Spirituality and Health Care

1. Spirituality and Health Care Anita S. Kablinger MDAssociate Professor Psychiatry and Pharmacology

2. Audience Participation • What percentage of Americans says that they would welcome a conversation with their doctor about faith? • What do people pray for the most (give the top three)? • Scientific evidence for the following has been rated as WEAK, INADEQUATE, MODERATE or PERSUASIVE. Match the evidence to the following- • religion or spirituality slows the progression of cancer • religion or spirituality protects against disability • religion or spirituality improves recovery from acute illness • religion or spirituality protects against cancer mortality • being prayed for improves physical recovery from acute illness • religion or spirituality protects against cardiovascular disease • church attendance promotes longer life

3. Definitions • Religion means to “bind together” and a belief in and reverence for a supernatural power regarded as creator and governor of the universe. • Spirituality, on the other hand, is defined as a dynamic, personal, and experiential process of belief.

4. Religion/Spirituality Involvement in Medicine: • -JCAHO requires routine assessment of spirituality needs • -APA issued “Guidelines Regarding Possible Conflict Between Psychiatry’s Religious Commitment and Psychiatry’s Practice” • -DSM-IV includes “Religion or Spirituality Problem” section • -instruction in religion-spiritual issues is a curricular requirement of accredited psychiatric residencies • -APA recommends that doctors inquire about religion and spiritual orientation of patients

5. Background • The percentage of those who believe in God has changed little over the past 50 years (96% in 1944 and 95% in 1993). • Eighty-nine percent of the population state that they pray to God on a regular basis. • Ninety-four percent of people regard their spiritual and physical health as equally important and the majority of physicians believe spirituality is an important factor in health care. • In fact, one-third of the population regards religion as the most important dimension in their life.

6. Scientist and Clinician Beliefs: Rates of Atheism and Agnosticism U.S. Population 6% American Men and Women of Science: 1916 and 1996 55% Vermont Family Practitioners 36% Psychologists 28% Psychiatrists 21% Bergin and Jensen, Psychotherapy, 1990, 27:3-7. Maugans and Wadland, Journal of Family Practice, 1991, 32:210-213.

7. Myths about religion and health care: • What research does NOT show: • -religious people do not get sick • -illness is due to lack of faith • -spirituality is the most important factor • -doctors should prescribe religious activities • -other factors explain the association between religion and spirituality and better health outcomes

8. Benefits to clinicians of religious/spirituality focus: • -communicates to patient that their life experience is of interest and value to them • -increases understanding of clinical condition’s association with a religious-spiritual problem • -allows the development of a case formulation of interpersonal responses and psychiatric patterns • -identifies areas of support and community involvement that may be helpful adjuncts to treatment

9. Reasons to acknowledge and support a patient’s spirituality: • -people regard spiritual and physical health as equally important • -enhances coping and quality of life during illness • -enhances cultural sensitivity • -enriches the doctor/patient relationship

10. Barriers (reasons doctors have problems assessing religion/ spirituality): • -doctors practice in biomedical model • -fewer doctors regard themselves as religious or spiritual as compared to patients • -taught infrequently in medical training • -patients regarded as having complex or daunting needs • -not addressed due to time constraints, lack of confidence, and role uncertainty

11. Illness Prevention:Spirituality and Life Satisfaction • Study sample: reviewing findings from three national surveys totaling more than 5,600 older Americans • Study results: Attending religious services was linked with improved physical health or personal well-being. • Other studies: 12 other studies published since 1980 found persons in organized religious activity had higher levels of life satisfaction. • Levin JS, Chatters LM. Religion, health, and psychological well-being in older adults: findings from three national surveys. J Aging Health 1998;10(4):504-531.

12. Patient Need:Patient Views Regarding Spirituality When Seriously Ill Pulmonary Patients Consider self religious 51% Welcome religious questions in medical history 66% Not welcome religious questions 16% Physician asking about their spiritual or religious beliefs would increase trust in the physician 66% Ehman JW, Ott BB, Short TH. Archives of Internal Medicine 1999;159 (15):1803-1806.

13. Recovery from Surgery:Hip Replacement Hip fracture patients with stronger religious beliefs and practices were less depressed and could walk a greater distance at discharge than patients with lower levels of religious commitment. Pressman P, et al. Am J Psychiatry 1990;147:758-760.

14. Those who are religious tend to demonstrate: • -less cardiovascular disease • -decrease in blood pressure and hypertension • -more health promoting behaviors • -a decrease in depression, anxiety, and suicide • -less alcohol abuse or use of illicit drugs

15. Illness Prevention:Substance Abuse • “Individuals suffering from these (alcohol or drug abuse) problems are found to have a low level of religious involvement . . . spiritual re(engagement) appears to be correlated with recovery.” • Miller WR. Addiction 1998;93(7):979-90.

16. Illness Prevention: Spirituality and Marijuana Use Survey undertaken by Harvard School of Public Health and University of Michigan’s Survey Research Center. Study Sample: 17,592 college students sampled from 140 U.S. colleges with survey sample nationally representative of U.S. college population. Study Results: Increased Risk-Marijuana Use - Lower Grades – Grade “B” and below - More time “hanging” with friends - Four-Fold Increased Risk: Parties Important or Very Important - Five-Fold Increased Risk: Cigarette Smoking - Six-Fold Increased Risk: Binge Drinking Bell R., et al, “The correlates of college student marijuana use: results of a US National Survey.” Addiction. 1997; 92(5);571-581.

17. Illness Prevention: Spirituality and Marijuana Use Study Results (cont.): Lowered Risk-Marijuana Use - One-Half Risk: students who viewed Community Service as “important” to them - One-Fourth Risk: Students who viewed Religion as ”very important” to them - Religion as important – strongest predictor of marijuana use, even stronger in size than identification as “party animal” - After controlling for other predictor variables - Religion as important – still at ONE-THIRD the risk “This study supports the notion that college drug use is social in nature (which) makes it resistant to change…however the findings do suggest approaches to prevention” Bell R., et al, “The correlates of college student marijuana use: results of a US National Survey.” Addiction. 1997; 92(5);571-581.

18. Patient Need: Social Histories of Chronic Drug andAlcohol Abuse Study Results (cont.): Religious Histories: Parents and Subjects Frequency Comparison (as ratios) for: Narcotic Abusers (NA) and Alcohol Abusers (AA) to control sample: Religious History Items:NA/ControlsAA/Controls Mother’s Religious Involvement no difference one-fifth higher Father’s Religious Involvement one-half three-fourths During Adolescence: Increased Religious Interest one-fourth one-eighth During Adolescence: Decreased Religious Interest 4 times greater 4½ times greater Larson DB & Wilson WP. Religious life of alcoholics. Southern Medical Journal. 1980; 73(6): 723‑727. • Cancellaro LA, Larson DB, Wilson WP. Religious life of narcotic addicts. Southern Medical Journal. 1982; 75(10): 1166‑1168.

19. Illness PreventionSpirituality and Blood Pressure Status Importance of Religion for those 55 & Older Age  55*Mean Systolic BPMean Diastolic BP High Importance of Religion 139.7 82.6 Not High Importance 146.2 88.5 High VS Not High Difference 6.5 mm Hg 5.9 mm Hg * Adjusted for socioeconomic status and smoking Larson DB, Koenig HG, Kaplan BH et al. The Impact of Religion on Man’s Blood Pressure”. Journal of Religion & Health. 1989;28(4):265-278.

20. Systematic ReviewA Review of Findings Concerning Spirituality and Hypertension Study Results: For the Religious Commitment Studies: Of the seven studies found, six revealed higher levels of religious commitment were associated with lower rates of hypertension. By 2000, 11 years later, Koenig, McCullough and Larson noted that “of the 16 studies that have examined the relationship between the level of religious involvement and blood pressure, 14 (88%) found lower blood pressure (levels) among the more religious.” Levin JS, Vanderpool HY. Social Science and Medicine 1989; 29:69-78. Koenig HG, McCullough ME, Larson DB. Handbook of Religion and Health. Oxford University Press, Inc. 2001.

21. Illness Prevention:Spirituality and Smoking • Study sample: Duke Central Carolina sample of nearly 400 adults over age 65 • Study results: • Older adults who both attended religious services and prayed (or read the Bible) were nine times less likely to smoke. • Frequently attending services -- strongest predictor of not smoking (much stronger than prayer/Bible reading). • Koenig HG, et al. The relationship between religious activities and cigarette smoking in older adults. J Gerontol: Medical Sciences 1998;53A(6):M1-M9. • Bell R., et al. The correlates of college student marijuana use: results of a U.S. national survey. Addiction 1997;92(5):571-81.

22. Improving Treatment OutcomesSpirituality and Elective Cardiac Surgery Group Participation X Religious Strength and Comfort Percent Who Died Post Surgery: • Group Participation and Strength 3% and Comfort from Religion • Group Participation But 7% No Strength and Comfort from Religion • No Group Participation But 8% Strength and Comfort from Religion • No Group Participation and 20% No Strength and Comfort from Religion Oxman TE, Freeman DH and Manheimer ED. Lack of Social Participation or Religious Strength or Comfort as Risk Factors For Death after Cardiac Surgery in the Elderly. Psychosomatic Medicine. 1995; 57:5-15.

23. Illness PreventionSuicide and Religious Affiliation Studies have found that those with no Religious Affiliation versus those with a Religious Affiliation: • find suicide more acceptable • are more likely to have suicidal ideation • are more likely to have attempted suicide • if providers, they have more favorable attitudes towards physician-assisted suicide

24. Illness Prevention: Mothers’ Religion and Depression in their Children • Study sample: 60 mothers and their 151 children who were followed up 10 years later • Study results: If mothers viewed religion as highly important: • daughters (not sons) 60% less likely to have had major depressive disorder • mothers themselves 80% less likely to have had major depressive episode during 10 year follow-up • Miller, L., et al. Religiosity and depression: ten-year follow-up of depressed mothers and offspring. J Am Acad Child Adolesc Psychiatry 1997;36(10):1416-25.

25. “Bottom Line” of Prevention:Living Longer “Respect for God is the beginning of wisdom; and the knowledge of the sacred is understanding. By wisdom your days will be MULTIPLIED and the years of your life will be INCREASED.” Proverbs 9:10-11

26. Illness Prevention: Living Longer • Study sample: national sample of 21,000 U.S. adults with 10-year follow-up. 1987 National Health Interview Survey with 1997 NCHS Multiple Cause of Death File • Study results: • “Life expectancy gap between those who attend more than once a week and those who never attend is over 7 years.” • For Blacks, the life expectancy gap is 14 years. • Hummer RA, et al. Religious involvement and U.S. adult mortality. Demography 1999;36(2)273-85.

27. U.S. Life Expectancy at Age 20by Religious Attendance (n=21,204) Average Age at Death Frequency of Attendance Hummer et al (1999). Demography 36:273-285

28. Stages of death and dying – Elizabeth Kubler-Ross • talked to 400 dying patients • knew they were dying even if not told • they need to talk about it • need to maintain hope, even if not hope of a cure

29. 5 stages that most dying people go through from the time they learn they are dying to actual death: Denial Anger Bargaining Depression Acceptance She also described unfinished tasks of the dying including: reconciliations, resolution of conflicts, and the pursuit of specific remaining goals.

30. Breaking the news of impending death: • physician should be present • spouse should be present if possible • relatives need comfort, as does the patient • use simple words, even with educated patients • show compassion and support, do not be abrupt or blunt • guessing how long a patient has to live is often inaccurate and unadvisable • encourage and answer questions • truth is not the enemy of hope • communicate willingness to see patient through death • explain the situation and introduce the next step

31. Greatest fears of a dying person: • abandonment • pain • shortness of breath

32. The Forgotten Factor:Systematic Reviews of the Findings Of studies examining religious commitment variables in clinical research: Family Frequency PsychiatryMedicineof Worship Clinical harm --ALL less than 5%-- Clinical benefit-- ALL greater than 80%--

33. Questions That Can Be Used to Facilitate Clinical Discussions About Patient Spirituality From “SPIRITual History:” • What does your spirituality/religion mean to you? • What aspects of your religion/spirituality would you like me to keep in mind as I care for you? • Would you like to discuss the religious or spiritual implications of your health care? • As we plan for your care near the end of life, how does your faith impact on your decisions? Maugans TA. The SPIRITual history. Arch Fam Med 1996; 5:11-6.

34. Questions That Can Be Used to Facilitate Clinical Discussions About Patient Spirituality • How close do you feel to God or a higher power? • Have you ever had an experience that convinced you that God or a higher power exists? • How strongly religious (or spiritually oriented) do you consider yourself to be? McBride JL, et al. The relationship between a patient’s spirituality and health experiences. Fam Med 1998; 30(2):122-6. Kass JD, et al. Health outcomes and a new index of spiritual experience. J Scientific Study of Religion 1991; 30:203-11.

35. Taking a spiritual history. . . • S Spiritual Belief System • P Personal Spirituality • I Integration in a Spiritual Community • R Ritualized Practices and Restrictions • I Implications for Health Care • T Terminal Events Planning (advance directives, DNR wishes, DPOA etc..)

36. Research tells us: • -patients want clinicians to consider spiritual issues • -religious commitments are associated with health enhancing behaviors and attitudes influence preventative practices in all aspects of medicine • -incorporating spiritual concepts in some areas of treatment enhances their relevance for patients • -using religion-oriented treatments for religious patients may be effective for treating some psychiatric disorders • -recovery from episodes of major mental illness may be associated with religious involvement