Whole Person Medicine- Addressing Spiritual Issues in Primary Care and Psychiatry

1. Whole Person Medicine- Addressing Spiritual Issues in Primary Care and Psychiatry Teresa Cutts, Ph.D. Director of Research and Innovative Practice Center of Excellence in Faith and Health, Methodist LeBonheur Healthcare Annual Review Course for the Family Physician and 3rd Joint Family Medicine/Psychiatry CME Conference, 3-25-2011

2. Spiritual Issues: Roadmap Overview of impact of spirituality on health Overview of infusing spirituality into primary care and psychiatry Best Practice models: Individual, provider to patient (Kristeller, Koenig, Prochalski, Assets based tools) Emerging Best Practice models for Community: MLH Congregational Health Network, Emotional Fitness Centers, Dennis H. Jones LifeNet Center

3. Spirituality and Health Majority of patients would like their healthcare provider to ask about and discuss spiritual aspects of their illness 95% of Americans profess a belief in a Higher Power or God 9/10 Americans pray regularly 69% reported membership in church or synagogue; 40% attend regularly

4. Spirituality and Health Definitional difficulties in spirituality (broader term referring to a dynamic, personal and experiential process, including quest for meaning and purpose, transcendence [sense that being human is more than simple material existence, connnectedness (with others, nature, Divine) and values ( love, compassion, justice)]

5. Spirituality and Health Transcendence is hard to measure! Measuring spirituality is difficult: Measures of Religiosity (Hill & Hood) cites over 200 different scales and subscales (Mysticism scale measures assesses person�s intense experiences, sense of unity, not necessarily religious ones)

6. Spirituality and Health Methodological Problems No control for confounders (age, gender) Cross-sectional design cannot determine the temporal sequence of events Inadequate measurement of religion/spirituality or of physical health No statistical analyses Earlier reports on the same cohort

7. Spirituality and Health Regular church/service attendance may Enhance social roles that promote self-worth and purpose through helping (Increase sense of personal control and decrease depression) Be associated with ongoing experience of positive emotions May offer a lifeline of resources to those most disadvantaged (female, lower SES, minority)

8. Spirituality and Health Evidence is strongest that Religion/Spirituality impacts physical and mental health by serving: 1) As a protective resource that prevents the development of disease in healthy people AND/OR 2) As a coping resource that buffers the impact of disease in patients

9. Spirituality and Health Regular church/service attendance May increase the opportunity to observe vicariously and consistently those who model a variety of positive, hopeful, compassionate and caring behaviors, attitudes and beliefs that are highly conducive to living a healthy lifestyle: Spiritual Modeling (Bandura; Oman and Thoresen, 2003)

10. Spirituality and Health Religion and Spirituality: Linkages to Physical Health: Powell, Shahabi, Thoresen, 2003, American Psychologist Looked at mediated model (impact of RI/SI on health, regardless of other mediators) Looked at independent model (RI/SI as a new, independent protective factor on health)

11. Spirituality and Health Church/service attendance protects against death: Persuasive evidence for both mediated and independent models Religion or spirituality protects against cardiovascular disease: Some evidence for both models Being prayed for improves physical recovery from acute illness: Some evidence

12. Spirituality and Health Religion or spirituality impedes recovery from acute illness: Some evidence from both models The �Why Me God?� Hypothesis

13. Spirituality and Health Religion or Spirituality DOES NOT: Protect against cancer mortality or slow progression of CA Improve recovery from acute illness Protect against disability Protect against death (in deeply religious)

14. Spirituality and Health Summary: The relationship between physical health and religion and/or spirituality is more limited and complex than some suggest More research is needed to define these relationships and translate findings to clinical care delivery

15. Spirituality and Health Specific studies on impact in primary care and psychiatry RI/SI associated with improved attendance at scheduled PC appts., greater cooperativeness and compliance and improved medical outcomes RI/SI associated with less substance abuse, cigarette smoking, increased exercise

16. Spirituality and Health Specific studies on impact in primary care and psychiatry continued: RI/SI may enhance coping ability by counteracting stress-related physiological changes that have negative impact on all organ systems (Allostatic load theory of response to stress, McEwen, 1998) RI/SI associated with stronger immune function and lower cortisol levels

17. Spirituality and Health Specific studies on impact in primary care and psychiatry continued: RI/SI (intrinsic religiosity) increased speed of remission in depression recovery in medical inpatients RI/SI associated with better mental health, greater social support RI/SI has mixed results in chronic pain (prayer vs. meditation and prayer)

18. Spirituality and Health Specific studies on impact in primary care and psychiatry continued: Cognitive behavioral treatment for depression, couched within particular religious tradition had stronger impact on preventing depression reoccurrence Pargament and colleagues have developed spiritually integrated psychotherapy to address mental illness, sexual abuse, cancer

19. Spirituality and Health:Best Practice Models Jean Kristellar, Ph.D. at Indiana Oasis (Oncologist Assisted Spiritual Intervention Study) Model for Oncology Patients 5-7 minute patient centered intervention that improves patients� quality of life and sense of well-being Used Spiritual Well-Being scale of Funtional Assessment of Chronic Illness Therapy, measuring domains of meaning/peace and faith After 3 weeks, >40% reported more satisfaction in care and 33% reporting improved coping Kristellar JL, Rhodes, M, Cripe LD, Sheets V. Oncologist assisted spiritual intervention study (OASIS): patient acceptability and initial evidence of effects. Int J Psychiatry Med, 2005; 35(4): 329-347.

20. Spirituality and Health:Best Practice Models Harold Koenig, M.D. at Duke Clinical application information is missing Less than 50% of physicians tackle this area Asking about religious or spiritual beliefs is often a powerful intervention unto itself Fiduciary Relationship: Proselytizing is not allowed Invite, don�t assume that a patient is comfortable with prayer or other spiritual offerings/questions. Be ready to refer to pastoral or spiritual advisor Koenig H. An 83-Year-Old Woman with Chronic Illness and Strong Religious Beliefs, JAMA, July 24/31, 2002: 288(4), 1-7.

21. Spirituality and Health: Best Practice Models George Washington Institute for Spirituality and Health: Dr. Christina Puchalski 102/144 accredited medical and osteopathic schools incorporate spirituality into curricula Through interdisciplinary collaboration provide physicians with insight into spirituality�s impact on patients� well-being

22. Spirituality and Health: Best Practice Models George Washington Institute for Spirituality and Health, continued: 7 Hospital sites looked at failure of communication between providers and patients (75% providers� vs. 15% patients were satisfied that the spiritual dimensions were addressed) Compassion and/or kindness are not sufficient�.need specific competencies and training in this area

23. Spirituality and Health: Best Practice Models George Washington Institute for Spirituality and Health, continued: FICA [Faith, Belief, Meaning; Importance and Influence; Community; and Address/Action to Care] is a spiritual history tool, with in-depth training Available on website: http://www.gwumc.edu/gwish/ficacourse/out/main.html

26. Spirituality and Health Authentic Happiness (Seligman, 2004) Values in Action Strength Survey (VIASS) Identifies 24 values/Spiritual strengths/gifts across 6 domains: wisdom and knowledge, courage, justice, temperance, humanity and love, transcendence Life of Leaders assessment--helps craft a integrated health behavior change plan based on assets, not pathology

27. Spirituality and Health Self-Disclosure (James Pennebaker, Ph.D.) Series of experiments showing that �confession� is good for the soul or at least immune system and ANS! Talking to person Speaking into a tape recorder Journalling

28. Spirituality and Health Telling your Story (Trauma work): Oakland earthquake survivors (all children) tracked over a several year period Stories changed, took on more meaning, found a kernel of good, even in horrible circumstances

29. Spirituality and Health Biology is your biography: Caroline Myss, Ph.D. We carry unresolved trauma in our bodies Body work (exercise, therapeutic touch, massage therapy) helps resolve trauma Why People Don�t Heal and How they Can

30. Spirituality and Health Forgiveness: Everett Worthington, Ph.D. Had magnificent opportunity to practice the tenets of his forgiveness program when his mother was murdered

31. Spirituality and Health Aging with Grace, David Snowden, Ph.D. Start something new later in life Exercise Eat green vegetables Be optimistic Manage depression

32. Spirituality and Health Altruism: ��.serve somebody�� Helpers High Long-term Effects Alameda Study on volunteerism Vicarious effects, too (Mother Teresa film) Hands on service vs. giving money or material goods is best

33. Spirituality and Health Optimism (Seligman, Kiecolt-Glaser) Negative events are viewed as local, temporary and changeable Impacts immune system functioning positively Increase optimism via ABCDE model: Adversity Beliefs that automatically occur. Consequences of belief Disputation of usual routine belief Energization that occurs when you dispute successfully

34. Congregational Health Network or CHN What is the CHN? The CHN is a partnership between the hospital and 322 congregational partners developed by networking congregational, hospital and community leaders. CHN builds healthier communities by creating a health system integrating clinical care in the hospital with outside caregiving

36. Volunteer Liaison Roles (>500 Unpaid Staff) � Recruits congregational members into the network � Collects data on network members � Notifies CHN navigators of developments/changes � Follows network members into and out of the inpatient setting � Coordinates transition from hospital � Marshals community resources � Provides information and referral services � Facilitates wellness activity participation

38. CHN Partner: The Emotional Fitness Center Led by Bishop William Young and Pastor Dianne Young of the The Healing Center Full Baptist Church Partnered with Dr. Frieda Outlaw of State of TN Dept. of Mental Health and Developmental Disabilities Partnered with Magellan Health Services 13 Local Memphis and adjacent churches

39. The Emotional Fitness Center Work started in response to tragedy > 15% of Shelby county citizens have some form of mental illness or substance abuse problem 6,000 children and 6,300 adults (TennCare eligible) don�t access available services Barriers to African Americans seeking mental health treatment: fear, stigma, lack of support system

40. The Emotional Fitness Center Targets African American population to overcome stigma and cultural myths about mental illness The African American church has unique connection in communities, historically and currently; place of hope, renewal, restoration, sanctuary; buffer to oppression Power of the pulpit is strong in Memphis

41. The Emotional Fitness Center Now: Church successfully has become the hub for public health interventions The Emotional Fitness Center has 10 sites in Memphis (most under-served zip codes) and 3 in proximal counties Model uses church as the entry point for needed emotional distress services

42. The Emotional Fitness Center Goals of Approach: Get services to individuals traumatized by life, including all types of abuse, violence, losses, stress Provide preventive services to those at risk for becoming perpetrators of violent acts Develop a �live� link between the faith community and health providers

43. The Emotional Fitness Center Steps for Entry: 1. Call (901) 370-HOPE (4673) for phone triage 2. Navigator will assign client to area or closest church (or site selected) 3. Peer Advocate Liaison (PAL) makes initial contact within hours. Schedules and conducts screening

44. The Emotional Fitness Center Role of PALS: Front-line triage via screening tool Follow up via phone calls, to make sure those screened stay in the system Have had mental illness or family member with mental illness themselves, so are advocates with training who know the landscape of mental illness

45. The Dennis H. Jones LifeNet Center Methodist LeBonheur Healthcare is developing an initiative to help people cope with depression and anxiety, which sometimes expresses itself in suicide. Important life transitions, such as retirement, lay-offs, serious health issues, divorce, death of spouse, empty nest issues, and caring for the elderly and children (sandwich generation) often can trigger depression and anxiety, which may go unnoticed. We hope to create a Center that can provide a broad range of services and �safety net� for such individuals. In order to accomplish this mission, we plan to use a multiple systems approach of community care - engaging physicians, clergy and business leaders along with traditional mental health providers, to address all aspects of health: physical, mental and spiritual.

46. The Dennis H. Jones LifeNet Center Community Wide Plan, in development, would: Provide training, support and networking resources for diverse stakeholders such as primary care physicians, clergy and human resource/business leaders. Give these different professional groups additional, easy to access entry points for help for the individual in need. Diminish the stigma of depression and anxiety in the community at large. Highlight exemplary �champions�, meaning those who have overcome depression and/or anxiety symptoms and/or navigated life transitions successfully Successfully �connect the dots� between current mental health services and the stakeholders groups described above: primary care providers, clergy, as well as human resource and business leaders

47. Congregational Health NetworkEmotional Fitness Centers, LifeNet The Memphis Model: Building a Health System for all, seamlessly connecting the hospital to other resources, particularly volunteer caregivers More intentional integration with primary care providers and psychiatrists needed, to extend scope and scale of work further into the community, via CHN, EFC and LifeNet

48. Spirituality and Health Questions & Answers ? Teresa Cutts, Ph.D. (901) 516-0593 cutts02@gmail.com