george fitchett december 2006 religious struggle and its impact on health: implications for ministry
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George FitchettDecember 2006
Religious Struggle and Its Impact on Health: Implications for Ministry
Outline• Definition • Evidence from Research
• harmful effects• prevalence• determinants
• Screening• Case Examples• Implications for Spiritual Care
Religious StruggleA woman in her fifties with advanced cancer
told a chaplain, “Why? Why me? I just can’t figure it out. And I get so depressed that I just want to
give up on life altogether, you know? And I’m so very angry at God. So angry. I
refuse to speak to Him. You know what I mean?”
What is Religious Struggle?Religious struggle is having high spiritual
needs and low spiritual resources with which to address those needs.
Religious struggle is marked by underdeveloped, conflicted, overwhelmed, or negative spirituality.
Negative Religious Coping (Brief RCOPE)
not at all
some-what
quite a bit
a great deal
8. I wondered whether God had
abandoned me. 0 1 2 3
9. I felt punished by God for my
lack of devotion. 0 1 2 3
10. I wondered what I did for God to
punish me. 0 1 2 3
11. I questioned God’s love for me. 0 1 2 3 12. I wondered whether my church
had abandoned me. 0 1 2 3
13. I decided the devil made this
happen. 0 1 2 3
14. I questioned the power of God. 0 1 2 3 Pargament et al, 1998
Religious Struggle: Other Measures
A. Difficulty Forgiving God
1. I sometimes find it difficult to forgiveGod for things that happen.
strongly stronglyagree disagree1 2 3 4 5 6
2. At times I feel frustrated ordisappointed with God. 1 2 3 4 5 6
3. Have you ever found it difficult toforgive God for something?
never manytimes
0 1 2 3
B. Feelings of Alienation from GodTo what extent are you having each ofthese experiences?
not at all extremely0 1 2 3
1. Difficulty trusting God 0 1 2 32. Feeling that God is far away 0 1 2 33. Difficulty believing that God exists 0 1 2 34. Feeling that your faith is weak 0 1 2 35. Feeling abandoned by God 0 1 2 3
JJ Exline et al, 1999.
Religious Struggle: Early Models
• Stoddard, 1993• spiritual concern, spiritual distress, spiritual despair
• Berg, 1994, 1999• Spiritual Injury Scale
• NANDA• Spiritual distress (1978)• Potential for enhanced spiritual well-being (1994)• At risk for spiritual distress (1998)
• Other Chaplaincy Models• Derrickson, 1994-5• Hodges, 1999• Wakefield & Cox, 1999
Spiritual Injury ScaleHow often do you feel guilty over past behaviors?
Does anger or resentment block your peace of mind?
How often do you feel sad or experience grief?
Do you feel that life has no meaning or purpose?
How often do you feel despair or hopeless?
Do you feel that God/life has treated you unfairly?
Do you worry about your doubts/disbelief in God?
Do you worry about or fear death?
© Gary Berg. www.spiritualassessment.com.
How often do you feel guilty over past behaviors?
Does anger or resentment block your peace of mind?
How often do you feel sad or experience grief?
Do you feel that life has no meaning or purpose?
How often do you feel despair or hopeless?
Do you feel that God/life has treated you unfairly?
Do you worry about your doubts/disbelief in God?
Do you worry about or fear death?
© Gary Berg. www.spiritualassessment.com.
Do you worry about or fear death?
© Gary Berg. www.spiritualassessment.com.
Spiritual Distress: NANDADefinition
Disruption in the life principle that pervades a person's entire being and that integrates and transcends one's biological and psychosocial nature.
Related factors [etiology] Separation from religious and cultural tiesChallenged belief and value system (e.g., result of moral or ethical
implications of therapy or result of intense suffering)
Defining characteristicsExpresses concern with meaning of life and death and/or belief systemAnger toward God (as defined by the person)Questions meaning of sufferingVerbalizes inner conflict about beliefsUnable to choose or chooses not to participate in usual religious practicesRegards illness as punishmentDoes not experience that God is forgiving
Anger With God and Rehabilitation Recovery
9.2 8.9
10.7
14.5
0123456789
1011121314151617
Anger (n=6) No anger (n=89)
So
ma
tic
Au
ton
om
y (
AD
L)
Admission
Follow-up
Fitchett et al, 1999.
Religious Coping and Health Status in Hospitalized Older Adults (N= 577)
Negative Religious Coping
Depressed Mood
Quality of Life
Self-Rated Health
Punishing reappraisal
Demonic reappraisal
Reappraisal of God's Power
Passive religious deferral
Self-directed religious coping
Spiritual discontent
Interpersonal religious discontent
Pleading for direct intercession
.25***
.17***
.15***
.09*
.22***
.22***
.27***
.10*
-.17***
-.10**
-.16***
-.06
-.19***
-.18***
-.21***
-.04
-.12**
-.12**
-.12**
-.14**
Values are standardized betas from regression models that included demographic variables, and for depressed mood and quality of life, severity of illness. *p<.05, **p<.01, ***p<.001 Koenig et al., 1998, Jnl of Nervous and Mental Disorders
Any Religious Struggle At
Group Baseline 2 Year
Follow-Up Number Percent Outcome at Follow-Up*
No Struggle No No 94 39% reference group
Transitory Struggle Yes No 40 17% ns
Acute Struggle No Yes 44 18% ns
Chronic Struggle
Yes Yes 61 26% > depression > functional limitations < quality of life
Two Year Change in Religious Struggle and Its Effects on Outcomes Among Elderly Medically Ill Patients
*Models adjusted for demographic factors and baseline values.
Source: Pargament et al, Journal of Health Psychology, 2004
Religious Struggle as a Predictor of Mortality (N=567)
Pargament et al.,2001, Arch Intern Med
Model Adjusted RR 95% CI1. Religious struggle adjusted for the
effects of demographic factors, physicalhealth, mental health, and positivereligious coping
2. Model 1, plus frequency of church attendance
3. Single Religious Struggle Items
“Wondered whether God had abandoned me”
“Questioned God’s love for me.”
“Decided the devil made this happen.”
1.06
1.06
1.28
1.22
1.19
1.01-1.11
1.00-1.10
1.07-1.50
1.02-1.43
1.05-1.33
Religious Struggle and Emotional Distress
Diabetic Outpatients
CHF Outpatients
Oncology Inpatients
psychological distress (PAID) .31*
depressed mood (CMDI) .35**
emotional symptoms (LHFQ) .30*
depression (POMS) .42*** .22*
anxiety (POMS) .32* .16
hostility (POMS) .29* .16
emotional well-being (FACT-G) -.23*
*p<.05, **p<.01, ***p<.001
Values are partial correlations, adjusted for age and gender.
From Fitchett et al, 2004
Conflict About Prayer• Unanswered prayer (13/30)• Hesitancy about petitionary prayer (10/30)• Conflict about control (9/30)• Questions about the nature of God (8/30)• Questions about meaning and theodicy (8/30)• Bargaining (5/30)• Doubt about the efficacy of prayer (4/30)• Doubt about personal spirituality and worth (4/30)• Praying the “right” way (4/30)
20% of patients had four to six types of spiritual conflict associated with praying about their cancer.
Taylor, et al., 1999
Study Sample, Design Results
Peteet, 1985
n=50 cancer patients seen in psychiatric consultation, 76% with adjustment disorder with depressed or anxious mood.
64% of patients had a religious dimension to their concern, including: -recent loss of religious support; -pressure from others to adopt a different religious position; -unusual religious beliefs; -conflict between religious views and view of the illness; -preoccupation with the meaning of life and illness.
Taylor et al, 1999
n=30, 14 men, 16 women, avg age 58 years, 73% white, variety of religious backgrounds
20% of patients had four to six types of spiritual conflict associated with praying about their cancer, 33% had one to three types of spiritual conflict.
Moadel et al., 1999
n=248 out-pts in NYC, 48% white, 25% African-Am, 19% Hispanic, 58% Christian, 15% Jewish, 59% women, 50% currently receiving Rx.
75% of an ethnically diverse sample of cancer patients had one or more spiritual needs, 31% had five or more needs, including finding hope, meaning or peace of mind, or finding spiritual resources.
Gall et al, 2002 n=39 women with breast cancer.
5/39 women (13%) report ambivalent or negative relation with God.
Manning-Walsh, 2005
n=100 breast cancer patients recruited through Internet; majority Stage I/II, avg age 46 years, 93% white, 30% some graduate edu, avg 10 mnths since dx, > 50% completed tx.
In unadjusted models, negative religious coping (Brief RCOPE) inversely associated with EWB (r = -0.34**), composite QoL (r = -0.36**), and life satisfaction (LS, r = -0.31**). In models adjusted for age, the associations with QoL and LS remain significant.
Religious Struggle and Psychological Adjustment Among Cancer Patients
Study Sample, Design Results
Peteet, 1985
n=50 cancer patients seen in psychiatric consultation, 76% with adjustment disorder with depressed or anxious mood.
64% of patients had a religious dimension to their concern, including: -recent loss of religious support; -pressure from others to adopt a different religious position; -unusual religious beliefs; -conflict between religious views and view of the illness; -preoccupation with the meaning of life and illness.
Taylor et al, 1999
n=30, 14 men, 16 women, avg age 58 years, 73% white, variety of religious backgrounds
20% of patients had four to six types of spiritual conflict associated with praying about their cancer, 33% had one to three types of spiritual conflict.
Moadel et al., 1999
n=248 out-pts in NYC, 48% white, 25% African-Am, 19% Hispanic, 58% Christian, 15% Jewish, 59% women, 50% currently receiving Rx.
75% of an ethnically diverse sample of cancer patients had one or more spiritual needs, 31% had five or more needs, including finding hope, meaning or peace of mind, or finding spiritual resources.
Gall et al, 2002 n=39 women with breast cancer.
5/39 women (13%) report ambivalent or negative relation with God.
Manning-Walsh, 2005
n=100 breast cancer patients recruited through Internet; majority Stage I/II, avg age 46 years, 93% white, 30% some graduate edu, avg 10 mnths since dx, > 50% completed tx.
In unadjusted models, negative religious coping (Brief RCOPE) inversely associated with EWB (r = -0.34**), composite QoL (r = -0.36**), and life satisfaction (LS, r = -0.31**). In models adjusted for age, the associations with QoL and LS remain significant.
Religious Struggle and Psychological Adjustment Among Cancer Patients
Study Sample, Design Results
Peteet, 1985
n=50 cancer patients seen in psychiatric consultation, 76% with adjustment disorder with depressed or anxious mood.
64% of patients had a religious dimension to their concern, including: -recent loss of religious support; -pressure from others to adopt a different religious position; -unusual religious beliefs; -conflict between religious views and view of the illness; -preoccupation with the meaning of life and illness.
Taylor et al, 1999
n=30, 14 men, 16 women, avg age 58 years, 73% white, variety of religious backgrounds
20% of patients had four to six types of spiritual conflict associated with praying about their cancer, 33% had one to three types of spiritual conflict.
Moadel et al., 1999
n=248 out-pts in NYC, 48% white, 25% African-Am, 19% Hispanic, 58% Christian, 15% Jewish, 59% women, 50% currently receiving Rx.
75% of an ethnically diverse sample of cancer patients had one or more spiritual needs, 31% had five or more needs, including finding hope, meaning or peace of mind, or finding spiritual resources.
Gall et al, 2002 n=39 women with breast cancer.
5/39 women (13%) report ambivalent or negative relation with God.
Manning-Walsh, 2005
n=100 breast cancer patients recruited through Internet; majority Stage I/II, avg age 46 years, 93% white, 30% some graduate edu, avg 10 mnths since dx, > 50% completed tx.
In unadjusted models, negative religious coping (Brief RCOPE) inversely associated with EWB (r = -0.34**), composite QoL (r = -0.36**), and life satisfaction (LS, r = -0.31**). In models adjusted for age, the associations with QoL and LS remain significant.
Religious Struggle and Psychological Adjustment Among Cancer Patients
Study Sample, Design Results
Peteet, 1985
n=50 cancer patients seen in psychiatric consultation, 76% with adjustment disorder with depressed or anxious mood.
64% of patients had a religious dimension to their concern, including: -recent loss of religious support; -pressure from others to adopt a different religious position; -unusual religious beliefs; -conflict between religious views and view of the illness; -preoccupation with the meaning of life and illness.
Taylor et al, 1999
n=30, 14 men, 16 women, avg age 58 years, 73% white, variety of religious backgrounds
20% of patients had four to six types of spiritual conflict associated with praying about their cancer, 33% had one to three types of spiritual conflict.
Moadel et al., 1999
n=248 out-pts in NYC, 48% white, 25% African-Am, 19% Hispanic, 58% Christian, 15% Jewish, 59% women, 50% currently receiving Rx.
75% of an ethnically diverse sample of cancer patients had one or more spiritual needs, 31% had five or more needs, including finding hope, meaning or peace of mind, or finding spiritual resources.
Gall et al, 2002 n=39 women with breast cancer.
5/39 women (13%) report ambivalent or negative relation with God.
Manning-Walsh, 2005
n=100 breast cancer patients recruited through Internet; majority Stage I/II, avg age 46 years, 93% white, 30% some graduate edu, avg 10 mnths since dx, > 50% completed tx.
In unadjusted models, negative religious coping (Brief RCOPE) inversely associated with EWB (r = -0.34**), composite QoL (r = -0.36**), and life satisfaction (LS, r = -0.31**). In models adjusted for age, the associations with QoL and LS remain significant.
Religious Struggle and Psychological Adjustment Among Cancer Patients
Boscaglia et al, 2005
n=100 women with recent dx of gyne cancer, Melbourne, avg age 52 years, 70% married, avg 22 weeks since dx.
In models adjusted for demographic, disease and other religion variables, negative religious coping was significantly associated with higher depressive symptoms (p<.001) and anxiety (p=.03).
Sherman et al, 2005
n=213 patients with multiple myeloma being evaluated for stem cell transplant, avg age 59 years, 60% male, 89% white, 84% married, avg 3 months since dx.
In unadjusted analyses, negative religious coping was associated with higher total distress, depression, and pain and with poorer mental functioning and energy. These associations remained significant after adjustment for demographic, disease, and other religion variables.
Burker et al, 2005
n=81 patients with end-stage lung disease being evaluated for lung transplant, avg age 35 years, 43% male, 93% white, 48% married, 64% dx with CF.
In models adjusted for non-religious coping and other dimensions of religious coping, punishing God reappraisals were significantly associated with greater depression, anxiety and disability.
Rippentrop et al, 2005
n=122 pain clinic patients, avg age 53 years, 44% male, 92% white, 57% married, 55% back pain, 26% disabled/retired due to illness
In unadjusted analyses negative religious coping was associated with poorer mental health (p<.001) and greater total pain (p<.01). In models adjusted for demographic factors, pain, and mental health, these associations were not longer significant.
Religious Struggle and Psychological Adjustment Among Cancer and Other Patients
Boscaglia et al, 2005
n=100 women with recent dx of gyne cancer, Melbourne, avg age 52 years, 70% married, avg 22 weeks since dx.
In models adjusted for demographic, disease and other religion variables, negative religious coping was significantly associated with higher depressive symptoms (p<.001) and anxiety (p=.03).
Sherman et al, 2005
n=213 patients with multiple myeloma being evaluated for stem cell transplant, avg age 59 years, 60% male, 89% white, 84% married, avg 3 months since dx.
In unadjusted analyses, negative religious coping was associated with higher total distress, depression, and pain and with poorer mental functioning and energy. These associations remained significant after adjustment for demographic, disease, and other religion variables.
Burker et al, 2005
n=81 patients with end-stage lung disease being evaluated for lung transplant, avg age 35 years, 43% male, 93% white, 48% married, 64% dx with CF.
In models adjusted for non-religious coping and other dimensions of religious coping, punishing God reappraisals were significantly associated with greater depression, anxiety and disability.
Rippentrop et al, 2005
n=122 pain clinic patients, avg age 53 years, 44% male, 92% white, 57% married, 55% back pain, 26% disabled/retired due to illness
In unadjusted analyses negative religious coping was associated with poorer mental health (p<.001) and greater total pain (p<.01). In models adjusted for demographic factors, pain, and mental health, these associations were not longer significant.
Religious Struggle and Psychological Adjustment Among Cancer and Other Patients
Boscaglia et al, 2005
n=100 women with recent dx of gyne cancer, Melbourne, avg age 52 years, 70% married, avg 22 weeks since dx.
In models adjusted for demographic, disease and other religion variables, negative religious coping was significantly associated with higher depressive symptoms (p<.001) and anxiety (p=.03).
Sherman et al, 2005
n=213 patients with multiple myeloma being evaluated for stem cell transplant, avg age 59 years, 60% male, 89% white, 84% married, avg 3 months since dx.
In unadjusted analyses, negative religious coping was associated with higher total distress, depression, and pain and with poorer mental functioning and energy. These associations remained significant after adjustment for demographic, disease, and other religion variables.
Burker et al, 2005
n=81 patients with end-stage lung disease being evaluated for lung transplant, avg age 35 years, 43% male, 93% white, 48% married, 64% dx with CF.
In models adjusted for non-religious coping and other dimensions of religious coping, punishing God reappraisals were significantly associated with greater depression, anxiety and disability.
Rippentrop et al, 2005
n=122 pain clinic patients, avg age 53 years, 44% male, 92% white, 57% married, 55% back pain, 26% disabled/retired due to illness
In unadjusted analyses negative religious coping was associated with poorer mental health (p<.001) and greater total pain (p<.01). In models adjusted for demographic factors, pain, and mental health, these associations were not longer significant.
Religious Struggle and Psychological Adjustment Among Cancer and Other Patients
Boscaglia et al, 2005
n=100 women with recent dx of gyne cancer, Melbourne, avg age 52 years, 70% married, avg 22 weeks since dx.
In models adjusted for demographic, disease and other religion variables, negative religious coping was significantly associated with higher depressive symptoms (p<.001) and anxiety (p=.03).
Sherman et al, 2005
n=213 patients with multiple myeloma being evaluated for stem cell transplant, avg age 59 years, 60% male, 89% white, 84% married, avg 3 months since dx.
In unadjusted analyses, negative religious coping was associated with higher total distress, depression, and pain and with poorer mental functioning and energy. These associations remained significant after adjustment for demographic, disease, and other religion variables.
Burker et al, 2005
n=81 patients with end-stage lung disease being evaluated for lung transplant, avg age 35 years, 43% male, 93% white, 48% married, 64% dx with CF.
In models adjusted for non-religious coping and other dimensions of religious coping, punishing God reappraisals were significantly associated with greater depression, anxiety and disability.
Rippentrop et al, 2005
n=122 pain clinic patients, avg age 53 years, 44% male, 92% white, 57% married, 55% back pain, 26% disabled/retired due to illness
In unadjusted analyses negative religious coping was associated with poorer mental health (p<.001) and greater total pain (p<.01). In models adjusted for demographic factors, pain, and mental health, these associations were not longer significant.
Religious Struggle and Psychological Adjustment Among Cancer and Other Patients
Religious Struggle and Emotional Distress Down Under
10.69.4
20.0
0
5
10
15
20
25
0 (25) 1 (5) 2+ (6)
Negative Religious Coping Items (number of cases)
mea
n T
MD
S
36 medical/surgical patients, Melbourne; F (2,35) = 3.7, p = .03.
Source: Ano and Vasconcelles, Journal of Clinical Psychology, 2005.
Correlation Between Negative Religious Coping And Negative Psychological Adjustment
Number Cumulative Confidence of Studies Effect Size Interval
22 .22* .19 to .24
Meta-Analysis of Negative Religious Coping and Psychological Adjustment
Religious Struggle and Recovery from Heart Surgery (n=232)
All Cases DeathsVariable (N = 232) (N=21, 9%) Adj OR (95% CI)History of cardiac surgery no 214 14 (7%) 10.07 (2.77, 36.55) yes 18 7 (39%)ADL impairment not severe 204 13 (6%) 6.14 (1.88, 20.05) severe 28 8 (29%)Participation in social groups yes 97 4 (4%) 4.26 (1.15, 15.73) no 135 17 (13%)Age 55 - 69 122 6 (5%) 3.38 (1.08, 10.60) 70+ 110 15 (14%)Strength and comfort from religion a little or a great deal 158 9 (6%) 3.25 (1.09, 9.72) none 74 12 (16%)Oxman et al., 1995, Psychosomatic Medicine
Comfort from Religion and Religious Struggle
149 patients with diabetes or CHF
60%
28%19%
0%
25%
50%
75%
100%
none (5) a little (39) a great deal (105)
How much strength and comfort from religion? (number)
Per
cen
t w
ith
mo
der
ate
or
hig
h
reli
gio
us
stru
gg
le
Determinants of Religious StruggleVariable Standardized BetaAge -0.289***Female (vs male) -0.091
Patient Group (reference group Oncology) Diabetic 0.022 CHF 0.164*
Attend Worship (reference group Never) Rarely -0.024 Monthly -0.053 Weekly or more -0.251*
Positive Religious Coping (reference group 0-5) 6-9 0.221* 10-14 0.148 15-18 0.241** 19+ 0.280**Model adjusted for marital status, race and education.
From Fitchett et al, 2004
Differences in RS by Patient Group
1.8
2.7
2.1
0
1
2
3
4
5
diabetes (71) chf (70) oncology (97)
Differences in RS by Age
1998 GSS also found an age difference in negative religious coping (2 items, p<.05); mean scores: < 65: 1.25 > 65: 1.18
4.1
2.9
2.1 2.11.7
0.3
0
1
2
3
4
5
< 40 (18) 41-50 (32) 51-60 (58) 61-70 (68) 71-80 (53) 81-90 (9)
Differences in RS by Gender
10.2
12.8
2.61.8
0
5
10
15
male female
Me
an
Re
ligio
us
Co
pin
g S
co
re
positive coping negative coping No gender differences in GSS study.
Gender difference:-negative religious coping, ns-positive religious coping, t = -3.0, p=.003
Differences in RS by Level of Worship Attendance
2.4
3.32.9
1.5
0
1
2
3
4
5
never (39) rarely (50) monthly (26) weekly or more(123)
Differences in RS by Positive Religious Coping
1.7
2.5
1.52.0
3.0
0
1
2
3
4
5
0 - 5 (44) 6 - 9 (55) 10-14 (42) 15-18 (49) 19+ (48)
Isn’t Religious Struggle Really Just Depression?
The size of the correlations between religious struggle and depression in our study (r from 0.22 to 0.42) suggest religious struggle is associated with but cannot be reduced to depression.
Religious struggle predicts both poor recovery and mortality in models which adjust for depression.
Prevalence of Religious Struggle
None 7 items scored "not at all" 123 52%
Low
1 item scored "quite a bit" or "a great deal," or 1 or more items scored "somewhat" 80 34%
Moderate2 items scored "quite a bit" or "a great deal" 17 7%
High3 or more items scored "quite a bit" or "a great deal" 18 8%
From Fitchett et al, 2004
Prevalence of Religious Struggle
PatientsGeneral
Population
Feel abandoned by God 9% 5%
Feel punished by God 11% 5%
Responses of “quite a bit” or “a great deal.”
Prevalence of Religious StruggleStudy Sample Measure Prevalence
Gall et al, 200239 women with breastcancer
report ambivalent or negative relation withGod 13%
Taylor, et al,1999
30 men and women withcancer
express 4-6 types of spiritual conflictabout praying about their cancer 20%
Jacobson et al,2006
19 men and women withHIV/AIDS
responses indicate religious/spiritualseeking 21%
Stoddard, 199327 patients who died inthe hospital
chaplain chart note about spiritual distressor spiritual despair 40%
Moadel et al,1999
248 ethnically diversecancer out-patients inNYC
express 5 or more needs, including findhope, meaning, peace of mind, spiritualresources 31%
Oxman et al,1995
232 older elective heartsurgery patients
report no strength and comfort fromreligion 32%
Fitchett et al,1999 96 medical rehab patients high score, negative religious coping 12%
Pargament et al,2004
239 elderly medicalpatients
evidence of negative religious coping atbaseline and 2 year follow-up 26%
FetzerInstitute/NIA,1999 1,400 US adults, GSS
feel abandoned by God or punished byGod “quite a bit” or “a great deal” 5%
19931,455 persons, age 15-90,in Yukon Terr, Canada “poor” or “fair” self-rated spiritual health
men 29%women 16%
Dimensions and Course of Religious StruggleDimension Description
The Challenge of Suffering
Wondering why God permits suffering
The Challenge of Cultivating Virtue Facing our sins
The Challenge of Supernatural Evil Diabolical attributions
The Challenge of Religious Community
Experience of betrayal or injury from religious authority or others
From Exline and Rose, 2005
Screening for Religious Struggle
Screening for religious struggle is an attempt to identify patients who may be experiencing religious struggle.
Screening for religious struggle employs a few, simple questions, that can be asked by health care colleagues.
Aim of Screening: Identifying Lost Sheep (and improving patient satisfaction)
Patient Response
Lost SheepRefer for spiritual assessment
Hungry Sheep Refer for spiritual care
Happy Non-Believer No further action needed
Religious Struggle and Requests for Spiritual Care (percent who request spiritual care)
Religious Resources
low high
Potential Need
low 9% 35%
high 31% 59%
Chi-square = 21.19, p <.001From Fitchett et al, J Pastoral Care, 2000
Pilot Study Results
Dates
New Admissions Screened
Cases of Struggle Identified
Cases of Struggle Confirmed by Chaplain Assessment
Other Requests for Spiritual Care
Phase I
Jan-Mar 2006
78/159 (49%) 7/78 (9%) 7/7 (100%)
51/78 (65%) Chaplain visit
22/78 (28%) Communion
Phase II
July & August 2006 10/46 (22%) 0/10 (0%) N/A
2/10 (20%) Chaplain visit
0 Communion
Chaplain Rounds during Phase II
July & August 2006 36/46 (78%) 4/36 (11%)
4/4 (100%)
(Plus 2 additional false negative cases) N/A
Barriers to ScreeningPhase I, Patient Care Technicians
• PCTs felt overwhelmed by other tasks and couldn’t administer the protocol because of time constraints.
• Turnover of PCTs made follow through difficult.• The protocol was sometimes misunderstood and not
followed.
Phase II, Medical Residents• The heavy Resident work load was a major barrier.• Turnover of Residents made consistency difficult. • Resident’s lack of training about the importance of
spiritual struggle was a problem.
Hershey Medical Center: Questions in Admission Assessment that Trigger Pastoral Services Referral
Percent of Referrals
Oct 05 - Jan 06
1. Would you like to see Pastoral Services while in thehospital? (Yes) 25%
2. Do you have any spiritual practices/needs you wish tocontinue while hospitalized? (Yes) 8%
3. Are your resources (emotional, social, spiritual) enough todeal with the stress in your life? (No) 15%
4. Emotional support available? (No) 8%
5. Have you experiences significant loss in the past year oranticipate significant change because of your illness? (Yes) 11%
For further information contact Paul Derrickson, pderrickson@psu.edu
Child/Adolescent Spiritual Screening Tool (CAAST)
How often do you think that. . .
1. A good God watchesover me. Never Sometimes Often Always
2. I have to live with God’spunishment. Never Sometimes Often Always
4.My shame makes me feeldirty. Never Sometimes Often Always
Daniel Grossoehme, Cincinnati Children’s Hospital,daniel.grossoehme@cchmc.org
Others Models for Screening• Stoddard• Derrickson• Berg• Hodges• Wakefield & Cox• GF Review, CT, 1999
Three Levels of Inquiry About Religion/Spirituality
• screening for religious struggle
• religious/spiritual history taking
• spiritual assessment
Case Example: Alienated from ReligionThe chaplain was referred to the patient who was a
candidate for a heart transplant because he appeared very discouraged. He was also receiving medication for depression.
The patient told the chaplain about a negative experience he had with a particular church and pastor. As a result of this experience, the patient was angry with God and alienated from religious institutions.
The chaplain helped the patient separate his experience with the church from his relationship with God. She helped him rebuild his relationship with God and find a new church home.
As he did these things the patient’s depression resolved and the medication was discontinued.
The Case of Mrs. FisherMrs. Fisher was a 74 year old women with a
history of toe amputation on her left foot. She had an ulcer on a toe on her right foot and had just had an operation to replace a section of the artery in her right leg.
Her doctor had recently told her that her prognosis was very good, that she would be able to do all that she had been doing prior to the surgery.
As she made a referral to the chaplain, the nurse described Mrs. Fisher as very depressed. From: Whitby, 1999
The Case of Mrs. FisherChaplain: Sounds like you’re angry with
God?Mrs. F: (Looking up sharply) Yes I am.
No one has said that to me before.Chaplain: No. Have you told Him?Mrs. F: No. Do you think He’d listen?
(Looking over her glasses challengingly.)
Chaplain: Yes. I think He would. (Mrs. F. looked intently at the
chaplain.)
Implications for Spiritual Care
For chaplains For other health
professionals For congregations
Implications for Chaplains Chaplains come to term with their own
religious struggles Finding the Lost Sheep
“I ask God to lead me to the ones who need me.” A two – step process
1. screening by healthcare colleaguesand if indicated
2. indepth spiritual assessment by a trained chaplain
Responsible screening and “intervention”
The 7 x 7 Model for Spiritual Assessment
Holistic Assessment Spiritual Assessment Medical Belief and Meaning Psychological Vocation and Obligations Family Systems Experience and Emotions PsychoSocial Courage and Growth Ethnic, Racial, or Cultural Ritual and Practice Social Issues Community Spiritual Authority and Guidance
Pastoral Responses to Religious Struggle• Assess
• sources of struggle• duration: new, transient, leading to growth,
chronic• available resources
• Giving Voice, Being Heard • muteness, lament, companionship
• Finding Meaning• creating a new narrative• creating a new future story
Implications for Chaplains: Three Questions• How did you decide which patients to see
this week?
• How did the staff you work with determine who to refer and who not to refer?
• What evidence did you generate this week that your ministry made a difference in measurable patient outcomes?
QuestionImplication for SpiritualCare
How did you decide which patients tosee this week?
Good Stewards of ScarceResources
How did the staff you work withdetermine who to refer and who not torefer?
Protocol for Screening andReferral
What evidence did you generate thisweek that your ministry made adifference in measurable patientoutcomes?
Accountability andDocumentation
Implications for Chaplains
Implications for Chaplains
Early identification and follow-up of patients with religious struggle may:
• improve their adjustment• improve their recovery• reduce their risk of mortality
Documenting the prevalence of religious struggle provides a measure of spiritual acuity and a basis for determining chaplaincy staffing levels
Implications for Spiritual Care For other health professionals
For congregations Provide narratives and models
for lament and religious struggle Follow-up with lost sheep
Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine”“Can You Measure a Sunbeam with a
Ruler?” (Lederberg and Fitchett, 1999)
Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine”“Can You Measure a Sunbeam with a
Ruler?” (Lederberg and Fitchett, 1999)
“While such measurement may be possible, it cannot capture the essence of the sunbeam and in fact may distort it” (R Sloan, 2006).
Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine”“Can You Measure a Sunbeam with a
Ruler?” (Lederberg and Fitchett, 1999)
“While such measurement may be possible, it cannot capture the essence of the sunbeam and in fact may distort it” (R Sloan, 2006).
“It is our hope that the contents of this special issue will help psycho-oncologists smoothly integrate religion and spirituality into their therapeutic and research pursuits without short-changing their patients with too much uncritical enthusiasm, or too much ignorance, indifference or cynicism” (Lederberg and Fitchett).
AcknowledgmentsRehabilitation Study
Bruce Rybarczyk, Gail DeMarco, John Nicholas
Three Patient Groups Study
Pat Murphy, Jo Kim, Jim Gibbons, Jacqueline Cameron, Judy Davis
Screening Pilot Study Jay Risk, Pat Murphy
Mrs. Fisher Allison Whitby
NIA K08 AG20145
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