Holistic Trauma-Informed Care: Integrating Spirituality & Psychotherapy by Creating a Healing Sanctuary

1. Holistic Trauma-Informed Care: Integrating Spirituality & Psychotherapy by Creating a Healing Sanctuary H. Jack Perkins, D. Min., LADC Admission Director, Rose Rock Recovery Center ODAPCA’s 39th Spring Conference April 4, 2014

2. Integration of Spirituality & Psychotherapy: A Holistic Path for Making Meaning Through Trauma. . . . . . is an interactive session to assist participants gain an understanding of trauma-informed counseling, explore meaningful ways of integrating spirituality into evidenced-based interventions, and to demonstrate the use of sacred literature and exercises to enhance the healing process. Learning Objectives: • Develop a greater sensitivity regarding the impact of trauma. • Learn how to integrate spirituality in assessments and interventions in the healing process. • Learn how spiritual metaphors, practices and rituals enhance hope and meaning. • Review ethical issues when integrating spirituality in a thoughtful and ethical manner.

3. Why include spirituality? American Association of Medical Colleges (AAMC) “…incorporate awareness of spirituality, and culture beliefs and practices, into the care of patients in a variety of clinical contexts… [and to] recognize that their own spirituality, and cultural beliefs and practices, might affect the ways they relate to, and provide care to, patients.” Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013

4. CBS Poll: Prayer Can HealFebruary 11, 2009 Praying Often And Praying For Others: Sixty percent of Americans say they pray at least once a day. Two thirds say they pray for their own health, and 82 percent say they pray for the health of others. But praying for people they don't know is less common. Protestants are more likely to pray for people they don't know than Catholics are.

5. A ROSE OF HOPE: TOWARD A NEW NEURO-PSYCHO-SPIRITUAL APPROACH FOR PERSONAL FORMATION OF ORPHAN PERSONS WITH DISABILITIESSuelaNdoja, MSc Clinical Psychologist Italian-Albanian Association “Project Hope for Orphan‟s Persons with Disabilities”, Address: L: 3 Heroj, Rr: Pal Engjëlli, Nr- 5 Shkoder, Albania

6. American Psychiatric Association:Practice Guidelines for the Psychiatric Evaluation of Adults “Important cultural and religious influences on the patient’s life…evaluation ought to be performed in a manner that is sensitive to the patient’s individuality, identifying issues of development, culture, ethnicity, gender, sexual orientation, familial/genetic patterns, religious/ spiritual beliefs…. Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013

7. In 1999 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the body charged with evaluating and accrediting nearly 19,000 health care organizations and programs in the United States, established Spiritual Assessment Standards as a response to the growing need for a greater understanding of how spirituality impacts patient care and service. www.jcaho.org Examples of elements that could be but are not required in a spiritual assessment include the following questions directed to the patient or his/her family: • Who or what provides the patient with strength and hope? • Does the patient use prayer in their life? • How does the patient express their spirituality? • How would the patient describe their philosophy of life? • What type of spiritual/religious support does the patient desire? • What is the name of the patient's clergy, ministers, chaplains, pastor, rabbi? • What does suffering mean to the patient? • What does dying mean to the patient? • What are the patient's spiritual goals? • Is there a role of church/synagogue in the patient's life? • How does your faith help the patient cope with illness? • How does the patient keep going day after day? • What helps the patient get through this health care experience? • How has illness affected the patient and his/her family?

8. The American Nurses Association (ANA) Code of Ethics The measures nurses take for the patient enable the patient to live with as much physical, emotional, social, and spiritual well-being as possible. Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013

9. Social WorkersThe NASW Standards for Social Work Practice in Health Care Settings The biopsychosocial-spiritual perspective recognizes that health care services must take into account the physical or medical aspects of ourselves (bio); the emotional or psychological aspects (psycho); the sociocultural, sociopolitical, and socioeconomic issues in our lives (social); and how people find meaning in their lives (spiritual). Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013

10. Spirituality in Mental Health Care For over a century, the divide between health care and religion has been deepest and widest in the mental health specialties. MH professionals have long considered religious beliefs to be neurotic and often inimical to good mental health . . . (p. 213) Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013

11. Research on religion and mental health • Religious/spiritual persons with acute emotional problems tend to have better MH, not worse • R/S cope better with illness, have less depression & recover more quickly from depression, often experience less anxiety, & have lower rates of AOD use. • Those with Severe & persistent MH disorders & are involved in R/S activities cope better & have fewer exacerbations requiring acute hospitalizations. Harold Koenig, Spirituality in Patient Care, 3rd Edition, 2013

12. Spirituality Research: Measuring theImmeasurableDavid O. Moberg • The growing body of evidence that there is a strong positive relationship between spiritual health and other forms of physical, psychological, and social health would seem to suggest that therapeutic interventions with clients might be enhanced by addressing spiritual dimensions of the client’s life experiences. • ~ Simpson, Newman, Fuqua, “Spirituality & Personality”

13. Defining the terms:Religion and Spirituality • Generally, spirituality is considered as a characteristic of individuals, while religion is considered to be a social or organizational phenomenon. For present purposes, we adopt the definitions of religion and spirituality offered in Koenig, McCullough and Larson 52: • Religion is an organized system of beliefs, practices, rituals and symbols designed to: facilitate closeness to the sacred or transcendent (God, Higher Power, or ultimate truth/reality) and foster an understanding of a person’s relationship and responsibility to others in living together in a community. • Spirituality is the personal quest for understanding answers to ultimate questions about life, about meaning and about relationship to the sacred or transcendent, which may (or may not) lead to, or arise from, the development of religious rituals and the formation of community.

14. FIVE AREAS OF PERSONAL DEVELOPMENT • Your spiritual side is what you believe about the purpose of life--why you and others are here and what happens to you once you die. • Your emotional side . . . consists of your feelings--how you recognize, accept, and express them. • Within your intellectual side, we include your beliefs, ideas, theories, opinions, and logic, as well as the ways in which you learn, make decisions, and think. • Your social side is the part of you that interacts with other people, God, and even animals. It includes your ways of talking, listening, playing, celebrating, fighting, and otherwise being with others. • Finally, your physical side includes your appearance, health, energy or vitality, sexual drive, and the physical activities you pursue such as walking, running, painting, swimming, dancing, and playing croquet. • G. Brain Jones and Linda Phillips-Jones, Men Have Feelings, Too! (Wheaton: Victor Books, 1988), 22-23.

15. The impact of trauma

16. What’s the problem? • An estimated 70% of adults in the US have experienced a traumatic event at least once in their lives, & up to 20% of these people will go on to develop PTSD. • More than 13 million Americans have PTSD at any given time. • Approximately one in 13 people in this country will develop PTSD during their lifetime. • An estimated one out of 10 women will get PTSD at some point in their lives. • Women are twice as likely as men to develop PTSD. • Almost 17% of men & 13% of women have experienced more than three traumatic events. http://www.chaada.org/default.asp

17. It has been shown that 3-7% of boys are sexually abused by the time they reach eighteen and 2-5% of girls • About 3% of American men – a total of 2.78 million men – have experienced a rape at some point in their lifetime (Tjaden & Thoennes, 2006). • In 2003, one in every ten rape victims was male. While there are no reliable annual surveys of sexual assaults on children, the Justice Department has estimated that one of six victims are under age 12 (National Crime Victimization Study, 2003). • 71% of male victims were first raped before their 18th birthday; 16.6% were 18-24 years old, and 12.3% were 25 or older (Tjaden & Thoennes, 2006). • Males are the least likely to report a sexual assault, though it is estimated that they make up 10% of all victims (RAINN, 2006). • 22% of male inmates have been raped at least once during their incarceration; roughly 420,000 prisoners each year (Human Rights Watch, 2001).

18. The estimated risk for developing PTSD after any of the following traumatic events: • Rape (49 percent) • Severe beating or physical assault (31.9 percent) • Other sexual assault (23.7 percent) • Serious accident or injury; for example, car or train accident (16.8 percent) • Shooting or stabbing (15.4 percent) • Sudden, unexpected death of family member or friend (14.3 percent) • Child’s life-threatening illness (10.4 percent) • Witness to killing or serious injury (7.3 percent) Natural disaster (3.8 percent) http://www.chaada.org/default.asp

19. PTSD AMONG COMBAT PERSONNEL: • Lifetime occurrence (prevalence) in combat veterans 10 – 30%. • In the past year alone the number of diagnosed cases in the military jumped 50% – and that’s just diagnosed cases. • Studies estimate that 1 in every 5 military personnel returning from Iraq and Afghanistan has PTSD. • 20% of the soldiers who’ve been deployed in the past 6 years have PTSD. That’s over 300,000. • 17% of combat troops are women; 71% of female military personnel develop PTSD due to sexual assault within the ranks. • Doing the breakdown by war: • Afghanistan = 6 – 11% returning vets have PTSD • Iraq = 12 – 20% returning vets have PTSD ~ http://healmyptsd.com/education/post-traumatic-stress-disorder-statistics

20. Teens and Children and PTSD: • 15-43% of girls and 14-43% of boys will experience a traumatic event • 3-15% girls and 1-6% of boys will develop PTSD • As many as 30 – 60% of children who have survived specific disasters have PTSD • According to the National Center for PTSD: “Rates of PTSD are much higher in children and adolescents recruited from at-risk samples. The rates of PTSD in these at-risk children and adolescents vary from 3 to 100%.” • 3 -6% of high school students in the U.S. who survive specific disaster develop PTSD • More than 33% of youths exposed to community violence with experience PTSD ~ http://healmyptsd.com/education/post-traumatic-stress-disorder-statistics

21. PTSD & GENDER • Men have 30% greater risk of being involved in a traumatic event than women, since they are more prone to witnessing a death/injury and experiencing accidents, nonsexual assault, combat, disaster, fire, serious illness, and injury. • Sexual abuse is more common among women than men and is more likely to lead to PTSD than other type of trauma. Consequently, women have twice the reported risk of PTSD as men. • The more severe women's PTSD, the more likely they are to experience physical symptoms, such as shortness of breath, headaches, joint pain, and abdominal pain. • Men may under-report psychiatric symptoms and develop other responses, such as alcohol/drug abuse, conduct disorders, and violence.

22. Are We Living In A Traumatized Society? The entire experience with trauma provoked disturbing insights that have shaken us out of our complacency. The insight that humans have a predisposition to repeat traumatic experience has led to the eruption of a profound and disturbing fear: Our society appears to be in the grips of a post-traumatic deterioration that could also end in self-destruction, just as it does with patients who remain locked in the patterns of the past. We have become convinced that trauma is not an unusual or rare experience, but that it is in fact normative. Just as a traumatic experience can become the central organizing principle in the life of an individual victim, so too is trauma a central organizing principle of human thought, feeling, belief, and behavior that has been virtually ignored in our understanding of human nature. Without this understanding we cannot hope to make the sweeping changes we need to make if we are to halt a universal post-traumatic deterioration. Sandra Bloom, Creating Sanctuary: Toward The Evolution Of Sane Societies (1997).

23. AVOIDANCE OF PTSD TREATMENT These percentages are likely to be somewhat understated, not only because the prevalence of PTSD may increase during the two years after exposure to trauma, but also because of soldiers' fears of the repercussions of admitting they are having difficulty. Even among soldiers with no mental health symptoms, general distrust and perceived barriers to seeking mental health services were obvious. Eighteen percent of these study participants reported they would be too embarrassed to seek mental health services. Twenty four percent felt admitting a problem could hurt their careers, and 31 percent felt they would be seen as weak.

24. Integration of Spirituality in assessments & interventions

25. EVIDENCE OF RELIGIOSITY/SPIRITUALITY • Over 90% of Americans believe in God or in a higher power; • 60% belong to a local religious group; • 60% think that religious matters are important or very important in how they conduct their lives; • 40% attend religious services almost weekly or more; • 80% are interested in “growing spiritually” Pargament (2007) and reported in the National Opinion Research Center’s General Social Survey (Schott 2007),

26. (Bergin, 1983; Gartner et al., 1991; Meichenbaum, 1994) • A National survey conducted by Schuster et al. (2001) found that after the terrorist attacks of September 11, 2001, 90% of Americans reported that they turned to prayer, religions or some form of spiritual activity with loved ones in an effort to cope; • Following Hurricane Katrina, 92% of those who survived and who were evacuated to shelters in Houston said that their faith played an important role in helping them get through (www.kff.org/newsmedia/7401.cfm);

27. PATHWAY TO RECOVERY:Integrating Spirituality & Psychotherapy “Doing the will of God from your heart.” Ephesians 6:6 The Path to Recovery & Healing )( Soul,ψυχη Psuche Psychology Paradigms Spiritual Paradigms Extreme Humanism Extreme Religiosity Integrated Paradigm Jack Perkins, D. Min, LADC (2005)

28. PsychospiritualModel of Spiritual FormationDavid Benner This “psychospiritual” framework “refers to the fact that the inner world has no separate spiritual and psychological compartments” (1998, p. 110). Suggesting that the terms soul and spirit are used interchangeably in Scripture, Benner states that psychospiritualityrepresents the “immaterial inner core of human personality” (1998, p. 540). Consequently, he understands human beings as integrated beings, and even more fundamentally that “all persons are created spiritual beings” (1988, p. 104). Our spirituality represents the “human quest for and experience of meaning, God, and the other” (1998, p. 87). This spirituality is what it means to be human (2002b, p. 15).

29. Spirituality: “The response to a deep & mysterious human yearning for self-transcendence & surrender” 4 Expressions of our spiritual essence: • Spirituality as a search for self-transcendence • Spirituality is that we inherently seek to surrender to, or align ourselves with, this self-transcendent being or thing • Spirituality is a human desire to resolve issues of identity, to have a personal sense of meaning and to know that our existence is not an accident • We seek an integration of our being But me—who am I, and who are these my people, that we should presume to be giving something to you? Everything comes from you; all we’re doing is giving back what we’ve been given from your generous hand. As far as you’re concerned, we’re homeless, shiftless wanderers like our ancestors, our lives mere shadows, hardly anything to us. God, our God, all these materials—these piles of stuff for building a house of worship for you, honoring your Holy Name—it all came from you! 1 Chronicles 29:14 (MSG)

30. Views According to Various Traditions: • Nullification and absorption within God's Infinite Light (Chassidic schools of Judaism) • Complete detachment from the world (Kaivalya in some schools of Hinduism, including Sankhya and Yoga; Jhana in Buddhism) • Liberation from the cycles of Karma (Moksha in Sikhism, Jainism and Hinduism, Nirvana In Buddhism) • Deep intrinsic connection to the world (Satori in Mahayana Buddhism, Te in Taoism) • Union with God (Henosis in Neoplatonism and Theosis in Christianity, Brahma-Prapti or Brahma-Nirvana in Hinduism) • Innate Knowledge (Irfan and fitra in Islam) • Experience of one's true blissful nature (Samadhi or Svarupa-Avirbhava in Hinduism) • Liberating the individual to return to a natural state (Dionysian Mysteries)

31. FAITH QUESTIONS • What are you spending and being spent for? What commands and receives your best time, your best energy? • For what causes, dreams, goals or institutions are you pouring out your life? • As you live your life, what power or powers do you fear or dread? What power or powers do you rely on and trust?  • To what or who are you committed in life? In death? • With whom or what group do you share your most sacred and private hopes for your life and for the lives of those you love? • What are those most sacred hopes, those most compelling goals and purposes in your life? James Fowler, The Psychology of Human Development and the Quest for Meaning, p. 3.

32. William James' Definition of Religious Experience Psychologist and PhilosopherWilliam James described four characteristics of religious / mystical experience in The Varieties of Religious Experience. According to James, such an experience is: • Transient -- the experience is temporary; the individual soon returns to a "normal" frame of mind. • Ineffable -- the experience cannot be adequately put into words. • Noetic -- the individual feels that he or she has learned something valuable from the experience.

33. Meditation & The Brain“Think on these things…”“For God so loved the cosmos…” Research by neurotheology indicates that during a deep state of meditation: • Attention: Linked to concentration, the frontal lobe lights up during meditation • Religious Emotions: The middle temporal lobe is linked to emotional aspects of religious experience, such as joy and awe • Sacred Images: The lower temporal lobe is involved in the process by which images, such as candles or crosses, facilitate prayer and meditation • Response to Religious Words: At the juncture of three lobes, this region governs response to language • Cosmic Unity: When the parietal lobes quiet down, a person can feel at one with the universe

34. SIGNS OF SENSORY INTEGRATION DISORDERAccording to Sensory Integration International • Extreme sensitivity (or underreaction) to touch, movement, sights, or sounds • Distractibility • Social and/or emotional problems • Activity level that is unusually high or unusually low • Physical clumsiness or apparent carelessness • Impulsivity, or lack of self-control • Difficulty making transitions from one situation to another • Inability to unwind or calm one's self • Delays in speech, language, or motor skills • Delays in academic achievement

35. SANCTUARY. . . Ahhh . . . a sanctuary--a place of protection, safety, peace and rest. A sanctuary of God is a place inhabited by God--the Almighty Creator, our Savior, Friend, and Comforter the Holy Spirit.

36. SPIRITUAL QUALITIES

37. Learn How to Integrate Spirituality in Assessments & Interventions in the Healing Process

38. RESPONSES TO TRAUMA

39. Clinical Diagnoses Related to Trauma • If the trauma did not involve an experience so intense as to warrant a diagnosis such as Acute Stress Disorder (see below), and if the symptoms do not represent ordinary bereavement , then an Adjustment Disorder may be diagnosed. • The predominant symptoms which characterize an Adjustment Disorder can be depressed mood, anxiety, disturbance of conduct(e.g., fighting, vandalism, reckless driving), or other maladaptive reactions (e.g., physical complaints, work or academic inhibition, social withdrawal). By its definition, an Adjustment Disorder cannot last longer than 6 months, unless the precipitating experience is ongoing or has ongoing consequences.

40. Clinical Diagnoses Related to Trauma, Cont. • If, however, the precipitating experience involved actual or threatened death or physical injury; the symptoms have elements of dissociation, re-experiencing (i.e., flashbacks), avoidance of reminders of the experience, and anxiety; and the symptoms persist for several days and cause a serious impairment in normal daily functioning, a diagnosis of Acute Stress Disorder (ASD) may be made. If symptoms persist for longer than one month, Posttraumatic Stress Disorder (PTSD) may be diagnosed. • Children subject to repeated, ongoing abuse may also develop Dissociative Identity Disorder, commonly known as “multiple personality.”

41. We conclude that veterans’ pursuit of mental health services appears to be driven more by their guilt and the weakening of their religious faith than by the severity of the PTSD symptoms of the deficits in social functioning . . . . This raises the broader issue of whether spirituality should be more central to the treatment of PTSD Fontana & Rosenheck, 2004

42. How can you assess your client’s spirituality and the role it plays in his/her life? • How can you, as a psychotherapist (helper), incorporate your client’s spirituality into treatment? • How can you nurture your client’s spiritual coping efforts? • What are the barriers/obstacles of integrating spirituality into your psychotherapeutic efforts and how can these be anticipated and addressed? • What are the dangers of highlighting your client’s spirituality and how can these be anticipated and addressed?

43. Spirituality’s affect on clinical issues • Isolation and Social Withdrawal. Defining spirituality as a connection to the sacred, and encouraging trauma survivors to seek supportive, healthy communities can directly address these symptoms. • Guilt and Shame. Though not part of the diagnostic criteria for PTSD, guilt and shame are recognized as important clinical issues. Spirituality may lead to self-forgiveness and an emphasis on compassion toward self. • Anger and Irritability. Beliefs and practices related to forgiveness can address anger and chronic hostile attitudes that lead to social isolation and poor relationships with others. • Hypervigilence, Anxiety, and Physiological arousal. Inwardly-directed spiritual practices such as mindfulness, meditation, and prayer may help reduce hyperarousal. • Foreshortened Future and Loss of Interest in Activities. Rediscovery of meaning and purpose in one's life may potentially have enormous impact on these symptoms.

44. Shame and the loss of hope ~ a future Shame is a deep, debilitating emotion, with complex roots. Its cousins are guilt, humiliation, demoralization, degradation and remorse. After experiencing a traumatic event, whether recent or in the distant past, shame can haunt victims in a powerful and often unrecognized manner. Shame impairs the healing and recovery process causing victims of trauma to stay frozen, unable to forgive themselves for being in the wrong place at the wrong time. Shame leaves victims with feelings of sadness and pain at the core of their being. They are unable to feel the fullness of joy in their lives. Trauma allows “shame thinking” to blossom from deep roots in culture, religion, family or our childhood past. As children we tend to blame ourselves for things that happen around us, because we are limited in our capacity to think about others being responsible. In a five-year old’s mind if something bad happened, then she or he must have deserved it, therefore the universe makes sense. It is not until around age 12 that we gain the cognitive capacity to see how others’ actions and behaviors are more complex with varying degrees of culpability. However, there are many confusing messages about responsibility in our culture, causing even adult victims of trauma confusion over responsibility for the perpetrator’s actions. For example, the way a woman was dressed being part of the questioning by a police officer investigating a sexual assault. Shame can dissolve positive self-esteem and leave victims of trauma feeling different and less worthy and in some cases even bad or evil themselves. The trauma and the resulting shame potentiate each other, causing greater intensity in the psychological wounds. The end result is that a traumatized person no longer feels worthy of being loved, accepted, and having good things happen to them in their life. Dr. Angie Panos, “Healing from Shame Associated with Traumatic Events”

45. Spiritual Assessment Spiritual assessment is defined as the process of gathering and organizing spiritually based data into a coherent format that provides the basis for interventions (Hodge, 2001a; Rauch, 1993). The subsequent interventions may or may not be spiritually based. As implied above, a spiritual assessment may be conducted for the purposes of using traditional, non-spiritual, interventions in a manner that is more congruent with clients’ beliefs and values. Spiritual assessments should be multidisciplinary. Physicians, therapists, nurses, and clinical pastoral staff should receive training on the value of spiritual assessments and the tools that should be used to assess a patient’s spirituality. Joint Commission: The Source [vol. 3, no. 2 (February 2005): 6-7]

46. Characteristics of Competent Assessors ■ A willingness and a desire to learn about how to conduct a spiritual assessment ■ An understanding that there are many different spiritual and religious perspectives ■ An ability to focus on spiritual issues with a patient without forcing one’s own beliefs on him or her ■ A comfort level with discussing spiritual issues ■ A knowledge of appropriate responses to spiritual disclosures, including prayer, meditation, walks in quiet nature areas, and so forth. Joint Commission: The Source, February 2005, Volume 3, Issue 2

47. Beyond PTSD: Soldiers Have Injured SoulsDiane Silver Post Traumatic Soul Disorder

48. The spirituality history genreAustralian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009 spiritual history arguably forms its own genre. A “genre” is defined as “a category of artistic, musical, or literary composition characterized by a particular style, form, or content” (Webster, 1977). Harold Koenig provides the groundwork for this genre study in Spirituality in Patient Care where he presents five criteria he considers critical for a spiritual history (2007): • It must be brief. • It must be easy to remember. • It must obtain appropriate information. • It must be patient-centered. • It must be validated as credible by experts. When all five of these criteria are used together, the critic is able to adjudicate the strengths and weaknesses of various spiritual histories (LaRocca-Pitts, 2008b). However, when discussing spiritual histories as a distinct genre only the first three of these criteria are needed.

49. The spirituality history genre, continuedAustralian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009 When we modify these three criteria in light of published spiritual histories, we get the following requirements for this genre: • 1. A spiritual history is brief: it contains a brief series of categories or topics with pertinent questions. • 2. A spiritual history is easy to remember: a memorable acronym is used to recall the categories. • 3. A spiritual history obtains appropriate information: its questions address the patient’s spiritual resources, the patient’s use of them in his/her past and current situation, and how these resources and uses impact the patient’s medical care.

50. HOPE (Anandarajah & Hight, 2001) • H – Sources of hope, meaning, comfort, strength, peace, love, and compassion: What is there in your life that gives you internal support? What are the sources of hope, strength, comfort, and peace? What do you hold on to during difficult times? What sustains you and keeps you going? • Organized religion: Do you consider yourself as part of an organized religion? How important is that for you? What aspects of your religion are helpful and not so helpful to you? Are you part of a religious or spiritual community? Does it help you? How? • Personal spirituality/practices: Do you have personal spiritual beliefs that are independent of organized religion? What are they? Do you believe in God? What kind of relationship do you have with God? What aspects of your spirituality or spiritual practices do you find most helpful to you personally? • Effects on medical care and end-of-life issues: Has being sick (or your current situation) affected your ability to do the things that usually help you spiritually? (Or affected your relationship with God?) As a doctor, is there anything that I can do to help you access the resources that usually help you? Are you worried about any conflicts • H – Sources of hope, meaning, comfort, strength, peace, love, and compassion: What is there in your life that gives you internal support? What are the sources of hope, strength, comfort, and peace? What do you hold on to during difficult times? What sustains you and keeps you going? between your beliefs and your medical situation/care decisions? Are there any specific practices or restrictions I should know about in providing your medical care? Australian Journal of Pastoral Care and Health Vol. 3, No. 2, December 2009