Spirituality and Health Research: Introduction and Context

Spirituality/Religion & Health Research: Introduction and Context Chaplain John W. Ehman Penn Presbyterian Medical Center Philadelphia, PA 4/25/16

Research as a “Way of Knowing” (Empiricism is just an epistemological strategy.)

Number of Medline-Indexed English Articles by Year, with Keywords: RELIGION and SPIRITUALITY [ Includes the variations: religious, religiosity, religiousness, and spiritual ] John Ehman, 2016

Polls re: Religion/Spirituality in the US • 90-96% of adults in the US say they “believe in God” • over 40% say they attend religious services regularly, usually at least once a week • 50-75% say religion is “very important” in their lives • 90% say they pray, and most (54-75%) say they pray at least once a day • over 80% say that “God answers prayers” • 79-84% say they believe in “miracles” and that “God answers prayers for healing someone with an incurable illness” --These percentages are summary characterizations of numerous national surveys showing fairly consistent results across time

Number of Medline-Indexed English Articles by Year, with Keywords SPIRITUAL or SPIRITUALITY John Ehman, 6/30/09

Among the factors in the mid-1990saffecting the study of spirituality/religion & health: • Greater attention paid to religious values, beliefs, and practices as key aspects of patient diversity (e.g., new emphasis by the Joint Commission) • Growing sense among health care providers and researchers of religion’s role in health-pertinent behaviors and health care decision-making -- important for “knowing your patient” • Research begins accumulating significant data that patients’ spirituality/religiosity may be important to medical outcomes and thus to the process of “healing your patient” • Grants availability for research and medical school programs on spirituality & health

Three things to keep in mind about the modern field of Spirituality and Health: 1)The field is still nascent, though a great deal of research has laid a good foundation 2)The field uses somewhat fluid terminology 3)Currently a drive within chaplaincy organizations to develop research in order to demonstrate chaplains’ effectiveness and inform chaplains’ practice (--including some people pushing for chaplaincy to be an “evidence-based” profession)

In the health care literature, religion is associated with institutional systems of beliefs and practices, whereas spirituality is associated with personal experiences and an individual quest for meaning. Spirituality is generally seen as a broad concept, going beyond the “limits” of religion.

The Two Most Common Views of the Relationship of Spirituality to Religion in the Current Health Care Literature Spirituality Spirituality Religion Religion

A New and Important Definition of Spirituality: ‘‘Spirituality is a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence, and experience relationship to self, family, others, community, society, nature, and the significant or sacred. Spirituality is expressed through beliefs, values, traditions, and practices.’’ — p. 646 of Puchalski, C. M., et al., "Improving the Spiritual Dimension of Whole Person Care: Reaching National and International Consensus," Journal of Palliative Medicine 17, no. 6 (June 2014): 642-656

Terminology pairings in Medline articles, 1998-2011

The character of spirituality as a concept in the current health care literature: •interest in inclusivity and diversity •interest in going beyond the “limits” of religion •focus on the here-and-now, individual, human experience (--concept not essentially theistic) •focus on pragmatic value in the healthcare context (e.g., coping with illness) •concept accepted as somewhat ambiguous

While the broad concept of spirituality holds strong appeal in the practice of health care and is prominent in the literature, religion tends to be favored as the focus of research because the concept highlights factors that can be more easily specified, observed, and quantified.

While the broad concept of spirituality holds strong appeal in the practice of health care and is prominent in the literature, religion tends to be favored as the focus of research because the concept highlights factors that can be more easily specified, observed, and quantified. However, a growing problem with religion-focused research is that Americans are increasingly less likely to see themselves and fit themselves in traditional categories of religion.

Americans and Religious Affiliation A 2012 Pew Research Center survey found that one-fifth of the U.S. public – and a third of adults under 30 years old – now describe themselves as “religiously unaffiliated.” This is partly due to an increasing trend to drop all sense of connection to a specific religious tradition when there is not an active social involvement in a congregation. Moreover, 18% of American adults describe themselves now as “spiritual but not religious.” Pew Research Center’s Forum on Religion & Public Life, "'Nones' on the Rise…,” report issued October 9, 2012

Religion-focused research remains the driving force in the overall field of “Spirituality & Health” because it is conducive to drawing practical connections with health issues. For example: •fewer dangerous behaviors (e.g., less substance abuse, unsafe sex, or neglect of health screenings) • less suicide and generally greater aversion to suicide • less depression and faster recovery from depression • greater sense of meaning/purpose in life, hopefulness --See: Koenig, H.G, et al., Handbook of Religion and Health, 2001/2011; and Koenig, H.G., Testimony to the US House of Representatives Subcommittee on Research and Science Education, 9/18/08

• lower rates of coronary artery disease • lower cardiovascular reactivity • greater heart rate variability • lower blood pressure and generally less hypertension • tendency for better outcomes after cardiac surgery • better endocrine function • better immune function • lower cancer rate and better outcomes • lower mortality and longer survival generally --ibid.

Theoretical Model of How Religion Affects Physical Health --adapted from Koenig, et al., Hand- book ofReligion and Health, 2001 Religion also affects Childhood Training, Adult Decisions, and Values & Character; which then in turn affect mental health, social support, and health behaviors. Stress Hormones Infection Mental Health Cancer Immune System R E L I G I O N Heart Disease Hyper- tension Social Support Autonomic Nervous System Stroke Stomach & Bowel Disease Detection and Treatment Compliance Health Behaviors Liver & Lung High Risk Behaviors (smoking, drugs) Accidents & STDs

7 Basic Difficuties for Spirituality & Health Research • Assumptions about the mechanisms of cause and effect • Problem of concepts coming from different conceptual bases • Problem of generalization across diverse populations • Qualitative vs. Quantitative / Descriptive vs. Interventional • Measures: Trait vs. State (--and how to capture change) • Size of effect may be significant but not dramatic • Problem of a drive toward particularity in a field characterized by the subjective and the numinous

Spirituality, the Brain, and Cell Life Studies using MRI indicate not only that certain kinds of religious/spiritual meditative practices can influence blood flow and activity in the brain but can even have a lasting effect on brain function and perhaps structure. --Newberg, A. B., et al., "Cerebral blood flow differences between long-term meditators and non-meditators,“ Consciousness & Cognition 19, no. 4 (Dec 2010): 899-905. Some forms of mindfulness meditation, practiced over time, appear to control cognitive stress reactions like threat appraisal and rumination to such a degree as to protect against the cellular process of the deterioration of telomeres, affecting cell life. --See: Epel, E., et al., "Can meditation slow rate of cellular aging? Cognitive stress, mindfulness, and telomeres," Annals of the New York Academy of Sciences 1172 (Aug 2009): 34-53.

Frontal Lobe Activity of Buddhists Meditating --see Newberg, et al., "The measurement of regional cerebral blood flow…,” Psychiatry Research: Neuroimaging 106, no, 2 (April 10, 2001): 113-122.

Parietal Lobe Activity of Buddhists Meditating --see Newberg, et al., "The measurement of regional cerebral blood flow…,” Psychiatry Research: Neuroimaging 106, no, 2 (April 10, 2001): 113-122.

Non-Meditators and Long-Term Meditators --Newberg, A. B., et al., "Cerebral blood flow differences between long-term meditators and non-meditators,“ Consciousness & Cognition 19, no. 4 (Dec 2010): 899-905.

Spiritual/Religious Support & Medical Costs • A multisite study by a Harvard group found that medical costs for cancer patients in the last week of life (n=339) were higher for those who reported not receiving sufficient spiritual/religious support from the care team as a whole. • On average, care cost $2441 more than for those who received spiritual/religious support from the team, but $4060 for “high religious coping” patients and $4206 among racial/ethnic minorities • Costs centered around ICU care and hospice care in the last week of life. -- Balboni, T., et al., “Support of cancer patients’ spiritual needs and associations with medical care costs at the end of life,” Cancer 117, no. 23 (Dec 1, 2011): 5383-5391

Recent health care literature largely addresses religion/spirituality as… … a ground for “religious” social support … a value basis for personal meaning-making (and therefore understanding illness and coping with crises) and decision-making … a context for behavior that can influence the way the body works (e.g., meditation that can affect physiological reactions to stress)

Two Immediately Pressing Questions about Research and Chaplaincy What is the connection between spirituality & health research and spiritual assessment/intervention? What is the difference between chaplaincy as a research-informed profession and an evidence-based profession?

RESOURCES ACPE Research Network www.ACPEresearch.net Annual Bibliographies on Spiritualty & Health Posted annually on the Penn Medicine Pastoral Care website: www.uphs.upenn.edu/pastoral

john.ehman@uphs.upenn.edu

Variety in Patients’ Sense of “Spiritual Needs” Hospice patients were first asked: “What does the word spiritual mean to you personally?” and then “What needs can you identify related to your spirituality as you described it?” Need for Religion: to pray, go to services, read/use scripture, read/use inspirational material, sing/listen to music Need for Companionship: need to be with family and friends, talk with others, care for others, be with children Need to Experience Nature: to look outside, be outside, have flowers Need for Positive Outlook: to see smiles of others, laugh, think happy thoughts, take one day at a time Need for Involvement and Control: to have input into own life, be as independent as possible, be involved with family activities, have information about own care, be helped by others, have things stay the same Need to Finish Business: to do a life review, finish life tasks, come to terms with the present situation, resolve bitter feelings --Hermann, C. P., "Spiritual needs of dying patients: a qualitative study," Oncology Nursing Forum 28, no. 1 (Jan-Feb 2001): 67-72

Study of Perceived/Met Spiritual Needs at EOL Perceived (%)Met (%) Laugh 100 65 Think happy thoughts 98 76 See the smiles of others 97 81 Be with family 96 65 Be with friends 96 64 Pray 95 96 Talk about day-to-day things 95 82 Have information about family and friends 88 77 Be with people who share my spiritual beliefs 88 74 Go to religious services 85 30 Be around children 83 72 Sing or listen to music 80 80 Read a religious text 80 64 Talk with someone about spiritual issues 79 75 Read inspirational materials 68 69 Use phrases from religious text 65 86 Use inspirational materials 59 86 --from: Hermann, C. P., “The degree to which spiritual needs of patients near the end of life are met,” Oncology Nursing Forum 34, no. 1 (Jan 2007): 70-78

Spirituality and Health Research: Introduction and Context