrases either clinically, at the holiday dinner table, or streaming across your social media platform: “We are asking for your prayers”; “We know he will remain strong and keep fighting”; “God is good and will grant us a miracle”; “I am granted the strength everyday to get through this”; “If I stay the path, I know I will get better”; and “It’s in God’s hands now”.
These colloquial expressions do more than fill the empty space in conversations with people who are suffering. They constitute the unseen, untouchable, sometimes-mysterious part of illness and disease – a belief in something bigger than themselves.
Patients want to be asked about their spirituality, in fact, upwards of 94% of them do.1 How often are they asked? Not often enough. Ten percent of physician’s and 56% of mental health professionals report asking patients about their spirituality or religious practices.2, 3
For decades now in our clinical and academic work, we have been making strides to “reattach the head to the body”. In this blog post I am attempting to push you a little further: “reattach the S to the BPS-S model”. Part 1 of this 2 part series will offer a quick primer (i.e., background information, research on health outcomes), and a starter guide (i.e., assessments and measures to be used in practice and research). Part 2 will follow up by focusing on collaborative practices with spiritual providers within the healthcare system (e.g., chaplains).
From BioMed to Biopsychosocial-Spiritual
Prior to 1977, illness was generally thought to be influenced by deviations in biological norms. Thus, clinicians relied primarily on the Biomedical Model. Engel4 developed the Biopsychosocial Model (BPS) to expand the picture of illness beyond the biological to include psychological and social dimensions. Wright, Watson and Bell5 later expanded BPS to incorporate Spirituality as an equally important influencer in health and illness. The outcome was the inception of the model that clinicians, academics, and researchers ascribe to as the primary epistemology in the practice of family centered health care - the Biopsychosocial-Spiritual Model (BPS-S).
Spirituality/Religion: and/or & both/and
Due to space restrictions, this post will not fully go into the differences and similarities of spirituality and religion. For a comprehensive review of how these terms are used and researched, refer to Koening.6 Research uses the terms spirituality and religion interchangeably so much so, that there is contamination and confounding constructs in the measures. Given the overlap, religion and spirituality will be used interchangeably and will be identified as “Spirituality” here on out.
Spirituality: Physical Health and Health Behaviors
Research has shown that those who self report higher levels of spirituality have healthier diets, healthier weight, and less risky sexual behaviors. Indirect associations between spirituality and physical health include positive outcomes for the following conditions: coronary heart disease, hypertension, stroke, dementia, immune function, cancer, pain and somatic symptoms, and mortality. How spirituality influences physical health has generally been researched via three pathways, through improved psychological health, increased social involvement, and improved health behaviors.
Spirituality: Mental Health
Levels of spirituality and mental health outcomes have been shown to have a significant inverse relationship. Spirituality has been shown to directly or indirectly influence various mental health pathways such as: use in coping with adversity, positive emotions, well-being/happiness, hope, optimism, meaning and purpose, sense of control, depression, anxiety, suicide, and substance abuse. Overall, spirituality influences mental health through many different mechanisms and has a substantial evidence base supporting its importance. Researchers attribute these impacts via the following mechanisms: spirituality provides resources for coping with stressful events, it provides guidelines for how to live life such as doctrines, and it promotes an altruistic, compassionate stance in life and encourages contact with community.
You Can’t Know If You Don’t Ask
Not too many moons ago I stumbled over how to assess spirituality in the clinical setting. Even with the presence of prompting question on the diagnostic assessment, I still threw out: “you’re religious right?” nodding my head in hopes we wouldn’t have to “go there”. It wasn’t until I was steeped in a family medicine residency program serving a high-risk population (e.g., multiple health disparities, trauma histories) that I made an intentional move to ask more purposeful questions regarding the role of religion and spirituality in my patient’s illness and suffering narratives.
Far too many of my patients would say things such as “if I pray enough God will cure my diabetes” and “I knew I was destined to get this disease, I was not a good person in my early life”. It dawned on me; no matter how many BPS interventions we could produce for these patients, their deeply seeded beliefs - intertwined with spirituality - could be impeding any actual healing. And, we would never know, if we didn’t ask.
First things first, we have to ask ourselves why we are not asking. We need to dive in and assess our own biases. What’s keeping us from asking? It is our own comfortability, our own lack of knowledge, or is it an unfamiliarity in resources and referral pathways? Second, we must recognize it is our requirement to ask. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)7 sustain that “Physicians, therapists, nurses, and clinical pastoral staff should receive training on the value of spiritual assessment and the tools that should be used to assess a patient’s spirituality” (p. 6).
JCAHO7 “requires organizations to include a spiritual assessment as part of the overall assessment of a patient to determine how the patient’s spiritual outlook can affect his or her care, treatment, and services” (p. 6). It is the clinician who is responsible for doing these initial screeners. If spiritual needs are discovered, a referral to pastoral care is made to further address these needs (stay tuned for Part 2 of this blog series for more information on these transactions). Lastly, a gentle reminder that any assessment of spirituality should be patient and family-centered and patient driven. Coercion is a no-no, and the patient should feel in control of the pace and depth they reveal information pertaining to spirituality.
In conclusion, the impacts of spirituality on health outcomes are becoming more apparent. As clinicians and researchers looking to expand upon the principles of family centered health care, it is essential that we make a purposeful effort to reattach the “S” to the “BPS” model. Below are a list of resources and measures that may be used to assess and measure spirituality.
FICA Spiritual History Tool
HOPE Approach so Spiritual Assessment
The Open Invite Mnemonic Assessment (page 3)
Duke University Religion Index (DUREL)
Spiritual Assessment Inventory (SAI)
Brief Multidimensional Measure of Religiousness and Spirituality (BMMRS)
1. Williams JA, Meltzer D, Arora V, Chung G, Curlin FA. Attention to inpatients’ religious and spiritual concerns: predictors and association with patient satisfaction. Journal of General Internal Medicine. 2011;26;1265-1271.
2. Curlin FA, Chin MH, Sellergren SA, Roach CJ, Lantos JD. The association of physicians’ religious characteristics with their attitudes and self-reported behaviors regarding religion and spirituality in the clinical encounter. Medical Care. 2006;44;5;446-453.
3. Curlin FA, Lawrence RE, Odell S. Religion, spirituality, and medicine: psychiatrists’ and other physicians’ differing observations, interpretations, and clinical approaches. American Journal of Psychiatry. 2007;164;12;1825-1831.
4. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196;4286;129-136.
5. Wright LM, Watson WL, Bell JM. Beliefs: The Heart of Healing in Families and Illness. New York, NY: Basic Books; 1996.
6. Koenig HG, George LK, & Titus P. Religion, spirituality, and health in medically ill hospitalized older patients. Journal of the American Geriatrics Society. 2004;52;4;554-562.
7. Joint Commission on the Accreditation of Healthcare Organizations. Evaluating your spiritual assessment process. 2005. http://www.professionalchaplains.org/files/resources/reading_room/ evaluating_your_spiritual_assessment_process.pdf. Accessed July 10, 2017.
Stephanie Trudeau, M.S., LAMFT, is a doctoral candidate at the University of Minnesota in the Department of Family Social Science's Couple and Family Therapy program. Her clinical and research interests include family medicine, family coping with chronic illness and end of life, provider well-being, and integrated behavioral healthcare model design, development, and evaluation. She credits her two little monkeys for being the most influential teachers of life, love, play, and well-being.