Spirituality and Health: Multidisciplinary Explorations

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SPIRITUALITY HEALTH Multidisciplinary Explorations Augustine Meier | Thomas St. James O’Connor Peter L. VanKatwyk | editors


Spirituality and Health Multidisciplinary Explorations


Spirituality and Health Multidisciplinary Explorations

edited by Augustine Meier Thomas St. James O’Connor Peter VanKatwyk

We acknowledge the financial support of the Government of Canada through the Book Publishing Industry Development Program for our publishing activities. We acknowledge the financial support of the Society for Pastoral Counselling Research (SPCR).

Library and Archives Canada Cataloguing in Publication Spirituality and health : multidisciplinary explorations / edited by Augustine Meier, Thomas St. James O’Connor, Peter VanKatwyk. Includes bibliographical references and index. ISBN 0-88920-477-2 1. Health—Religious aspects. 2. Medical care—Religious aspects. 3. Spiritual healing. I. Meier, Augustine, 1933– II. O’Connor, Thomas St. James, 1950– III. VanKatwyk, Peter BL65.M4S675 2005

201'.661

C2005-906722-5

Cover design by Sandra Friesen, using a photograph by Jeremy Henderson. Text design by Catharine Bonas-Taylor. ©2005 Wilfrid Laurier University Press Waterloo, Ontario, Canada www.wlupress.wlu.ca

Printed in Canada Every reasonable effort has been made to acquire permission for copyright material used in this text, and to acknowledge all such indebtedness accurately. Any errors and omissions called to the publisher’s attention will be corrected in future printings. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, without the prior written consent of the publisher or a licence from The Canadian Copyright Licensing Agency (Access Copyright). For an Access Copyright licence, visit www.accesscopyright.ca or call toll free to 1800-893-5777.




Contents

About the Editors vii Contributors ix Acknowledgements xv Preface xvii Introduction 1 Part 1 Faith Perspectives and Challenges 1 Towards a Joint Paradigm Reconciling Faith and Research 11 Thomas St. James O’Connor and Elizabeth Meakes 2 A Critical Dialogue between Theology and Psychology 23 Paul J. Rennick 3 Assessing Plurality in Spirituality Definitions 43 Pam McCarroll, Thomas St. James O’Connor, and Elizabeth Meakes 4 Spirituality and Family Medicine 61 Cheryl Levitt 5 Congregational Life after Abuse 73 Carol Penner 6 Islamic Spiritual Care in a Health Care Setting 85 Nazila Isgandarova

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Part 2 Spiritual Practices in Health Care 7 Communication in Spiritual Care among People with Dementia 105 Ellen Bouchard Ryan, Lori Schindel-Martin, and Amanda Beaman 8 Spirituality and Addiction 123 Lori Edey 9 Spirituality in Occupational Therapy 139 Sue Baptiste 10 Using a Labyrinth in Spiritual Care 149 Ingrid Bloos 11 A Wholistic Approach to Healing: An Individual, Family, and Community Model 167 Calvin Morrisseau Part 3 Frontiers and Research 12 Old Religion, New Spirituality, and Health Care 191 Carlton F. Brown 13 God-Talk in the Spiritual Care of Palliative Patients 211 Colleen Lashmar 14 Measuring and Assessing Suffering in Arthritic Patients 227 Beverley Clarke, A.R.M. Upton, Claudia Castellanos, and Mary Lou Schmuck 15 Psychosomatics and the Spiritual Entities of the Human Psyche 241 Marie-Line Morin 16 Life-Threatening Illness: A Dangerous Opportunity 265 Beverly Musgrave 17 The Neurobiology of Consciousness and Spiritual Transformation in Healing 285 Stephen M. Sagar Index 307




About the Editors*

Augustine Meier is a professor emeritus in the Faculty of Human Sciences, Saint Paul University, Ottawa, Ontario, an adjunct research professor in the Department of Psychology, Carleton University, Ottawa, and a certified clinical psychologist in private practice. For twenty years, he taught graduate courses in psychotherapy and psychopathology and trained graduate students in individual counselling. He currently teaches a theory course on object relations therapy and self-psychology and provides advanced training in the same. Dr. Meier has reviewed manuscripts for a number of journals, including Psychotherapy Research, The Journal of Consulting and Clinical Psychology, and Pastoral Sciences. He has published numerous articles on psychotherapy, psychopathology, and pastoral counselling in refereed journals, and presented advanced workshops on the use of mental imagery in psychotherapy and on themeanalysis. He has been the English editor of the journal Pastoral Sciences, is the editor of the book In Search of Healing (2003), co-editor of the book The Challenge of Forgiveness (2001) and a contributor to both books. His recent publication is “Narrative in psychotherapy theory, practice, and research: A critical review.” Professor Meier is the founder and first president of the Society for Pastoral Counselling Research. *The three editors, all of whom are also contributors to this volume, share close ties in their active role in the Society for Pastoral Counselling Research, a forum for graduate students. As well, they are established teachers and practitioners in their fields, presenting papers on their practical and theoretical research. The editors have worked as equal partners in coordinating this publication as a tribute to the richness that marked the Society’s Eighth Annual Conference on Spirituality and Health Care held at McMaster University and Hamilton Health Sciences in May 2001.

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Thomas St. James O’Connor holds the Delton J. Glebe Chair, Pastoral Counselling, at Waterloo Lutheran Seminary, and is also the director of pastoral counselling programs at Waterloo Lutheran Seminary, Wilfrid Laurier University, Waterloo. He is an associate clinical professor in family medicine at McMaster University. He was co-educator (with Elizabeth Meakes) of the residency program in spiritual care at St. Joseph’s Healthcare in Hamilton, and a teaching chaplain at Hamilton Health Sciences. Dr. O’Connor is a teaching supervisor in the Canadian Association for Pastoral Practice and Education (CAPPE) and an approved supervisor in the American Association for Marriage and Family Therapy (AAMFT). Currently, he is the president of the Society for Pastoral Counselling Research (SPCR). He has authored and co-authored over thirty book chapters and papers in peer-reviewed journals, and is the author of Clinical Pastoral Supervision and the Theology of Charles Gerkin (1998). He is on the editorial committee of The Journal of Pastoral Care & Counseling and consulting editor for the Journal of Religion, Disability & Health. He is the book review editor for Pastoral Sciences. Peter L. VanKatwyk has, in the last twenty-five years, conducted a therapy practice and directed clinical education programs as a supervisor certified by the Canadian Association for Pastoral Practice and Education (CAPPE) and the American Association for Marriage and Family Therapy (AAMFT). He has worked as a professor of Pastoral Care and Counselling at the Waterloo Lutheran Seminary, Wilfrid Laurier University, Waterloo, Ontario. He has authored numerous articles in the area of spiritual care and therapy, and is the co-editor of and a contributor to the book The Challenge of Forgiveness (2001). He is a former president of the Society for Pastoral Counselling Research, and contributor to In Search of Healing (2003), the collected papers from the Society’s annual conferences. His most recent book is Spiritual Care and Therapy: Integrative Perspectives (2003).




Contributors

Sue Baptiste is the assistant dean of Occupational Therapy at the School of Rehabilitation Science in the Institute of Applied Health Sciences, McMaster University, Hamilton, Ontario. One of her research interests is in the area of occupational therapy and spirituality. Amanda Beaman is a graduate student in clinical psychology at the Centre for Research in Human Development, Concordia University, Montreal, Quebec. Past research included an examination of the many positive outcomes of fostering person-centred communication with cognitively impaired older adults, and the relationships between autobiographical memory, cognitive ability, and interpersonal problem solving in older adults. Ingrid Bloos is a family therapist in private practice in Kitchener-Waterloo, Ontario. Her MTS thesis was on the labyrinth and pastoral counselling. She has co-authored (with Tom O’Connor) an article on the labyrinth and narrative therapy that was published in Pastoral Psychology in 2002. She has given many workshops on using the labyrinth for health and healing. Carlton F. Brown is a specialist in pastoral counselling (CAPPE), an associate teaching supervisor in CAPPE, and a clinical member of AAMFT. Mr. Brown is in private practice and has done clinical work with mental health clients. Beverley Clarke is a professor in the School of Rehabilitation Science at McMaster University, Hamilton, Ontario, and is a neurology associate in ix

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the Division of Neurology. She has developed and implemented four free-standing multidisciplinary courses in the Faculty of Health Sciences at McMaster University on the subject of the wounded spirit and health. She has also published in the areas of epilepsy and physiotherapy, suffering in physiotherapy practice, and suffering and cost containment, as well as on the topics of cognitive motor control and postural instability in patients who have received brain stimulators to control epileptic seizures. Claudia Castellanos is a research assistant in the neurology program at McMaster University, Hamilton, Ontario. Lori Edey is an International Certified Alcohol and Drug Counsellor (ICADC). She is a teaching supervisor in the Canadian Association for Pastoral Practice and Education (CAPPE) and assistant clinical professor of family medicine at McMaster University in Hamilton, Ontario. She currently works as a counsellor and educator, with a strong interest in personal and professional integration for physicians, clergy, and religious. Nazila Isgandarova is a journalist who was educated in Azerbaijan and the United Kingdom. She has completed her Ph.D. thesis on early translations of the Qur’an and is preparing for its defence in the United Kingdom. She was a resident chaplain at St. Joseph’s Healthcare, Hamilton, Ontario, offering spiritual care to Muslim and non-Muslim patients. She is married with two children and is a practising Muslim. She has written three books, the most recent being Land of Hope: Modern Political History of Azerbaijan (2004). She also writes for the Hamilton Spectator. Colleen Lashmar is a member of the Congregation of the Sisters of St. Joseph, Hamilton, Ontario, and is the director of spiritual care at Cambridge Memorial Hospital, Cambridge, Ontario. She is an adjunct professor at Waterloo Lutheran Seminary, Waterloo, where she co-teaches in aging and spirituality and health care. Colleen is a teaching supervisor in the Canadian Association for Pastoral Practice and Education (CAPPE) and a clinical member of the American Association for Marriage and Family Therapy (AAMFT). Her doctoral thesis was on God-talk and palliative care patients. Cheryl Levitt is chair of the Department of Family Medicine at McMaster University, Hamilton, Ontario. She was born in South Africa, trained there, and did her internship at Baragwanath Hospital, Soweto. She left in 1977 for Canada and practised in rural British Columbia from 1977 to

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1984. Dr. Levitt has been an academic family physician since 1984 at McGill and McMaster universities. She is involved in family medicine leadership at a national, provincial, and local level, with involvement in primary care. Dr. Levitt is an executive member of the Ontario College of Family Medicine, and has published widely on primary care issues, medical migration of foreign doctors, and maternal and child health. Pam McCarroll was the continuing education coordinator at Knox College at the University of Toronto. She has published a number of articles in peer-reviewed journals. Her research work has focused on spirituality in palliative care, quantity and types of research articles in various databases, the Helping Styles Inventory (HSI), and the critique of theology on health-care spirituality. Elizabeth Meakes was a pastoral educator at St. Joseph’s Healthcare in Hamilton, Ontario, and is an adjunct professor at Waterloo Lutheran Seminary, Waterloo, where she co-teaches graduate courses in aging and gender and spirituality. Ms. Meakes has co-authored over ten articles published in peer-reviewed journals such as The Journal of Pastoral Care & Counseling, Pastoral Sciences, and the Journal of Religion, Disability & Health. She is on the editorial board of the Journal of Religion, Disability & Health, and reviews manuscripts for Pastoral Sciences. Ms. Meakes is a specialist in pastoral counselling in the Canadian Association for Pastoral Practice and Education (CAPPE), and a clinical member of the American Association for Marriage and Family Therapy (AAMFT). Marie-Line Morin is a professor of Pastoral Counselling at the Faculté de théologie, d’éthique et de philosophie de l’Université de Sherbrooke, Quebec. Her research interests relate to the concept of fundamental value and its various applications to pastoral counselling. She is also interested in applying the phenomenological method of research developed by Amedeo Giorgi to analyze pastoral counselling experimentations. Calvin Morrisseau is a member of the Couchiching First Nation near Fort Frances, Ontario. Currently, he is the executive director of the Giizhikaandag Healing Centre at Couchiching, Fort Frances. He has also held the positions of the human and social services manager at the Couchiching First Nation and program manager at the Weechi-it-te-win Child and Family Services in Fort Frances. Based on his twenty years of training in counselling and addiction studies, his education in traditional practices by Aboriginal elders, healers, and teachers, and his personal recovery from addictions, abuse, assimilation, racism, and poverty,

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he has written a book, Into the Daylight, which presents a wholistic individual, family, community, and spiritual model of healing. He facilitates workshops relevant to the wholistic model that he advocates in his book. Beverly Musgrave is an assistant professor in pastoral counselling and spiritual care, Graduate School of Religion and Religious Education, Fordham University, New York. She has completed training in pastoral psychotherapy and psychoanalytic therapy at the Blanton-Peale Institute, and has a clinical practice in pastoral counselling in New York City. Professor Musgrave is a founder and former president of Partners in Healing, and a Fellow in the American Association of Pastoral Counselors. She is co-editor of Partners in Healing: Bringing Compassion to People with Illness or Loss (2003). Carol Penner has taught theology at Conrad Grebel University College at the University of Waterloo as well as religious studies at Brock University in St. Catharines, Ontario. She has worked as a chaplain and a congregational minister, and has published a number of articles in Consensus and The Journal of Pastoral Care & Counseling. She is currently pastoring a Mennonite congregation in Vineland, Ontario. Paul J. Rennick is the founding director of The Saint Basil Institute of Counselling and Mental Health Education at Assumption University, Windsor, Ontario. Before coming to Windsor, he was an in-patient therapist at Saint Luke Institute, Silver Spring, Maryland, a private psychiatric hospital for clergy and ministerial personnel from all over the world. He has graduate degrees in both theology and counselling. Currently, he is Vice-President, Academic, at Assumption University. Ellen Bouchard Ryan is a professor in the Department of Psychiatry and Behavioural Neurosciences and in gerontology at McMaster University, Hamilton, Ontario. Supported for twenty years by the Social Sciences and Humanities Research Council, her research program addresses intergenerational communication. She has developed aging models to highlight the central role of communication in promoting personhood and spirituality in later life. Dr. Ryan is a former director of gerontology at McMaster, as well as a former chair of psychology at the University of Notre Dame, Indiana. Stephen M. Sagar is an associate professor in the Department of Medicine at McMaster University, Hamilton, Ontario, and an oncologist at the Juravinski Cancer Centre (formerly the Hamilton Regional Cancer Cen-

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tre). He contributes to the educational programs at the Center for MindBody Medicine in Washington, DC. He is on the international editorial boards of the evidence-based journals Focus on Alternative and Complementary Therapies and Integrative Cancer Therapies. Lori Schindel-Martin is director of the Ruth Sherman Centre for Research and Education and a clinical nurse specialist in dementia care at Shalom Village in Hamilton, Ontario. She is an assistant clinical professor at McMaster University School of Nursing, and has completed her Ph.D. in clinical and health sciences at McMaster. Mary Lou Schmuck is a research assistant in the Programme for Educational Research and Development at McMaster University, Hamilton, Ontario. A.R.M. Upton is a professor of medicine in the area of neurology at McMaster University, Hamilton, Ontario. Dr. Upton is also the head of the Division of Neurology at Hamilton Health Sciences Corporation, McMaster Division.




Acknowledgements

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his book is a testament to my having been part of the Society for Pastoral Counselling Research for some ten years. When I attended my first annual conference, I was struck by the close interaction of students and teachers whose roles were reciprocated through the sharing of their practical and theoretical research. I have become deeply grateful for this learning community of friends and colleagues where I learned that good research is never dull, especially when targeted at the frontiers of pastoral counselling and spiritual care. This book also marks my official retirement in 2003 as director of the Pastoral Counselling Program at the Waterloo Lutheran Seminary, another community that has been on the cutting edge in the education of the varied pastoral care disciplines. As part of ongoing work commitments, this book exemplifies the transitory and ambiguous reality of my retirement. I am indebted to my wife, Myra, both for her patience with my protracted tasks and her conviction that this, too, will pass. — Peter L. VanKatwyk To assemble an edited book requires the collaboration of many people. The editor wishes to express his appreciation to the authors who contributed a chapter to the book for their commitment to the project and for their graciousness in accepting the editorial comments in the review process. Deepest appreciation is expressed to my co-editors, Peter VanKatwyk and Thomas St. James O’Connor, for the joy and delight in working together with them on this project and for their enthusiasm in

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bringing forth an interdisciplinary collection. Their passion for the integration of spirituality in the healing process added pleasure to the entire editorial process. I wish to express my heartfelt thanks to my wife, Micheline Boivin, and to our daughter, Molisa, for their interest in the project, their comments and far-reaching questions, and for accepting my many absences from home and from their lives. — Augustine Meier I am grateful to my co-editors, Peter L. VanKatwyk and Augustine Meier. Their hard work and dedication inspired me in my own work. I am also grateful to my wife, Elizabeth, and daughter, Angel-Marie, for their kindness and patience. Thank you as well to the students, administrators, and colleagues at St. Joseph’s Hospital in Hamilton and at Hamilton Health Sciences, the Waterloo Lutheran Seminary, and the Department of Family Medicine, McMaster University. It is in the context of these places that I became involved in the dialogue between spirituality and health. Special thanks to staff at WLU Press who were so helpful in the editing of this book, especially Carroll Klein, Jacqueline Larson, Beth McAuley, and Leslie Macredie. I also thank the staff at Waterloo Lutheran Seminary who helped in this book: Donna Erb, Karen Gastmeier, Bette Smith, Dawn Matthews, and Colleen Ginn. I dedicate this book to all of you. — Thomas St. James O’Connor




Preface Peter VanKatwyk

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his book marks a significant event in the history of the Society of Pastoral Counselling Research (SPCR), a research forum for theoretical and clinical approaches in pastoral counselling. This youthful professional society was conceived and born in Ottawa and nurtured by people associated with Saint Paul University, notably by the Society’s architect and first president, Augustine Meier. Rather than clinging to its secure home base, SPCR has right from its birth pushed its geographical and professional boundaries. Presenters at its annual conferences soon represented scholars and students from a variety of academic centres in North America. Representing the Waterloo Lutheran Seminary at Wilfrid Laurier University, I attended the second annual conference. I still remember the impact of its spirit of exuberance, generosity, and inclusivity. Past conference themes testify to the Society’s integrative scope in pastoral counselling: grief dynamics, family systems, trauma, power relations and gender issues, and crisis intervention. The theme of the 2000 annual conference, forgiveness and reconciliation, elicited a richness of presentations resulting in the publication of the book The Challenge of Forgiveness (Meier & VanKatwyk, 2001). This collection reflects SPCR’s Eighth Annual Conference, which was held at the Hamilton Health Sciences Corporation. Once again, the event demonstrated a first for the Society. Meeting at McMaster University, the site of the Faculty of Health Sciences and a centre of interdisciplinary research, the annual conference gathered around the theme of spirituality in health care. Significantly, the chaplaincy department hosted

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the convention. It set the stage for pastoral counsellors and institutional chaplains/spiritual care providers to meet as colleagues in ministry. The Canadian Association for Pastoral Practice and Education (CAPPE) distinguishes pastoral counsellors from pastoral care providers in chaplaincy in its standards for education and practice. In this conference, the two groups interconnected with the shared vision of pastoral care as a spiritual practice. Chaplains and pastoral counsellors have been segregated by their respective professional associations, and do not always feel comfortable with each other. Hamilton, at the time, represented one of the few CAPPE accredited educational centres where the two streams co-existed, even thrived, in cross-fertilization. SPCR has been unique in forging a link between the two professional groups, stressing the similarities rather than the differences between the two streams (O’Connor, 2003, pp. 3–14). This is in contrast to the message that pastoral counselling and institutional ministry need to be carefully separated and chaperoned in order to maintain the purity of each respective profession. The Hamilton conference intentionally mixed the two, creating a potentially subversive experience in pastoral care and counselling. In my presidential address to the conference, I highlighted that the pastoral counsellors came to Hamilton as guests of the chaplains. I chose the term ritual coordinator, a term coined by Donald Capps (1983) for the uniqueness of the pastoral role (pp. 55–80), to focus on three areas where pastoral counsellors could learn from the practice of spiritual care in the hospital. A ritual coordinator assists people in negotiating the critical developmental and situational shifts in their lives. In chaplaincy care, a ritual coordinator assists people in moving from their old world to a new world, specifically, from their everyday world of home and work to the world of the hospital. This is often experienced as a transition from being healthy to being sick, from a sense of personal agency and control to one of feeling helpless and dependent on others. In spiritual care, the ritual coordinator facilitates rituals of transition. In the study of primitive rituals (van Gennep, 1960; Turner, 1969), three stages have been distinguished: (1) the phase of separation, (2) the in-between phase, and (3) the phase of reincorporation. These three stages of transition define the human condition as encountered in institutional care and are core metaphors for pastoral counselling. At the separation phase, hospital chaplains meet patients who present themselves as psychological migrants, separated from their familiar world and their loved ones. At this juncture, the chaplain stands out in

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symbolizing and maintaining ongoing connections with the patient’s old world. Chaplains coordinate community contacts, bridging the gap between the hospital and the outside world. The chaplain is the one who is interested in the patient not primarily as a patient but as a person who had and has a life, and attends to life stories that are not confined to or defined by the hospital. It is the spirituality that connects us to home—the places where we come from. In the stage of separation, there is the threat of disconnection. Lying in a hospital bed and wearing hospital garb, tagged by debilitation and sickness, in a room flowing with unannounced, at times unwanted, traffic, patients frequently lose a sense of belonging and feel out of place. The second stage of transition is the in-between phase, or the socalled liminal phase. Beyond the stage of feeling separated from one’s world, the patient feels as though he/she is between worlds, sometimes experienced as being in limbo. What chaplains call a ministry of presence is the “being with” the patient in this existential vacuum. It is a spirituality connected not so much to the past as to the present. It is being there with the patient in a state of suspension, without clear structure, and without certain expectations. Ministry in this liminal phase is not task-driven, nor is it intended to do or fix anything. Counsellors will appreciate the spirituality of care in the hospital where “being with” often fits better than “doing for.” A ministry of presence casts the caregiver in the role of being a witness of the other, mirroring confirmation and acceptance. It is a ministry of grace in the here and now. The third phase of reincorporation is the shift from the in-between to a new connection with one’s life and community. It means a reorientation to oneself and a relocation of one’s place within the community. This shift is unique to each hospital patient in transition. For some, it is a return to one’s old life with revitalized energies, renewed hope, and fresh commitment. For others, the reincorporation may be primarily a spiritual revisioning of the self, a relocation or reorientation to the shifting, often narrowing, horizons of one’s life. This universal experience makes all of us migrants, moving from familiar worlds to unknown worlds where we start anew, stripped of acquired securities and abilities. Chaplains facilitate these migrations into a new space and time, into new life textures that hold a new identity. The rites of passage that trace the pathways of transition—separation, transition, and reincorporation—shape the chaplains’ ministry of spiritual care. Pastoral counsellors meet their chaplain guides at these portals of transition that frame the human story and envisage the task of spir-

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itual care. This comprehensive scope of the life cycle connects the chapters of this book while spanning a variety of multi-faith and interdisciplinary perspectives. The first part of the book—Faith Perspectives and Challenges—reflects the visions of the contributors. The visions come from diverse sources: teaching chaplains in hospitals; a theologian and pastoral psychotherapist directing a university institute of mental health; a team of researchers in spirituality and health care; a chair at a university Department of Family Medicine; and a parish pastor. The second part—Spiritual Practices in Health Care—grounds these theological perspectives in a sample of concrete contexts of caring for people at critical times. The third part—Frontiers and Research—traces the ongoing development of theory and practice in the largely uncharted geography and mystery of the spirituality and health dynamic. As a whole, this book affirms that our humanity is connected to a larger spiritual reality, a presence from which we derive the meanings to live by and the resilience to face and transcend what threatens to deny and undo our lives. REFERENCES Capps, D. (1983). Life cycle theory and pastoral care. Philadelphia, PA: Fortress. Meier, A., & VanKatwyk, P. (2001). The challenge of forgiveness. Ottawa, ON: Novalis. O’Connor, T. (2003). Pastoral counseling and pastoral care: Is there a difference? The Journal of Pastoral Care & Counseling, 57 (1), 3–15. Turner, V.W. (1969). The ritual process. London: Routledge and Kegan Paul. van Gennep, A. (1960). The rites of passage (M.B. Vizedom & G.L. Caffee, Trans.). Chicago, IL: University of Chicago Press.




Introduction Augustine Meier Thomas St. James O’Connor Peter L. VanKatwyk

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ccidents, abuses, serious illnesses, disabilities, and deaths remind us how prone human beings are to tragedies and losses. These experiences tax our very fibre. How do we cope with such events? How do we put our lives back together again? How do we come to peace with these events? Some of us turn to the spirit within for answers, meaning, and comfort. We turn to the most sacred, untouchable part of our humanness—to our spirituality. There we find a life-source that is indestructible, more powerful than the deadly forces of disease, death, and violence. It is here that we come to terms with life itself. In recent decades, helping professionals have become aware of the healing power of spirituality. In December 1995, the Harvard Medical School sponsored the Spirituality and Healing in Medicine Conference. Allen Bergin, in an address to the 1998 conference of the Society for Psychotherapy Research, held at Snowbird, Utah, strongly advocated that psychotherapy researchers pay more attention to the spiritual dimension in people’s lives. The contributors to a volume edited by Richard Gilbert (2002) demonstrate how one can listen to and assess spirituality in individuals struggling with issues concerning physical and emotional health. Peter VanKatwyk (2003), who has spent most of his professional career writing about spirituality in health care and counselling, offers models that integrate spirituality within the helping professions. The World Health Organization (1946) defined health as “an optimum state of physical, intellectual, emotional, social and spiritual well being and not merely as the absence of disease and infirmity” (p. 2). All of these activities and

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publications attest to the importance health care organizations, professionals, and counsellors are attributing to spirituality. This growing interest in integrating spirituality within the helping professions is reflected in Barbour’s (1997) observation of the four relationships that exist between religion and science. In reviewing the history of these relationships, Barbour observed that the initial relationship was that of antagonism. This difference in viewpoint progressed towards a second relationship of separation, in which religion was assigned the spiritual dimension of a person and science was assigned the bodily dimension. The third relationship engaged in a dialogue around boundary issues, and the fourth became a relationship of integration. While all four relationships still exist, the chapters in this book are framed by the third and fourth relationships. Two other changes within the social sciences have contributed to a greater collaboration between spirituality and health. Social sciences at the outset adopted a positivistic view of people, which claimed that people can be studied in terms of cause and effect. It changed this viewpoint and adopted a circular rather than a linear model, taking the position that there is a circular relationship between people and external factors. When applied to spirituality and health, it assumed that the one influenced the other. The second change was the adoption of qualitative research methods such as existential/phenomenological and hermeneutical approaches. This change in attitude made it possible to conduct interdisciplinary research. This new trend and interest in spirituality on the part of helping professional researchers brings with it a unique set of challenges. One of the challenges is to define spirituality, an enormous task given that spirituality is not limited to a particular discipline, era, or culture. There are also many similarities and differences between religion and spirituality. Religion, on the one hand, is usually associated with belonging to a particular faith group with its beliefs and practices. Spirituality, on the other hand, refers to those who belong to faith groups, as well as those who do not belong to any particular faith group but are interested in the spiritual. Spirituality is more inclusive than religion. A second challenge is to develop measures of spirituality or components thereof for the purpose of research. This book brings together scholars, researchers, and practitioners who have responded to these challenges and who, in their own ways, have opened doors for further research in this growing field. This book does not subscribe to any particular definition of spirituality. The authors of the individual chapters offer their definitions as they

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address their particular topics. Nevertheless, it might be useful to present a general definition of spirituality. Allen Bergin, a psychologist and psychotherapy researcher, provides a definition that might be useful for interdisciplinary research on spirituality. His definition comprises two components, namely, a state of being (attunement with God) and capacities to respond to all that a person might face in his/her life. In his own words, Bergin says that “we define spirituality as attunement with God, the spirit of Truth, or the Divine Intelligence that governs or harmonizes the universe…we assume that human nature includes spiritual capacities, i.e., ways of responding to, harmonizing with, or acting on the promptings, enlightenment, or sense of integration that may be associated with the Spirit of Truth” (Bergin, 1998). This definition includes the understanding of meaning-making, which is one of the dominant understandings of spirituality in the health care literature. Unique to this collection is the involvement of theology as an equal partner in the dialogue between spirituality and health. Most research and publication on spirituality and health is done by those in non-theological disciplines, that is, social and health care sciences. This book includes contributions from theologians and theological professionals such as chaplains and pastoral counsellors. This combination of theology, social science, and health care research makes for a rich variety of perspectives, a postmodern approach that fits with the theological tradition emphasizing variety, plurality, and ambiguity (Tracy, 1987). Such a tradition is found in the Hebrew Bible, where the Messianic banquet welcomes all to eat (Isa. 25:6–8), and in the Christian Scriptures, where the new heaven and new earth include diversity (Rev. 21:1–5, Jerusalem Bible). The book is organized in three parts. The first part, “Faith Perspectives and Challenges,” comprises six chapters that address the issues of faith and research, psychology and theology, the incorporation of spirituality in medicine, assessing plurality in spirituality, revealing abuse and finding congregational acceptance, and Islamic spiritual care. The second part, “Spiritual Practices in Health Care,” comprises chapters 7 to 11. Chapter 7 identifies how palliative patients and people with dementia speak about their spirituality. Chapters 8 and 9 show how professionals can work with spirituality in cases of addiction and in occupational therapy; chapter 10 proposes that a labyrinth can be used in spiritual care to guide individuals to finding their inner resources; and chapter 11 proposes a wholistic approach to healing. Chapters 12 to 17 constitute the third part, “Frontiers and Research.” The authors in these chapters tackle

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the problem of defining spirituality and measuring spirituality or its components, and advocate that both spirituality and science are necessary for human growth and health. PART ONE: FAITH PERSPECTIVES AND CHALLENGES

Chapter 1, by Thomas St. James O’Connor and Elizabeth Meakes, grapples with the debate concerning the integration of research findings in the delivery of pastoral and spiritual care. The authors present the Christian roots of spiritual and pastoral care and explain the current evidence-based approach in health care. They join both of these traditions and offer a new paradigm for the integration of faith and scientific research. Paul J. Rennick, in chapter 2, provides a brief history of the relationship of theology and psychology, and defines religion, spirituality, and theology. The author argues that theological anthropology, when compared with religion and spirituality, is best suited to engage in a meaningful dialogue with psychology in the articulation of a holistic model of person, pastoral counselling, and health care. He shows how theology and psychology, particularly cognitive therapy, share the common term cognitions, distinguishing between theological and psychological cognitions and maintaining that theological cognitions can be treated in the same way as psychological cognitions. Rennick demonstrates how an analysis and reformulation of the theological cognitions of a depressed person can be integrated into pastoral counselling. Pam McCarroll, Thomas St. James O’Connor, and Elizabeth Meakes, in chapter 3, report the results of their search of published health care literature for definitions of spirituality. The authors then proceed to tease out eight themes or terms that they observed in these definitions, reordering the themes to produce five paradigms that have the potential to make sense of the diverse understandings of spirituality. The chapter concludes with the authors offering their own model, one that integrates these diverse definitions. Cheryl Levitt, in chapter 4, describes the importance of exploring spirituality and religious beliefs routinely in family medicine. The author, a family physician, describes studies looking at spirituality and health, and personal experiences both with patients and as a patient. She presents some of the challenges that physicians face in integrating spirituality into family medicine. Levitt discusses the HOPE model, which family medicine practitioners can use to gather data regarding the patient’s spirituality.

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Using the metaphors of “being at home” and “creating a safe place,” Carol Penner, in chapter 5, explores the topic of spirituality and how this can be shattered for children who are wounded by childhood abuse. When the sense of “being at home” is shattered, the abused person feels disconnected, as though belonging nowhere and having no one to turn to. Home is no longer a safe place to be. The author uses mostly her own experience working in church congregations to develop her thoughts. To help those who have been abused, particularly by a member of the congregation, she suggests that congregations do “better housekeeping.” Nazila Isgandarova, in chapter 6, explores Muslim spiritual care. She roots this practice in the Qur’an and draws on the rich tradition of providing spiritual care for the sick. As a Muslim chaplain, Isgandarova draws on the experience of her own practice, especially working in a multi-faith environment. She also reflects on contemporary Muslim thinkers and on the role of spiritual care in healing the sick. PART TWO: SPIRITUAL PRACTICES IN HEALTH CARE

In chapter 7, Ellen Bouchard Ryan, Lori Schindel-Martin, and Amanda Beaman describe the primary spiritual needs of persons suffering from dementia. The authors present the stages of dementia, outline the diminishing cognitive skills and functions, and propose a model and techniques to help the sufferer maintain contact with self, others, and the community. One of the techniques proposes creating a Memory Box, which includes writings and meaningful objects from a person’s life. Lori Edey, in chapter 8, presents a relational model for the treatment of chemical and behavioural addictions, acknowledging the clinician’s self-awareness as a vital part of the healing relationship. To maintain the working relationship with the client, the author advocates the use of objective tests to help the client face his/her problem rather than to deny the problem. Spirituality is proposed as an integral aspect of the recovery process. Defining spirituality within the profession of occupational therapy is the topic of chapter 9. Although it is recognized as an essential component of occupational therapy, defining spirituality and demonstrating its relationship to the other elements is open for debate. Sue Baptiste provides a model of occupational therapy that recognizes spirituality as its core component.

6 Introduction

Ingrid Bloos, in chapter 10, describes the ancient and medieval labyrinth as a spiritual tool, and suggests its application as an adjunctive therapeutic tool in the health care environment. The author traces the history of the labyrinth, describing its characteristics and its potency for change, transformation, and wholeness. She points out how the labyrinth might be a complementary tool that combines kinesthetic movement with discourse to facilitate increased clarity and change. The chapter by Calvin Morrisseau is a reprint from his book Into the Daylight: A Wholistic Approach to Healing. In chapter 11, he narrates his own personal journey in recovering from addictions, abuse, poverty, assimilation, and racism. Based on these experiences, on his training in counselling and addiction studies, and on his education in traditional practices, he presents a wholistic individual, family, and community model of healing that espouses the values that permitted Aboriginal peoples to live in accord with each other in the past. The wholistic model centres on people accepting responsibility, making choices, and recapturing their sense of harmony, cooperation, sharing, balance, and spirituality. His model is an interdependent system of the individual, family, and community in which needs, desires, values, and purposes are communicated, and all share the responsibility to assure that everyone grows to their fullest potential. The model harmonizes individual responsibility with community care and support. Morrisseau’s wholistic approach to healing is grounded in the richness of Native spirituality. It is important to keep this in mind as one reads his chapter. PART THREE: FRONTIERS AND RESEARCH

Carlton Brown, in chapter 12, presents a brief history of the factors contributing to the separation of religion and medicine, particularly as it applies to health care. The Clinical Pastoral Education Movement was an attempt to reintegrate these two disciplines in both pastoral care and pastoral counselling. To provide a broader basis for the understanding of spirituality, the author draws on ontology as a method of investigation. He identifies three dimensions of spirituality, namely, self-integration, self-creation, and self-transcendence. To assess the prevalence of terms such as religion, spirituality, and pastoral care, and to determine the providers of pastoral care, the author analyzed the medical literature, which has produced interesting results. Chapter 13 describes the findings from a qualitative research project that studied the experience of God by palliative care patients in the

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context of their physical, emotional, and spiritual suffering. The data for the study comprised transcribed interviews from twenty-two patients, which were carried out within the context of narrative therapy. The author, Colleen Lashmar, concluded that the participants held God as central to their sense of hope in the midst of suffering, and that their speaking about God helped them to endure the suffering associated with a life-threatening illness. The construction of an instrument to measure suffering is presented in chapter 14. Beverly Clarke, A.R.M. Upton, Claudia Castellanos, and Mary Lou Schmuck distinguish between pain and suffering, provide an operational definition of suffering, and select items, which are indicative of suffering, for their measure. They provide validity and reliability data for their instrument, and report the results of a study that related suffering to pain. Chapter 15 presents the results of a phenomenological and existential analysis of transcripts of the counselling sessions of a woman suffering from fibromyalgia. Marie-Line Morin contends that psychoanalysis by itself is insufficient to address the healing of this condition. She proposes that in addition to psychoanalysis, concepts from psychosynthesis must be integrated, particularly concepts that pertain to the transcendent or spiritual dimensions, since these appear to have provided the healing experienced by the client. Chapter 16 is a qualitative research project exploring the nature of life-threatening illness and subjective experiences, the role of social support, meaning-making, and spiritual and religious influences. Twelve adult participants were solicited through physicians and self-help group facilitators. These participants were considered “expert witnesses” in their optimal coping with life-threatening illness. The results are consistent with the empirical literature that these “expert witnesses” documented a process, in which they searched to give their traumatic experience meaning. Spirituality and religion were important to them, and they developed greater empathy for self and others as part of the process. Chapter 17 focuses on the neurobiology of spiritual consciousness and the mind-body connection. It describes the neurobiological associations that occur with religious experience, and proposes that these can contribute to the evolution of individuals and the human race. Using ideas from Jung and Maslow, Stephen Sagar, a physician, argues for a spiritual intelligence that is complementary to rational and emotional intelligence. Spiritual intelligence is seen as being both adaptive and

8 Introduction

transformative. The author argues that both spirituality and sciences are necessary for human growth and health. Spirituality and Health: Multidisciplinary Explorations offers a window into the endeavours undertaken by a group of pastoral counselling and health care scholars and researchers to bridge the gap between spirituality and health. Current research on spirituality and health care is expanding at an exponential rate. Absent from this research, however, is a theological reflection on the relationship between spirituality and health and the involvement by pastoral counsellors and health care workers (Koenig, McCullough, & Larson, 2001). The editors hope that, in reading this book, pastoral counsellors, health care professionals, and chaplains will familiarize themselves with some of the work being done in this field and accept the challenge to work towards a greater integration of spirituality and health. REFERENCES Barbour, I. (1997). Religion and science. San Francisco, CA: HarperCollins. Bergin, A. (1998, June 3). Spiritual and religious issues in psychopathology and psychotherapy. Oskar Pfister Award Lecture. American Psychiatric Association, Toronto, Ontario. Gilbert, R.B. (Ed.). (2002). Health care and spirituality: Listening, assessing, caring. Amityville, NY: Baywood. Koenig, H., McCullough, M., & Larson, D. (2001). Handbook of religion and health. New York: Oxford University Press. Tracy, D. (1987). Plurality and ambiguity. San Francisco, CA: Harper & Row. VanKatwyk, P.L. (2003). Spiritual care and therapy: Integrative perspectives. Waterloo, ON: Wilfrid Laurier University Press. World Health Organization. (1948). International classification of diseases, injuries, and causes of death. Geneva, CH.


Part 1 Faith Perspectives and Challenges


1 Towards a Joint Paradigm Reconciling Faith and Research Thomas St. James O’Connor Elizabeth Meakes

T

he modern age, influenced by the scientific revolution that began during the Enlightenment, has made empirical evidence the norm for truth. In the twentieth and twenty-first centuries, science took this a step further and adopted an evidence-based approach to ascertain truth. In this view, truth is not revealed through sacred texts, as the world religions believed. Rather, truth is demonstrated by empirical studies with the double-blind, randomized control trial being the gold standard (McKibbon, 1999; Donald, 1992; Mays & Pope, 1995; O’Connor & Meakes, 1998; O’Connor, 2002; O’Connor, McCarroll-Butler, Meakes et al., 2002). Over the course of history, there has been a major divide between science and religion over what constituted truth. For example, both Galileo and Darwin offered empirical evidence for their truth claims that disagreed with the Christian Bible. Because of these differences in claims, the relationship between religion and science quickly developed into two forms. One was a relationship of antagonism where there was open hostility with each seeking to prove the other wrong, while the other was one of separation, a type of peaceful coexistence, in which religion dealt with the spirit and science dealt with the material, with little connection between the two (Barbour, 1997). This great divide between religion and science has influenced the delivery of health care through the ages and into today. Medicine, nursing, occupational therapy, psychiatry, physiotherapy, and most of the other health care professions have adopted empirical research evidence as the basis for their professional practice. Research evidence, in this

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view, ought to justify and inform the practice. This approach is known as evidence-based research, and was initially developed at McMaster University’s Faculty of Health Sciences (Donald, 1992; Rosenberg & Donald, 1995; O’Connor & Meakes, 1998; McKibbon, 1999). In the evidence-based approach, clinicians are required to look for solid evidence and then implement the best evidence in their practice (DiCenso, Cullum, & Ciliska, 1998). For example, Sprenkle (2002) edited Effectiveness Research in Marriage and Family Therapy using an evidence-based approach. The book gathers a huge volume of quantitative studies that demonstrate the effectiveness of various interventions based on evidence-based research: marriage and family therapy for conduct disorders (Henggeler & Sheidow, 2002); substance abuse (Rowe & Liddle, 2002); childhood behavioural and emotional disorders (Northey et al., 2002); alcohol abuse (O’Farrell & Fals-Stewart, 2002); marital problems (Johnson, 2002); domestic violence (Stith, Rosen, & McCollum, 2002); affective disorders (Beach, 2002); and physical disorders (Campbell, 2002). Gaps in criticisms of the research are also presented. The evidence-based approach is also critiqued in the broader medical literature (“Evidence-based medicine,” The Lancet, 1995). Where there are gaps in research evidence, clinicians need to use their clinical wisdom in making treatment decisions. The highest form of evidence in this approach is the randomized control trial. Chaplaincy, however, is different from the other health care disciplines. Spiritual care, which is the focus of a chaplain’s professional practice, is not driven by research evidence but by two thousand years of tradition and sacred texts. In the current postmodern age, however, science and religion/spirituality are opening up communications. This is especially true in the area of health care issues. Two studies indicate the vast amount of recent research linking religion and spirituality to health (Koenig, McCullough, & Larson, 2001; O’Connor et al., 2002). Most amazingly, the majority of this research is not being done by chaplains or theologians but by medical researchers who are intrigued by this link (VandeCreek, 1999; O’Connor et al., 2002; Koenig et al., 2001). Much of this research has been done in the last twenty years (Koenig et al., 2001; O’Connor et al., 2002). Now, there seems to be cooperation and, in some areas, integration between religion and science. What justifies the practices of spiritual care in health care? This chapter explores this question.

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SPIRITUAL CARE JUSTIFIED BY FAITH

In the texts of the Christian Bible, Jesus and the early Christian Church indicate that it is important, and indeed essential, for Christians to care for the sick. In Matthew 25:31–46, Jesus indicates that people will be judged for the way they take care of people. He tells the disciples that he is identified with the hungry, the sick, the stranger, the naked, and the prisoner, “the least of the brethren” (Matt. 25:40, Jerusalem Bible). When Christians visit and care for the sick, they are indeed visiting and caring for Christ. When they ignore the sick, they ignore Christ (Matt. 25:45, Jerusalem Bible). To ignore Christ is to bring on to oneself judgment and condemnation. There is a strong belief in Christianity, which begins with the Christian Bible, that visiting the sick and caring for the sick is indeed the very mission and essence of the community of believers. It is important to note that in this command, the reason for caring for the sick is not based on any evidence that visiting and caring might be helpful to the sick person, but that Christ has demanded Christians to do so. Those who minister to the sick are ministering to Jesus, even though the parable points out that the Christian cannot see that the sick person is Christ. This is only understood through the eyes of faith. The reward for the care of the sick is eternal life, and the punishment for failing to do so is eternal damnation. In the Christian tradition, the stakes are high. Justification for this spiritual practice is through faith, and not through research. In Healing in the New Testament, Pilch (2000) further explains this strong tradition in Christianity. The many miracles recounted in the four Gospels indicate Jesus’ compassion and care for those who are sick. Pilch notes that these miracle stories do not emphasize cure, but a renewal of spiritual meaning and a return to the community. At the time of Jesus, chronic illnesses such as leprosy separated the sick person from his/her community, and to be healed by Jesus was to receive spiritual care not only by him but also by members of the community. The long tradition in Christianity of spiritual care for the sick has taken many forms. Primarily, spiritual care meant nourishing the sick person’s soul. This was achieved through conversation that often verged on preaching. In the early Church, sickness was often associated with sin, and so the practice of spiritual care emphasized conversion and the cleansing of sins before he/she met God. This tradition of spiritual care continued from the early Church through to the nineteenth and twen-

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tieth centuries. Such an approach has a judgmental side to it, which Hunter (1990) refers to as moralizing. Spiritual care often involved prayers for healing and, in the case of Roman Catholics, the Sacrament of the Sick. Prior to Vatican II, this sacrament was known as Extreme Unction, and was given when death was imminent. The prayer for healing was primarily for healing the soul, and secondarily for healing the body. Spiritual care also meant making the sick person comfortable by caring for his/her bodily needs. In the fourth and fifth centuries of the Common Era, Christians set up hospices for those who were dying, or who had a chronic illness that could not be cared for at home (Koenig et al., 2001). These hospices offered comfort to the dying but no cures, a medical practice that continued into the twentieth century. Hospitals in the Western world were started by the Christian Church (Koenig et al., 2001), and they too offered mostly care without cure. Certainly, with Christianity, there was a strong belief that God could perform miracles and cure those dying of any kind of illness. There were holy places that the sick were taken to for a cure, but the primary reason for spiritual care for the sick was to live out the injunction from Matthew’s gospel, which was to “do unto the least of the brethren.” Often, spiritual care was called pastoral care. One of the oldest definitions of pastoral care is the “cure of souls” (McNeill, 1951). The priest or minister brought the cure of souls to the sick (Holifield, 1983; Gerkin, 1997), while the medical doctor brought the cure for the body. Clebsch and Jaekle (1967) divide this pastoral care into four types: guiding, sustaining, healing, and reconciling. They summarize two thousand years of pastoral care in the Christian Church and note that, in each age of the Church, certain functions of pastoral care seem to have dominated. In the twentieth century, for example, the goal was the healing of souls, or “the cure of souls,” and healing the body was secondary. The reiteration that the justification for spiritual care in the history of Christianity came not from the evidence that it was helpful but from the command of Christ and from the tradition of the Church. For Christians, that was justification enough. The Christian community did not run any randomized control trials to prove or disprove these claims. Rather, these kind acts, through the eyes of faith, were considered enough.

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SPIRITUAL CARE JUSTIFIED BY RESEARCH

As O’Connor et al. (2002) observed, there was little research exploring the link between spiritual care and health before 1970. Since then, the amount of research by health care professionals on spiritual care and health has exploded. To further investigate this explosion, O’Connor et al. (2002) updated their study by adding the years 2000 to 2003 (the first study covered the years 1966 to 1999). They used the term “spiritual” in searching MEDLINE, CINAHL, and HealthSTAR, identifying any combination of spiritual in the databases. One difference from the previous study is that MEDLINE and HealthSTAR were combined; another is that while the previous study examined the kinds of research being done between spirituality and health by using the categories of quantitative, qualitative, combined quantitative and qualitative, theoretical, and uncertain, the more recent study did not note these categories. The quantity of research they identified is shown in table 1: Table 1: Quantity of Spirituality Research in Three Health Care Databases (1966–2003) Year

Total Quantity of Spirituality Research in Three Health Care Databases for each time period

1966 1966–75 1976–80 1981–85 1986–90 1991–95 1996–99 2000–03

21 54 72 152 285 565 1,147 2,843*

Source: O’Connor et al., 2002. *Note: 1966–99 had the duplicates removed from the three databases. Years 2000– 2003 do not have the duplicates removed.

Table 1 indicates a dramatic rise in the number of citations published in these databases in the last thirteen years (1991–2003), indicating that medical research has become very interested in the relationship between spirituality and health. Certainly, this number could be explained for a number of reasons. First, there has been an increase in the practice of holistic medicine, especially holistic nursing, in which spirituality is an integral component. In addition to holistic nursing, many of the other health care dis-

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ciplines have adopted spirituality as a part of their work. As Cheryl Levitt, the chair of family medicine at McMaster University, notes in this volume, family medicine has begun to regain its soul. Also in this volume, Sue Baptiste emphasizes how spirituality defines the core of many occupational therapy practices. Beverley Clarke, a physiotherapist and professor at the School of Rehabilitation Science, also sees spirituality as important in her professional practice. Stephen Sagar, an oncologist at the Juravinski Cancer Centre in Hamilton, emphasizes the role of spiritual care when treating cancer patients. Sagar (2002) researched traditional Chinese medicine as a complementary care for his patients, and understands how spirituality can play a major role in its practice. Ellen Ryan, a psychologist who works with the frail elderly, acknowledges that addressing the spiritual needs of this population is very important. Almost every discipline in health care believes that the spiritual needs of the patients ought to be addressed in its caregiving plans. A second reason is the development and limited acceptance of qualitative research as an evidence-based approach (O’Connor & Meakes, 1998; Marks, 1999; McKibbon, 1999; O’Connor, 2002). Spirituality and religion are difficult to research because both are complex and very personal. Qualitative research has been used by many researchers, especially in nursing, for understanding and explaining the link between spirituality and various aspects of health (DiCenso et al., 1998). At the same time, researchers have become more creative in using quantitative research in studying spirituality and health. For example, in the area of prayer and cardiac care, two double-blind, randomized trials linking prayer from a distance to better cardiac recovery have been done with positive results (Byrd, 1988; Harris et al., 1999). With AIDS patients, a randomized control trial showed a positive benefit for those who were prayed for from a distance (Sicher et al., 1998). However, for patients struggling with poor self-esteem, high anxiety, or depression, there were no benefits to receiving prayers from a distance (O’Laoire, 1997). There has been a systematic review of studies using prayer from a distance (Astin, Harkness, & Ernst, 2000), which indicates mixed results. While these randomized control trials have received both strong theological (VandeCreek, 1999) and methodological critique (Sloan, Bagiella, & Powell, 1999; Sloan et al., 2000), quantitative researchers continue striving to measure how spirituality can influence health. Evidence-based spiritual and pastoral care is somewhat new (O’Connor & Meakes, 1998; O’Connor, 2002). The Handbook of Religion and Health by Koenig, McCullough, and Larson (2001) reviewed more than twelve

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hundred studies on religion and health. Over two-thirds of these studies showed a significant statistical relationship between religious activity, better physical and mental health, and lower use of medical services. The Handbook of Religion and Health, along with Table 1, indicate that there is a significant body of research that offers the foundation for an evidence-based approach in spiritual care. The development of qualitative research and the more creative and refined use of quantitative research partly explain the increase in this research as presented in Table 1. A third reason for this explosion in research is a change in attitude by many scientists towards religion and spirituality. For example, in psychiatry, the dominant belief for the first eight or nine decades of the twentieth century was that religion was an illusion based on the Oedipal complex (Freud, 1962). It often led to neurotic (Freud, 1962), obsessive-compulsive (Ellis, 1983), and destructive tendencies (Watters, 1992). Freud, Ellis, and Watters viewed religion as an illusion and believed that at best it was benign, and at worst, destructive (Koenig, 1997; Koenig et al., 2001). This view has been challenged by researchers such as Bergin (1983), Koenig, McCullough, & Larson (2001), and Levin, Larson, & Puchalski (1997), who examined the empirical research on religion and mental health and found the views of Freud, Ellis, and Watters to be unsubstantiated by the evidence. On the contrary, religion and spirituality were found to be, with a few exceptions (Koenig, 1997), a great coping mechanism for challenging mental health issues (Pargament, 1997). Quantitative and qualitative research indicate that religion and spirituality can help those with severe medical conditions better cope with their illness, and can offer hope in the midst of challenges (O’Connor & Meakes, 1998). These findings have been observed in palliative care (O’Connor et al., 1997), cancer care (Sagar, 2002), treating disabilities (O’Connor et al., 1997; Meakes, O’Connor, & Carr, 2002), and treating depression (Koenig et al., 2001). Even those who critique the research on spirituality and health admit that spiritual care and religion can be a great coping mechanism for dealing with challenging health conditions (Sloan et al., 1999). The randomized control trials cited above have opened up the possibility that spiritual care is more than a coping mechanism. Spiritual care might also be a determinant of health. While most of the research indicates an association between spiritual care and health, the randomized control trials usually seek to demonstrate that certain aspects of spiritual care can cause better health outcomes. This area is more controversial and has been widely critiqued in the literature (Sloan et al., 1999,

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2000; VandeCreek, 1999). The critique itself has been critiqued (Weaver et al., 2002) and the critique of the critique has been challenged (Heffernan, 2003; Baroody, 2003; O’Connor & Meakes, 2003). CONCLUSION: TWO IMAGES

What justifies the practices of spiritual care in health care? Is it faith and its traditions, or is it research? The answer is both. Certainly, the justification for both arises from different paradigms. At one time, these different paradigms were in strong conflict and could not coexist. Today, at times, that is still the case. However, something has changed, and the faith traditions and research can now exist in the same spiritual body. An apt image of this reality are Siamese twins. John Ralston Saul (1997) likens the Canadian experience to that of Siamese twins—a country with two different paradigms and mythologies thriving in the same country, joined together yet different. Both spiritual care by faith and spiritual care by research live together and strive for the well-being of the patient. Certainly, there is some difference in origin, justification, and view of God, but there are many similarities. Like Siamese twins, they are different yet similar. A second image is theological and is captured in the Joint Declaration on the Doctrine of Justification by the Lutheran World Federation and the Roman Catholic Church (2000). The doctrine on justification divided Roman Catholics and Lutherans over the role of faith and good works during the Reformation of the sixteenth century. Five hundred years later, both churches have developed a joint statement on justification: “Together we confess: By grace alone, in faith in Christ’s saving work and not because of any merit on our part, we are accepted by God and receive the Holy Spirit, who renews our hearts while equipping and calling us to good works” (p. 15). The words in this statement are carefully crafted in order to capture both similarities in belief and differences in emphasis. Similarly, the justification for spiritual care can be made by both religion and science through faith and research. Like the joint declaration, there are differences and similarities. Here, a new paradigm is being born. REFERENCES Astin, J.A., Harkness, E., & Ernst, E. (2000). The efficacy of “distant healing”: A systematic review of randomized trials. Annals of Internal Medicine, 132, 903–10.

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Baptiste, Sue (2005). Spirituality in occupational therapy. In A. Meier, T. O’Connor & P. VanKatwyk (Eds.), Spirituality and health: Multidisciplinary explorations. Waterloo, ON: Wilfrid Laurier University Press. Barbour, I. (1997). Religion and science. San Francisco, CA: HarperCollins. Baroody, A.J. (2003). Religion and health research: Theological interpretations oversimplified. The Journal of Pastoral Care & Counseling, 57 (1), 83–84. Beach, S. (2002). Affective disorders. In D.H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 289–309). Alexandria, VA: AAMFT. Bergin, A.E. (1983). Religiosity and mental health: A critical re-evaluation and meta-analysis. Professional Psychology: Research and Practice, 14, 170–84. Byrd, R. (1988). Positive therapeutic effects of intercessory prayer in a coronary care unit population. Southern Medical Journal, 81 (7), 826–29. Campbell, T.L. (2002). Physical disorders. In D.H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 311–37). Alexandria, VA: AAMFT. Clebsch, W., & Jaekle, C.R. (1967). Pastoral care in historical perspective. New York: Harper and Row. DiCenso, A., Cullum, N., & Ciliska, D. (1998). Implementing evidence-based nursing: Some misconceptions. Evidence-Based Nursing, 1, 38–39. Donald, A. (1992). Evidence-based medicine: A report from McMaster University Medical School and teaching hospitals. Brisbane, AU: Anglia and Oxford Health Authorities. Ellis, A. (1983). The case against religiosity. New York: Institute for Rational-Emotive Therapy. Evidence-based medicine, in its place. Editorial. (1995, September 23). The Lancet, 346, 785. Freud, S. (1962). The future of an illusion. In J. Strachey (Ed. and Trans.), The standard edition of the complete psychological works of Sigmund Freud. London: Hogarth. (Original work published in 1927.) Gerkin, C. (1997). An introduction to pastoral care. Nashville, TN: Abingdon. Harris, W.S., Gowda, M., Kolb, J., Strychacz, C., Vacek, J.L., Jones, P.G., et al. (1999). A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Archives of Internal Medicine, 159, 2273–78. Heffernan, H. (2003). Religion and health research: Interpretation sends wrong message regarding need for hospital chaplains in health care institutions. The Journal of Pastoral Care & Counseling, 57 (1), 79–82. Henggeler S.W., & Sheidow, A.J. (2002). Conduct disorder and delinquency. In D.H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 27–51). Alexandria, VA: AAMFT. Holifield, E.B. (1983). A history of pastoral care in America. Nashville, TN: Abingdon. Hunter, R. (1990). Moralizing. In R.J. Hunter (Ed.), Dictionary of pastoral care and counseling (p. 758). Nashville, TN: Abingdon. Johnson, S.M. (2002). Marital problems. In D.H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 163–90). Alexandria, VA: AAMFT. Koenig, H. (1997). Is religion good for your health? New York: Haworth. Koenig, H., McCullough, M., & Larson, D. (2001). Handbook of religion and health. New York: Oxford University Press.

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Levin, J.S., Larson, D.B., and Puchalski, C.M. (1997). Religion and spirituality in medicine: Research and education. JAMA, 278 (9), 792–93. Lutheran World Federation & Roman Catholic Church. (2000). Joint declaration on the doctrine of justification. Grand Rapids, MI: Erdmans. Marks, S. (1999). Qualitative studies. In A. McKibbon (Ed.), PDQ evidence-based principles and practice (pp. 187–204). Hamilton, ON: B.C. Decker. Mays, N., & Pope, C. (1995). Rigour and qualitative research. British Medical Journal, 311, 109–12. McKibbon, A. (Ed.). (1999). PDQ evidence-based principles and practice. Hamilton, ON: B.C. Decker. McNeill, J.T. (1951). A history of the cure of souls. New York: Harper. Meakes, E., O’Connor, T., & Carr, S. (2002). The great leveler: Gender and the institutionalized disabled on faith and disability. Journal of Religion, Disability & Health, 6 (1), 37–46. Northey, W.F., Wells, K.C., Silverman, W.K., & Bailey, C.E. (2002). Childhood behavioral and emotional disorders. In D.H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 89–121). Alexandria, VA: AAMFT. O’Connor, T. (2002). Is evidence-based spiritual care an oxymoron? Journal of Religion and Health 41 (3), 253–62. O’Connor, T., & Meakes, E. (1998). Hope in the midst of challenge: Evidencebased pastoral care. The Journal of Pastoral Care, 52 (4), 359–68. O’Connor, T., & Meakes, E. (2003). Religion and health research: Critique of critique not well balanced. The Journal of Pastoral Care & Counseling, 57 (1), 85–86. O’Connor, T., McCarroll-Butler, P., Meakes, E., Davis, A., & Jadad, A. (2002). Review of quantity and types of spirituality research in three health care databases (1962–1999): Implications for the health care ministry. The Journal of Pastoral Care & Counseling, 56 (3), 227–32. O’Connor, T., Meakes, E., McCarroll-Butler, P., Gadowsky, S., & O’Neill, K. (1997). Making the most and making sense: Ethnographic research on spirituality in palliative care. The Journal of Pastoral Care, 51 (1), 25–36. O’Farrell, T.J., & Fals-Stewart, W. (2002). Alcohol abuse. In D.H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 123–61). Alexandria, VA: AAMFT. O’Laoire, S. (1997). An experimental study of the effects of distant, intercessory prayer on self-esteem, anxiety and depression. Alternative Therapeutic Health Medicine, 3, 38–53. Pargament, K.L. (1997). The psychology of religion and coping: Theory, research, practice. New York: Guilford. Pilch, J. (2000). Healing in the New Testament. Minneapolis, MN: Fortress. Rosenberg, W., & Donald, A. (1995). Evidence-based medicine: An approach to clinical problem-solving. British Medical Journal, 310, 1122–25. Rowe, C.L., & Liddle, H.A. (2002). Substance abuse. In D.H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 53–87). Alexandria, VA: AAMFT. Ryan E.B., Pearce, K.A., Anas, A.P., & Norris J.E. (in press). Writing a connection: Intergenerational communication through stories. In M.W. Pratt & B.H. Fiese (Eds.), Family stories and the life course. Mahwah, NJ: Erlbaum.

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Sagar, S. (2002). Restored harmony: An evidence-based approach for integrating traditional Chinese medicine into complementary cancer care. Hamilton, ON: Dreaming Dragonfly Communications. Saul, J.R. (1997). Reflections of a Siamese twin: Canada at the end of the twentieth century. Toronto: Penguin. Sicher F., Targ, E., Moore, D., & Smith, H.S. (1998). A randomized double-blind study of the effect of distant healing in a population with advanced AIDS: Report of a small-scale study. Western Journal of Medicine, 169, 356–63. Sloan, R., Bagiella, E., & Powell, T. (1999). Religion, spirituality, and medicine. The Lancet, 353, 664–67. Sloan, R., Bagiella, E., VandeCreek, L., Hover, M., Casalone, C., Hirsch, T., et al. (2000). Should physicians prescribe religious activities? New England Journal of Medicine, 342 (25), 1913–16. Sprenkle, D.H. (Ed.). (2002). Effectiveness research in marriage and family therapy. Alexandria, VA: AAMFT. Stith, S.M., Rosen, K.H., & McCollum, E.E. (2002). Domestic violence. In D.H. Sprenkle (Ed.), Effectiveness research in marriage and family therapy (pp. 223–54). Alexandria, VA: AAMFT. VandeCreek, L. (1999). Should physicians discuss spiritual concerns with patients? Journal of Religion and Health, 38 (3), 193–201. Watters, W. (1992). Deadly doctrine. Buffalo, NY: Prometheus. Weaver, A., Flannelly, K., & Stone, H. (2002). Research on religion and health: The need for a balanced and constructive critique. The Journal of Pastoral Care & Counseling, 56 (3), 213–19.


2 A Critical Dialogue between Theology and Psychology Paul J. Rennick

People who talk to God we call saintly; people to whom God talks we call schizophrenic.

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his humorous aphorism captures a significant feature of the relationship that has existed, for most of the twentieth and the beginning of this century, between psychology and what is variously called religion, spirituality, and theology. Although most of the literature refers to psychology vis-à-vis either religion or spirituality, it is theology, especially the area of theological anthropology with its views of human nature and its methodological apparatus, that would seem the more likely candidate for interdisciplinary investigations. The absence of a substantial body of literature that could bring the disciplines of psychology and theology into dialogue with each other suggests that a problem exists between them. Further, a problem at the theoretical level is likely at the root of not wanting to address theological material in therapeutic settings. This chapter provides a brief historical overview of this relationship and suggests some reasons why theology is not included in more concrete ways. The overview serves as the backdrop against which the relationship among the terms religion, spirituality, and theology is articulated. With the terms defined and interrelated, I go on to suggest that theology is the more appropriate aspect of the religious dimension which psychology could engage and which the therapist could address. Moreover, this section of the chapter contends that the conflict between theology and psychology results from the fact that both disciplines claim to

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function as the interpretive key for the “spiritual/religious” dimension of the human person. This is the first way that theology is a problem for psychology. In addition to the problem theology poses for psychology at the speculative level is the problem it poses at the practical level in the clinical setting. In addressing this second problem, the chapter focuses on the practical reality of how theology can contribute to the issue that brings the client to therapy. Furthermore, if it is a contributing factor to the condition, it must be addressed in therapy. The cognitive theory and treatment of depression illustrates how theological material can be addressed in a therapeutic situation without damaging the client’s faith and without the therapist proselytizing. A BRIEF HISTORICAL PERSPECTIVE

At the beginning of the twentieth century, religion was an important focus for the newly emerging science of psychology. Major researchers of this period included Edwin Starbuck, William James, G. Stanley Hall, and George Coe, all of whom contributed to establishing the importance of studying religious phenomena (Arveson, 1992). William James’s The Varieties of Religious Experience (1961), originally published in 1902 during these vibrant early years, remains an influential work for present-day psychologists of religion. One commentator (BeitHallahmi, 1977) suggests that pastoral counselling may be the successor to this period and style of the psychology of religion. By the end of the first quarter of the century, psychology’s interest in religion had waned. The reasons for this are complex and numerous (Arveson, 1992). In part, the newly developing science of psychology was moving away from its philosophical roots, whereas the study of religion failed to separate from the philosophy of religion. For many, religious phenomena did not seem to lend themselves to the empirical and objective modes of research that were developing. Moreover, other branches of psychology, namely, psychoanalysis and behaviourism, began to eclipse earlier methods and areas of investigation. It should be noted that before the advent of the psychoanalytic and behaviouristic approaches and during the early period of relative openness to religious phenomena, the relationship between religion and psychology was marked by the characteristic that religion was an object of study by psychology. Religion was to be subjected to psychology’s categories and understood on psychology’s terms.

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The shift in attention to psychoanalytic and behaviouristic approaches heralded a period not simply of disinterest in religion but of antagonism towards religion. Freud’s attitude towards religion was evident from his earlier writings (Totem and Taboo, 1918) to his later works (The Future of an Illusion, 1928, and Moses and Monotheism, 1939). Behaviourism’s focus on the observable and measurable was inimical to valuing the spiritual/religious dimension. Antagonism towards psychology was also present on the part of religious groups and institutions. Freud’s description of the unconscious implied a degree of determinism that seemed to undermine Christian theology’s understanding of free will and moral responsibility. The behaviourists’ materialist/reductionist explanations of human activity were seen as an insult to human dignity. The insights of psychology were generally viewed as an assault on religious truth. The new science was experienced not as an attempt to help explain religion but as an attempt to explain religion away. While part of this perception was based on defensiveness and misunderstanding, it was in part an accurate perception of the attitude of some theorists. This mutual antagonism and suspiciousness between psychology and religion would remain until the last quarter of the twentieth century. Some degree of interest in religion on the part of psychology resurfaced around the middle of the century (Gorsuch, 1988). Publications that indicate this renewed interest include Gordon Allport’s The Individual and His Religion (1950) and the launch of the Society for the Scientific Study of Religion’s journal in 1961. However, an analysis of the social science publications concerning religion indicates that the resurgence of interest in religious phenomena was more a sociological than a psychological event (Arveson, 1992). Indeed, one history of psychology (Schultz, 1969) indicates that the main topics of interest for psychology at the time of its publication were learning, perception, motivation, and personality. Religion is not even mentioned under the catch-all category of “other developments.” By the 1970s, there were indications that interest in religion as an area of study had moved forward significantly. In 1975, the American Psychological Association (APA) incorporated Division 36 by absorbing PIRI (Psychologists Interested in Religious Issues) in response to the growing level of activity in this area (Arveson, 1992). The early 1970s saw the inauguration of the Journal of Psychology and Theology, and by 1982 the emergence of the Journal of Psychology and Christianity. Developments in the early 1990s indicated not only a renewed interest in but also a new valuing of religion. In 1992, the APA’s Ethical Principles of Pychologists

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and Code of Conduct included religion as a human difference. “This inclusion makes it incumbent upon all practitioners in the field of psychology to have an awareness of issues related to religiosity as well as an ability to effectively address clients’ religious concerns” (Hall, Tisdale, & Brokaw, 1994, p. 398). In 1994, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) included a V-code entitled “Religious or Spiritual Problem” as part of the category “Additional Conditions that may be a Focus of Clinical Attention” (p. 685). The most significant feature shaping psychology’s more recent investigations of religion is the methodological one of how religious phenomena are measured (Gorsuch, 1984). A legacy from the approach of William James (1961) emphasizes analysis at the level of the individual (Goldsmith, 1989) and concern with the ethical or behavioural features of the “religious individual” (Tracy, 1981). For gathering data, the questionnaire, especially the self-report, has proven the most feasible and popular instrument (Gorsuch, 1984). Despite the fact that religion is multi-dimensional, there has been a reliance on unidimensional (and non-denominational) measures of religiosity such as church attendance and religious orientation (Donahue, 1989). In their 1994 paper, Hall, Tisdale, and Brokaw examine some of the better-known instruments used in psychology of religion research, which are grouped into the following categories: • Measures of Religious Orientation • Measures of Religiosity/Spirituality • Measures of the Function/Use of Personal Faith • Measures of God Concept • Measures of Personal Experience of God • Additional Measures (e.g., Hood’s Mysticism Scale) The various measures are assessed on their theoretical bases and their psychometric properties. Missing from the discussion, however, is any definition of religious or spiritual as used within the instruments or differences of definitions among the instruments. Moreover, there is no explanation offered as to more fundamental questions such as what makes an experience religious? And who adjudicates that claim? Without a firm theoretical base that addresses such questions, there is the danger that measures of religious orientation may involve the “religification” of personality differences (Van Wicklin, 1990). Finally, the population from which samples have been drawn is overwhelmingly made up of Christian college students. It would require

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some extensive rewording of orientation scales to accommodate faith expressions other than Christian (Van Wicklin, 1990). Thus, much of the content of the term “religion,” in this context, may be Christianity and the Christianity of a particular age, education, socio-economic, and ethnic group. In assessing the current state of the psychology of religion, the consensus (Gorsuch, 1984; Hall, Tisdale, & Brokaw, 1994) is that the development of new instruments is not what is needed to advance the discipline in the production of significant and relevant data. Indeed, some researchers (Donahue, 1989; Goldsmith, 1989; Hood, 1989) are calling for the development of a role for theology in religious research, while others (Norager, 1996; Wulff, 1996) are arguing for at least the admission of a hermeneutical approach in the psychology of religion. A signal that psychology, within its own framework, was possibly experiencing the limitations of its unidimensional approach can be seen in the distinction that emerged between intrinsic and extrinsic religiosity. To some extent, this distinction contributed to the separation of religion and spirituality in the field of psychology. Religion became associated with the extrinsic and was seen as clustering the communal/ institutional features of religiosity, while spirituality became aligned with the intrinsic and was associated with the individual/personally committed features of this dimension. This split of the spiritual from religion may be a false dichotomy, and may be evidence of that shift in psychology that seeks to incorporate spirituality into its own discipline, while severing spirituality from religion. This results in the notion of religionless spirituality, which is popular in current North American culture and is not limited to the realm of psychology. In addition to the current understanding of religionless spirituality, there also seems to be an understanding of spirituality that is almost in opposition to religion (Smith, 2001). RELIGION, SPIRITUALITY, THEOLOGY

Although most people might think that the term religious refers first and foremost to God, the religious dimension first emerges not in a question about God but rather in a question about meaning. Usually, some experience prompts the emergence of this question, and this experience need not be, and usually is not, of a suprarational sort. The specifically religious quality of meaning referred to here is seen in the understanding of this meaning as the ultimate meaning and in the ultimate

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claim this type of meaning makes on the individual. When this ultimate meaning is named as “God,” the question of meaning moves to a theistic formulation; and when the idea of God is specified in a particular manner—as expressed in narrative, symbols, community, kerygma, dharma, doctrines—it becomes what we call religion or religions. Whether the theistic moment is necessary for the religious dimension to concretize as a religion is disputed, as can be seen in the case of Buddhism. There seem to be a variety of Buddhisms, some of which have a divine or semi-divine figure and others that do not acknowledge any deity. If one’s definition of religion requires a deity, then Buddhism might not qualify as a religion. However, in the approach taken here, such a distinction might be inconsequential since we are discussing the notion of ultimate meaning as fundamentally a religious phenomenon, and perhaps there may be no real need to distinguish between a religious perspective and a religion (Tracy, 1975). At the heart of religion is the spiritual reality. In this context, spiritual means that which exceeds one utterly; the sacred; the ground of all being; the holy; the numinous; the Other. What constitutes religion (narrative, symbols, community) is intended to convey, express, and hold this numinous reality. By definition, religion includes spirituality at the level of intention, if not always at the level of experience (Pargament, 1997). However, since the spiritual reality, which religion tries to express and participate in, can never be fully contained by the religion, there can be spiritual activity outside the formal context of religion. Generally, it seems possible to say that religion references the values of tradition and communal experience, while spirituality references the novel and individual experience, the two aspects being two sides of a coin. When communal experience and individual experience are severed, both sides run the risk of developing a solipsistic perspective that references nothing outside itself. Although distinctions between religion and spirituality can be made, too much distinction creates distortion. Theology is the Cinderella of the triad. The theological world, borrowing from the motto of Anselm of Canterbury, defines theology as “faith seeking understanding,” and, as such, theology stands as the cognitive part of the process described above. The theological moment is always present. It is there from the beginning of the search; whatever religion/spirituality one moves towards, it is because that religion holds or conveys the surplus of meaning that the originating experience introduced to one’s horizon. Theology addresses the question of what that meaning is and distills that meaning into expressions that usually take

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some form of proposition. Again, at the level of the dynamic, the theological moment cannot really be separated from the religious/spiritual dimension; it is, in fact, that same reality viewed from the perspective of a cognitive, reflective approach (Tracy, 1981). Contemporary psychology, when exploring religion, seems to seek a notion of spirituality that is severed from religion and dismissive of theology (Donahue, 1989). This may be the result of the residual elements in the psychotherapeutic movement that present psychology as the religious dimension which has come into maturity. When viewed as the ultimate meaning system, psychology has all the elements of a religion: a founding myth, doctrines, practices, language, ritualizations, saints, and heretics. And it must be recalled and admitted that psychoanalytic dicta and psychotherapeutic theories are almost as much belief systems as they are knowledge systems, and as such require acts of faith. There is also a notion of enlightenment in this psychology-as-religion, which could mean sanity born of the insight derived from working through inner conflict. It does not require grace, nor is it a gift of the Other, as it is in the great religious/spiritual traditions. Absolution does not come from the absolute beyond, but from the therapeutic authority sitting opposite. Theology is not needed because psychology functions as the interpretive key providing the cognitive formulation of meaning. One possible, and overlooked, reason why theology has not been taken up by psychology as a sister discipline that can offer insight into human behaviour is precisely because theology and psychology have been seen as competing systems of meaning rather than as complementary ones. Spirituality becomes an acceptable category for psychology, since, when it is severed from religion it can be voided of its “sacred” meanings and added to the psychological lexicon. This is especially admissible because spirituality, in its religionless mode, could reference some intangible element that could be shown to facilitate the therapeutic process (Hood, Spilka, Hunsberger, & Gorsuch, 1996), that is, the way to ultimate meaning. In this way, spirituality is rationalized and any realities—the great religious/spiritual traditions—that manifest or challenge the limits of the psychotherapeutic meaning system are supplanted, the question of God is bracketed, and the term spirituality is appropriated. But nothing has changed. Any spirituality that is more than simply an aesthetic suggests an ultimate dimension. Thus, by implication, spirituality suggests its content is about what it means to be a human being (an anthropology), and about

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what this ultimate dimension might be (a theology). No matter how inchoate and underdeveloped the articulation of this theology may be, not to explore it constitutes intellectual dishonesty. A way forward is possible, in part, because of the “turn toward the subject” taken by modern theology, which has occasioned a review of theological methodology and the development of methodological approaches that have opened up theology to dialogue with other disciplines. THEOLOGICAL DEVELOPMENTS

The erroneous understanding of theology as the elucidation of a belief system that exists for the purpose of proving the truth claims of/or a particular ecclesiastical body seems to be one of the reasons that psychologists did not see theology as an appropriate source of data for empirical study, let alone as a partner in the work of understanding human beings and their behaviour. However, some developments in the methodology of certain of its branches (especially fundamental and systematic theology) have moved it well beyond a sectarian discipline. One of the important features of theology’s new approach is an extended conversation with contemporary culture, including that aspect of culture articulated in the modern psychologies (Browning, 1987). Also, the twentieth century has been the age of methodological development, an area that had kept theology within a closed system that was unable to enter into a dialogical relationship with other disciplines. An example of these developments can be seen in the work on fundamental theology by American Catholic theologian David Tracy (1975). Fundamental theology is concerned with providing arguments that all reasonable persons, whether religious or not, can recognize as reasonable. Tracy proposes a new model for fundamental theology, the defining characteristic of which is “a rational insistence on employing the approach and methods of some established academic discipline to explicate and adjudicate the truth-claims of the interpreted religious tradition and the truth-claims of the contemporary situation” (Tracy, 1981, p. 62). His model has five theses: 1. Theology [i.e., Christian theology] has two sources, the Christian texts and common human experience and language. 2. The theological task involves the critical correlation of the results of the investigation of the two sources. 3. The source, common human experience, will be investigated by a phenomenology of the religious dimension in everyday expe-

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rience and language, and the religious dimension in scientific experience and language. 4. The Christian texts will be investigated by historical and hermeneutical investigation. 5. The results of these investigations will be correlated to discover their significant similarities and differences and their truth value will be determined using an explicitly metaphysical or transcendental mode of reflection. (Rennick, 1997, pp. 15–16)

There are certain terms in these theses that require further elaboration. The term “common human experience” refers not only to sensory data but also to “that immediate experiences of the self as self which can be reflectively mediated through such disciplines as art, history, cultural analysis, human scientific analysis and philosophical analysis” (Tracy, 1975, p. 69). The expression “religious dimension” is used instead of religious “experience” to indicate that religion is not a separate human activity but a dimension of all human activity (p. 59, n.24). The term “critical correlation” refers to bringing the questions and answers about meaning and truth, that arise from the two sources, into dialogue with each other to determine the legitimacy of their truth claims and their claim on us (p. 75). Along with the five theses, Tracy (1975) provides three criteria for establishing the relative adequacy of the sources: 1. Meaningfulness: signifying that the expressions of both sources have a disclosive power vis-à-vis some aspect of reality. 2. Meaning: signifying internal coherence. 3. Adequacy to experience: signifying that the reflection/expression is judged to be true. (Rennick, 1997, p. 17)

To these, Tracy adds a fourth criterion addressed specifically to the theologian. This is the criterion of appropriateness, which is part of the theologian’s responsibility to the source, the Christian texts, and makes it incumbent upon the theologian to show how his/her understandings are appropriate to the Christian understanding of existence. While this fourth, specifically theological criterion is not relevant to this chapter, what is important about the methodology sketched out above is the expansiveness of theology’s approach, which stands in marked contrast to the frequently perceived stereotype of religion as narrow and sectarian. Further, it is an approach that structurally requires dialogue with other disciplines, including psychology. Theology has moved in a direction that seems to have diminished one of the problems that psychology

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may have had with it at the speculative level; thus, there is an opening for a dialogue between theology and psychology that heretofore may not have been possible. The onus now seems to be on psychology to take advantage of this new situation, as the impasse at the speculative level no longer seems to be present. More pertinent to my discussion is the criterion of meaning that Tracy (1975) cites and the understanding of that criterion as internal coherence. In addressing theological content, the criterion of internal coherence, as I illustrate below, facilitates disclosure and a critique of the client’s personal theology. As previously indicated, the neglect of theology may be a consequence of the rivalry between psychology and theology as competing meaning systems. One practical result of this competition is that theological content goes unaddressed in clinical settings. There are several possible factors that may contribute to this situation: the client’s perception of theology as a sectarian value system, which the therapist has no business attempting to address; the therapist attempting to make theological understanding a focus of therapy, which could be seen as unethical on the grounds of the therapist’s lack of training or competence in this area; the client’s perception that the therapist is trying to proselytize. Each of these ethically dubious situations is serious and should be eschewed. However, it may be possible to include theological content in a treatment protocol even though the therapist is not a professional theologian and without proselytizing being involved. I explore this possibility by using Beck’s cognitive theory (Beck, Rush, Shaw, & Emery, 1979) for the treatment of depression as the exemplary therapeutic context. A brief review of Beck’s cognitive model will provide the likely locus of the theological component of an individual’s cognitive framework. BECK’S COGNITIVE MODEL

Aaron Beck’s cognitive model (1979) contains three central concepts used to explain the phenomenon of depression: the cognitive triad, schemas, and faulty information processing of cognitive errors. The cognitive triad consists of the negative view individuals have about themselves, their ongoing experiences and their future possibilities, in short, the individuals’ world. Beck refers to the activity of structuring the world of the cognitive structures as schemas, which are relatively stable patterns of interpreting and organizing perceptions. Experience is evaluated

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through a matrix of schemas, which yield automatic thoughts that constitute an internal communication system about self, life situations, and expectations. This internal communication system functions at a preconscious level, and though it usually exists outside everyday consciousness, it can be accessed and brought to conscious awareness. Simply, information processing comprises the typical ways we look at the world, which are more or less adaptive. In this theory, it is this system that goes awry in depression and results in faulty information processing. Depression, in this model, occurs when certain schemas are activated and there is a cognitive shift that first neutralizes the positive bias of the information system in non-depressed thinking, and then yields negative cognitions with faulty information processing that enhances the negative thinking that maintains the depressed mood. Negative thinking is an aspect of all depression, and cognitive therapy intends to alleviate the emotional distress of depression by altering the negative thought processes. This is done by bringing to consciousness people’s automatic subconscious thoughts—the internal conversations people carry on about themselves, their lived situations, and their expectations. These faulty information processes are then tested against experience in the context of a collaborative therapeutic relationship. The cognitive errors that occur in depression are marked by selective, global, absolutist thinking. Disclosing these errors as errors is not a matter of talking the client out of his/her attitudes using logic, nor is it coercing her/him to think differently. Rather, both the content and the cognitive structure of these misleading processes are altered by opening up new possibilities of thinking, of viewing the world, and of personal expectations for the client. THE GOD FACTOR

It is fairly common knowledge that public opinion polls consistently indicate that the majority of people in contemporary North America believe in some sort of God. The numbers vary, but believers continue to be in the majority. The questions of what God is like, or, even more important, what God wants and how God works in our lives, are certainly the questions of theology, but they are also the questions of ordinary believers, especially in times of crisis, even when those questions are at a subconscious level and are not phrased in such precise terms. The perennial popularity and the continuing significance of such questions are validated by their presence in works of literature, where

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lives are made and/or destroyed by “providential” interventions. Author Graham Greene is one writer whose works are known for grappling with theological questions, and whose characters are tormented in their struggle to please or appease the God they believe or fear may exist. The characters in his novel The End of the Affair (1951; reprinted 1975) provide us with a portrait of such lives. In the novel, Maurice and Sarah are involved in an adulterous love affair in blitz-torn London during the Second World War. During one of their trysts there is an air raid, and the house they are meeting in is bombed. Maurice is in the section of the house that explodes, and Sarah believes him to be dead. In her own voice, she describes her response: I knelt on the floor: I was mad to do such a thing: I never even had to do it as a child—my parents never believed in prayer any more than I do. I hadn’t any idea what to say. Maurice was dead. Extinct.…He would never have the chance to be happy again.…I knelt and put my head on the bed and wished I could believe. Dear God, I said—why dear, why dear?—make me believe. I can’t believe. Make me. I can’t do anything of myself. Make me believe. I shut my eyes…and I said I will believe. Let him be alive and I will believe. Give him a chance. Let him have his happiness. Do this and I’ll believe. But that wasn’t enough. It doesn’t hurt to believe. So I said, I love him and I will do anything if you make him alive. I said very slowly, I’ll give him up forever, only let him be alive with a chance,…and I said people can love without seeing each other, can’t they, they love You all their lives without seeing You, and then he came in the door and he was alive, and I thought now the agony of being without him starts, and I wished he was safely back dead again under the door. (Greene, 1975, p. 95)

Sarah breaks off the relationship with Maurice in accord with the bargain she has struck with the object of her prayer. The combination of guilt over adultery, the notion of a divine force that will miraculously intervene, the requirement of suffering for the intervention to occur, the notion of love as sacrificial, the quasi-believing quality of her faith all combine to create a thorny theological labyrinth. Moreover, these elements are not academic or theoretical considerations, but are immediate and profound and have a tremendous impact on her life, which is now marked with an inconsolable despair. The creators of fiction are free to present a picture of characters living out the consequences of their personal theologies and the several con-

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flicts of faith and values that such personal theologies may produce, without having to resolve the situations that their characters create. Literature provides a mirror to reflect the struggles and questions that we have to face without the onus of addressing solutions or answers. However, if the mirror that literature holds up to us provides an authentic reflection, then the problems it presents are real even if the characters remain fictional. I suggest here that the clients who come to us have personal theologies that impact their lives in important ways, especially during times of difficulty and struggle. The theologies they hold may not have the complexity or clarity of the situations presented in literature but they are nonetheless real, and the therapeutic arena must find a way to address them, especially when they may be significant contributors to psychological dysfunction, as they can be in depression. An individual’s personal theology would likely be located at the level of schemas—the internal communication system at the fringes of conscious awareness—but that can be easily accessed and brought to critical conscious under examination. It is important to remember that theological questions and outlooks are not in the first instance questions about God, but rather questions about meaning and, indeed, ultimate meaning. Moreover, in the ordinary individual’s thinking, these cognitions that point to ultimate meaning are often masked in statements like “everything happens for a reason,” “I guess it wasn’t meant to be,” or “what goes around comes around.” Such statements, although not overtly about God, point to a belief about the way the world works and are very possibly the bedrock of the person’s meaning system. Because these cognitions are foundational to an individual’s world view, and because they carry the valence of ultimate meaning, faulty thinking in this domain would be a significant contributor to the cognitive substrates of depression. It is for this reason that a substantial and lasting treatment for depression must address theological thinking, that is, the cognitions about ultimate meaning and even a client’s thinking about God. THEOLOGY AS COGNITIVE CONTENT

As previously stated, a traditional and still applicable definition of theology is one of faith seeking understanding. It is the element of faith and the decidedly personal quality of this element that gives the therapist pause when overtly religious content emerges in a therapeutic context. However, theology itself provides a way through this impasse.

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Classical theology makes a distinction between the fides qua, the faith by which one believes, or faith as a dynamic; and the fides quae, the faith which one believes, or faith as content. It is this second aspect of faith that can be, and indeed must be, part of the focus of attention in therapy if all the significant elements contributing to the mood and/or anxiety disorder are to be addressed. The faith which one believes is nothing other than belief distilled into particular propositions about the world, God, and human beings. These propositions can rightly be seen as cognitions, that is, thoughts about the nature of reality and, as such, are not qualitatively different from other cognitions that are the appropriate focus of a cognitive therapy of depression. There are distinctions to be made about exactly how therapy may proceed in the face of perspectives that are not available to reality testing; but as a general principle, cognitions with overtly religious content do not differ from other types of cognitions. Such cognitions constitute a personal theology, and as such are foundational to the individual’s world view and are part of the interpretive apparatus by which he/she evaluates and understands experience. Some therapists have incorporated religious images into their cognitive treatment of depression (Miller & Martin, 1988; Propst et al., 1992) as part of a protocol to alter dysfunctional self-statements. In these treatments, the religious imagery is used as an adjunct to the usual methods of correcting unrealistic thinking. Research in this area has shown that the use of religious imagery in this way is beneficial because it provides an enduring alleviation of depression (Ciarrocchi, 1993). There is less said about the theological thinking of the client as a focus in therapy and about the impact of faulty theological thinking on the development and the continuation of the depressive mood. This, of course, is where the problem lies: How does one say that another’s theology is wrong? In fact, one doesn’t say that and shouldn’t say that in therapy. What is being addressed is how the therapist may recognize that the client’s theological thinking is not life affirming for him/her as it emerges in therapy through the client’s own words and expressions. This is a subtle and thorny path for which some general guidelines are needed. ADDRESSING THE THEOLOGICALLY PROBLEMATIC

The theological material that needs to be addressed is only that material that seems to contribute to the client’s dysfunction and depressed mood. Whether one is a creationist or an evolutionist is not likely to impact one’s ability to function, and is the type of theological material that

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should not be addressed. The therapist needs to be discerning about which statements of theological import need to be explored. Statements that are suggestive of notions of a divine plan or a divine will are the likely contributors to a person’s sense of guilt or futility that often is present in depression. And as always, it is the client’s decision as to what will be addressed. As previously indicated, theological cognitions are located at the level of what Beck calls automatic thoughts, which need to be brought to consciousness so that they can be discussed. These automatic thoughts often emerge in offhand statements such as “I guess it wasn’t meant to be,” by which a client often attempts to give meaning to a present painful situation. The pain is bearable if it has meaning, and life is possible if there is ultimate meaning. In exploring what a client might mean by such a statement, the therapist’s exploratory questions should be as open-ended as possible so they are not taken as disagreement with such thinking. When it is the level of ultimate meaning that is being alluded to, what the client is thinking of is the very nature of reality, and defensiveness is heightened if dismissiveness is suspected. Gentle questioning following this almost offhand comment can bring to the surface information that is deeply personal and absolutely foundational to the client’s world view. It is important to stay in the room and to stay with what the client has articulated. In this most important matter of meaning there is usually a great desire to be right and to be certain. As the client attempts to explain what it is he/she really believes, there may be an emerging sense of uncertainty and/or irrationality to what is being said, which often moves the client to cite some authority for his/her position. The Bible or some official statement by a minister may be invoked for this purpose. The client may also try to draw out the therapist’s belief about what has just been disclosed. It is here that it is most important to stay with the task of establishing what the client believes and has expressed. Everything else constitutes an external authority. The point of this exploration is not to adjudicate the rightness of what the client has internalized, but to bring to conscious articulation what the client actually believes. Once they surface, these cognitions may surprise the client. In typical cognitive behavioural therapy, the information brought to the surface from the level of automatic thoughts is tested against the client’s experience or against reality by checking another’s experience. This avenue is not as readily available around the subject of theology. The question of how God is present in human experience is not a question

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for a therapist but for a spiritual director, spiritual companion, or spiritual guide usually functioning within the same creedal tradition as the client. What might irrational thinking mean when investigating the realm of the suprarational? It is important to remember that there is a difference between the irrational, that which goes against reason, and the non-rational, that which cannot be fully contained by rational categories. As Pascal (1995) remarked: the heart may have reasons, which reason doesn’t know. As I have suggested, theological cognitions essentially do not differ from other types of cognitions. Thus, theological cognitions can be addressed in a manner analogous to the way other issues are addressed. Therapists do not provide answers or solutions to their clients’ difficulties; rather, counsellors assist their clients in understanding the implications of maintaining certain beliefs as well as providing the opportunity and the critical support needed to reach new perspectives and resolutions. This is true no matter what the content of the cognition. In correcting faulty theological cognitions, the process is not one of replacing specific beliefs by finding a new authority to internalize. Rather, it is the process of moving towards internal coherence in the area of theological cognitions. (An application of Tracy’s notion of meaning as internal coherence.) The development of inner coherence is achieved by identifying the contradictory beliefs that the client may hold. This is the client’s meaning system in conflict with itself, which may be contributing to dysfunctional and self-defeating behaviour. As the contradictions are disclosed, the client may actually be engaged, for the first time, in a novel process of deciding what it is that he/she truly believes. The decision to take conscious responsibility for what one holds and on what one is going to base one’s life can be an empowering and liberating experience. Ironically, posing questions about faith as content can actually enhance the element of faith as dynamic, and the dynamic of faith can contribute to a sense of well-being and thus assist in alleviating the depressed mood. While the issue of invoking external authority has been cautioned against, theological thinking does not emerge out of, nor function within, a vacuum. There are some basic propositions about God that are held by the great faith traditions. If we restrict the discussion to the Judeo-Christian tradition, we can cite two fundamental principles that function as touchstones against which one could test the speculative adequacy of any explanation of how God is present and functions in the world. These two fundamental principles are that God is good and that human beings

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enjoy free will. As in regular cognitive therapy, where the client is asked to test her/his beliefs against reality, these two touchstones would define the theological reality and would function in a similar manner—the client would use them to test the appropriateness of her/his basic beliefs about the way the world works. Thus, any explanation of how God is present and active in the world that mitigated God’s goodness or compromised human freedom would be inadequate and would be classified as faulty theological thinking. A theology that approximates an accurate understanding of reality (which is all any of our thinking about any reality can be) will be consistent with an understanding of God as a benign being and human beings as having a relative degree of freedom consonant with being able to determine their future and being capable of taking responsibility for their actions. If the client’s understanding of the dynamics of reality or the way God works in the world honours these two theological touchstones, it is unlikely that his/her theology will be a factor in the depressive thinking and quite likely that it will be a factor in the alleviation of his/her depression. If, for example, we return to the expression “I guess it wasn’t meant to be,” it is easy to see how this statement could imply that there is some intelligence and intentionality behind the world we experience—something is orchestrating the way life unfolds. As it stands, this is a relatively neutral statement. However, further exploration might disclose that the client actually ascribes to a fatalistic world view and has a deeply imbedded, though perhaps subconscious, sense that all his/her best efforts are futile and that her/his life is shaped largely by uncontrollable external forces. In short, he/she is not much more than a marionette without any real choice. Clearly, the touchstone of human freedom has been lost, and a therapy that does not address such a fundamental shortcoming in the client’s world view or meaning system would have a questionable chance of effecting enduring change. Many therapists might be uncomfortable with applying such an explicit theological focus to their work. The validity of this approach might be made more evident from another perspective. If we don’t use the framework of religious faith, we can see that the two theological touchstones that we have been using (the goodness of God and human freedom) can be rephrased in a non-theistic mode as the goodness of life and the possibility of change. The goodness of life means that it is a good thing to be alive and, though it may sometimes be painful, life is worthwhile. The possibility of change refers to consciously self-directed personal development. When viewed in the context of this terminol-

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ogy, we can see that the same principles that anchor sound (realistic/ healthy) theology are also foundational to the possibility of an effective (health-inducing) therapy. It is precisely the perspectives of goodness and new possibility that have been eclipsed in the depressed client who feels hopeless and helpless. If it were not true that life is worthwhile and that change is possible, then depression would be a legitimate response. Indeed, to the extent that health can be defined as an appropriate conformity to reality, we would have to arrive at the oxymoronic conclusion that in such a world depression would manifest a mentally healthy response. But that is not the case. And so every therapist (and this would be especially true of pastoral counsellors) works from the unspoken presupposition that life is good and change is possible and, moreover, works to assist her/his depressed client to achieve the same disposition. Why would it then be less appropriate to explicitly address what we have called here the client’s personal theology—those cognitions that touch on ultimate meaning and reality—and frame the issue in terms of God and human freedom? When theology is understood as the cognitive side of an individual’s religious/spiritual dimension, which in turn is seen as an aspect of ordinary human self-understanding as contemporary theology suggests, the need to maintain a great chasm between the therapeutic and the theological is no longer valid. The question of whether the area of personal religious beliefs is too delicate and dangerous an area for the non-theologically trained may remain. Pastoral counsellors are among those therapists who are reluctant to engage in any kind of “God talk” in the clinical setting lest it compromise their identity as professionally trained psychological counsellors. Shouldn’t this area just be bracketed in the hope that, as the irrational thinking in other facets is corrected, the cognitions that are foundational to a person’s world view will self-correct? Are we not in danger of doing more harm by questioning faith? These are legitimate questions, but they must be asked in conjunction with the following: What harm is done when a client’s religious issues are ignored or when a client is informed that matters of faith do not belong in therapy? Are these attitudes, when expressed by a trusted authority, damaging to an individual’s self-respect as a believer, or do they weaken the conviction that believing religiously is a healthy or good thing? These concerns have gone largely unaddressed by the therapeutic community. By inviting people to take their faith seriously and to come to a deeper clarity about what they actually believe, the dynamic of faith, which can be an

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aid in alleviating depression, is strengthened. Consider the old adage, “a thousand questions do not add up to a single doubt.” This chapter has argued that people have personal theologies—convictions and cognitions about ultimate meaning and reality, usually understood in the theistic concepts of God and God’s interaction with the world. These theologies are not theoretical abstractions, but impact people’s lives in immediate and profound ways, and could be significant contributors to a mood disorder like depression. Since theological cognitions do not differ essentially from other types of cognitions, directly addressing theological issues with appropriate care may be a legitimate approach when it is discerned that theology is the problem. REFERENCES Allport, G. (1950). The individual and his religion. New York: Macmillan. American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. Washington, DC: APA. American Psychological Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.) Washington, DC: APA. Arveson, K. (1992). Who is studying religion? An analysis of religious variables in psychology dissertations 1983–1987. Doctoral dissertation, Loyola College, Baltimore, MD. Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford. Beit-Hallahmi, B. (1977). Curiosity, doubt, and devotion: The beliefs of psychologists and the psychology of religion. In H.N. Malony (Ed.), Current perspectives in the psychology of religion (pp. 381–91). Grand Rapids, MI: Erdmans. Browning, D. (1987). Religious thought and the modern psychologies. Philadelphia, PA: Fortress. Ciarrocchi, J. (1993). A minister’s handbook of mental disorders. Mahwah, NJ: Paulist. Donahue, M. (1989). Disregarding theology in the psychology of religion: Some examples. Journal of Psychology and Theology, 17 (4), 329–35. Freud, S. (1918). Totem and taboo (A.A. Brill, Trans.). New York: Moffat, Yard. Freud, S. (1928). The future of an illusion (W.D. Robson-Scott, Trans.). London, UK: Hogarth. Freud, S. (1939). Moses and monotheism (K. Jones, Trans.). New York: Vintage. Goldsmith, W.M. (1989). Through a glass darkly, but face to face: Comments on psychology and theology eyeing one another. Journal of Psychology and Theology, 17 (4), 385–93. Gorsuch, R. (1984). Measurement: The boon and bane of investigating religion. American Psychologist, 39 (3), 228–36. Gorsuch, R. (1988). The psychology of religion. Annual Review of Psychology, 39, 201–11. Gorsuch, R. (1990). Measurement in the psychology of religion revisited. Journal of Psychology and Christianity, 9 (2), 82–89.

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Greene, G. (1975). The end of the affair. London: Penguin. (Original work published in 1951.) Hall, T., Tisdale, T., & Brokaw, B. (1994). Assessment of religious dimensions in Christian clients: A review of selected instruments for research and clinical use. Journal of Psychology and Theology, 22 (4), 395–421. Hood, R.W., Jr. (1989). The relevance of theologies for religious experiencing. Journal of Psychology and Theology, 17, 326–42. Hood, R.W., Jr., Spilka, B., Hunsberger, B., & Gorsuch, R. (1996). The psychology of religion: An empirical approach (2nd ed.). New York: Guilford. James, W. (1961). The varieties of religious experience. New York: New American Library. (Original work published in 1902.) Miller, W.R., & Martin, J.E. (Eds.). (1988). Behavior therapy and religion. Beverly Hills, CA: Sage. Norager, T. (1996). Metapsychology and discourse: A note on some neglected issues in the psychology of religion. International Journal for the Psychology of Religion, 6 (3), 139–49. Pargament, K.I. (1997). The psychology of religion and spirituality? Yes and no. Psychology of Religion Newsletter, 22 (3), 1–9. Pascal, B. (1995). Pensées. New York: Penguin. (Original work published in 1670.) Propst, L.R., Ostrom, R., Watkins, P., Dean, T., & Mashburn, D. (1992). Comparative efficacy of religious and nonreligious cognitive-behavioral therapy for the treatment of clinical depression in religious individuals. Journal of Consulting and Clinical Psychology, 60, 94–103. Rennick, Paul J. (1997). In search of the religious imagination: An empirical study of David Tracy’s theory of the analogical imagination. Doctoral dissertation, Loyola College, Baltimore, MD. Schultz, D. (1969). A history of modern psychology. New York: Academic. Smith, H. (2001). Why religion matters. Toronto, ON: HarperCollins. Tracy, D. (1975). Blessed rage for order. New York: Seabury. Tracy, D. (1981). The analogical imagination. New York: Crossroad. Van Wicklin, J.F. (1990). Conceiving and measuring ways of being religious. Journal of Psychology and Christianity, 9 (2), 27–40. Wulff, D. (1996). Betwixt the object and the eye of the beholder: Thoughts on making the psychology of religion more interesting. International Journal for the Psychology of Religion, 6 (3), 151–57.


3 Assessing Plurality in Spirituality Definitions Pam McCarroll Thomas St. James O’Connor Elizabeth Meakes

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nterest in spirituality in the health care literature is increasing at a fast rate (O’Connor, McCarroll-Butler, Meakes, Davis, & Jadad, 2002). Questions are being raised about the role spirituality plays in the promotion of health and wellness in institutionalized health care. Currently, research in the field seeks to determine and understand the connections between spirituality, spiritual practice, and health outcomes. Given the vast amount of literature on the topic, it is important that the health care disciplines develop clear definitions of spirituality and appropriate practice of spiritual care. It is with these goals in mind that the research for this chapter was completed, that is, to attempt to delineate categories in the definitions of spirituality that are emerging in the ongoing and cross-disciplinary discussions. This chapter is divided into three parts, reflecting both micro and macro perspectives on definitions of spirituality in the literature. The first part presents the research findings into definitions of spirituality that emerged in systematic reviews of the health care literature. The plurality found in the findings raises a number of questions for practitioners and researchers: If a singular definition is neither ethical nor possible in our pluralistic age, how do we deal with the fact of plurality in understandings of spirituality? How do we begin to develop research models that are open systems enabling plurality while resisting falling into anti-ethical and relativistic nihilism? These are questions that the second part seeks to address through the presentation of a preliminary typology, which delineates five perspectives that shape the methods,

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goals, and understandings of research and practice. A methodological indicator is applied in order to understand spirituality and to consider the findings of the initial study in the light of each of the perspectives. The second part also invites readers to take a step back from these findings in order to reflect on why and how such plurality in definitions of spirituality exists in the health care literature. In the final part, a methodological proposal is offered that presupposes and is shaped by the concept of love. Contrary to the perspectives enunciated in the second part, the proposal urges us to rethink the methodological presuppositions in which we function as health care practitioners. As well, it provides a big picture and proposes an open-ended way of thinking about the particularities of multiple perspectives (whether in definitions of spirituality or in methods of research) without falling into anti-ethical relativism. SPIRITUALITY IN HEALTH-CARE LITERATURE— TWENTY-SEVEN SYSTEMATIC REVIEWS

Our study sought to analyze the definitions of spirituality through locating systematic reviews in five health-care databases— MEDLINE, CINAHL, Sociofile, HealthSTAR, and PsycLIT. In these systematic reviews, each of the articles searched included at least twenty other studies that were summarized, reviewed, and critiqued. To search for titles, the term “spiritual” was input as a subject heading, a keyword, and a title word in the five databases. After deleting the duplicates, the results revealed that, between 1975 and 1996, there were seventy-six systematic reviews that dealt with the topic of spirituality. Of these seventy-six articles, sixty-eight were accessed and reviewed for their definitions of spirituality, all of which contained operative definitions of spirituality. Twenty-seven of these explicitly articulated a definition of spirituality in the text. Among these twenty-seven definitions, however, there was little agreement. The research presented here includes the findings of an inductive analysis of the twenty-seven definitions that ascertained the central themes, of which eight emerged from the definitions. These findings were validated by researcher triangulation (Berg, 1998; O’Connor, Empey, Fox et al., 1997) wherein two other researchers reviewed the twentyseven definitions and confirmed the titles and descriptions of the eight themes. The findings were tested on a number of groups in the health care setting that supported the findings.

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The eight themes that emerged were meaning and purpose; connection and relationships; God/god(s)/Transcendent Other; transcendent Self; vital principle; unifying force or integrative energy; personal and private; and hope. Most of the definitions included at least two of the concepts listed in the eight themes. Each theme is briefly reviewed here.

1. Meaning and Purpose In twenty-three of the twenty-seven cases, the concepts of meaning and purpose are central aspects of spirituality (Bensley, 1991; BerggrenThomas & Griggs, 1995; Bradshaw, 1996; Burkhardt, 1989; Dossey & Guzzetta, 1994; Emblen, 1992; Fulton & Moore, 1995; Goddard, 1995; Harrison, 1993; Heriot, 1992; Levin & Vanderpool, 1987; McKee & Chappel, 1992; Mickley, Carson, & Soeken, 1995; Miller, 1995; Oldnall, 1996; Paton, 1996; Peri, 1995; Presti, 1990; Reed, 1992; Ross, 1994, 1995; Smith, 1995; Swanson, 1995). Nine of these identify that spirituality is that which shapes one’s values and approach to life and one’s orientation to the universe. In part of a definition, spirituality is described as “the underlying dimension of consciousness which strives for meaning” (Smith, 1995, p. 403). Meaning and purpose in life are understood, in some cases, to be that towards which humans consciously yearn, and in other cases, as humans giving meaning and purpose to life through unconscious meaning-making systems. When discussed, religious belief is considered as a meaning-making system in which an individual attempts to fulfill the human longing to find meaning, purpose, and fulfillment in life. The meaning and purpose in life includes life both in its particularity and universality, in its ordinary “everyday-ness,” and in its “extraordinariness.” In nine articles, spirituality as meaning and purpose is seen to manifest itself in a quest towards self-actualization and the search for human integrity.

2. Connections and Relationships In twenty-two articles, spirituality is understood to be manifested in and sustained by connections and relationships (Berggren-Thomas & Griggs, 1995; Burkhardt, 1989; Emblen, 1992; Feste & Anderson, 1995; Fulton & Moore, 1995; Goddard, 1995; Harrison, 1993; Heriot, 1992; Levin & Vanderpool, 1987; Lukoff, Lu, & Turner, 1992; Mickley, Carson, & Soeken, 1995; Miller, 1995; Narayanasamy, 1996; Oldnall, 1996; Paton, 1996; Peri, 1995; Presti, 1990; Reed, 1992; Ross, 1994, 1995; Smith, 1995; Swanson, 1995). These connections and relationships include those within the self and with others, the natural world, the cosmos, and/or a Transcendent

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Other. Some definitions refer to all these possible types of connections and relationships, some to only one type. In most cases, the connections and relationships identified are understood to be the means whereby spirituality is manifested in life. An individual’s relationships with self, other, the cosmos, and god/God are understood to be reflective of and shaped by one’s spirituality.

3. God/god(s)/Transcendent Other Twenty-two of the articles identify a relationship with God/ god(s)/Transcendent Other as the central aspect of spirituality (Bensley, 1991; Berggren-Thomas & Griggs, 1995; Burkhardt, 1989; Dossey & Guzzetta, 1994; Emblen, 1992; Goddard, 1995; Harrison, 1993; Heriot, 1992; Levin & Vanderpool, 1987; Lukoff, Lu, & Turner, 1992, 1995; McKee & Chappel, 1992; Mickley, Carson, & Soeken, 1995; Miller, 1995; Narayanasamy, 1996; Oldnall, 1996; Paton, 1996; Peri, 1995; Reed, 1992; Ross, 1995; Smith, 1995; Swanson, 1995). The majority of these definitions emphasize that a relationship with God/god(s)/Transcendent Other is not only the primary manifestation of spirituality (as in theme 2 above) but is also the origin of spirituality. Some of the definitions in these review articles distinguish between spirituality and religion. However, there is discrepancy here. Where most definitions identify that everyone is spiritual but not religious, others equate spirituality with religion.

4. Transcendent Self In twelve articles spirituality is understood as the means of enabling the individual to transcend the self in one capacity or another (Bensley, 1991; Berggren-Thomas & Griggs, 1995; Burkhardt, 1989; Dossey & Guzzetta, 1994; Emblen, 1992; Harrison, 1993; Miller, 1995; Paton, 1996; Peri, 1995; Presti, 1990; Reed, 1992; Ross, 1995). In some instances spirituality is viewed as that which enables the transcending of emotional and/or physical pain. In other instances it is that which enables the transcending of the self so as to identify with the experience of another person. This understanding of transcendence is anthropocentric in each case.

5. Vital Principle Eleven definitions identify the vital principle as a central aspect of spirituality (Berggren-Thomas & Griggs, 1995; Burkhardt, 1989; Dossey & Guzzetta, 1994; Emblen, 1992; Goddard, 1995; Harrison, 1993; Miller, 1995; Paton, 1996; Peri, 1995; Presti, 1990; Swanson, 1995). The vital prin-

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ciple is understood as the creative, animating force in self and/or world and/or universe. In these definitions, vital principle transcends or integrates subject-object dichotomies. It is a non-personified, incorporeal, common element that “vitalizes” the whole person and/or the cosmos.

6. Unifying Force or Integrative Energy Ten of the definitions refer to spirituality as the unifying force or integrative energy within the individual and/or world and/or cosmos (Bensley, 1991; Burkhardt, 1989; Dossey & Guzzetta, 1994; Emblen, 1992; Fulton & Moore, 1995); Goddard, 1995; Harrison, 1993; Miller, 1995; Paton, 1996; Peri, 1995). Like the theme above (vital principle), this understanding assumes something that transcends subject-object dichotomies. However, the aforementioned theme and this one differ in function. The unifying force/integrative energy is a non-personified, incorporeal common energy that unifies reality.

7. Personal and Private Seven articles highlight in their definitions that spirituality is personal and private in nature (Bensley, 1991; Emblen, 1992; Heriot, 1992; McKee & Chappel, 1992; Miller, 1995; Narayanasamy, 1996; Oldnall, 1996). All of these emphasize the subjectivity of spirituality and the fact that it is judgmental and value-laden. Connected with this focus on the personal and private nature of spirituality is a reticence for addressing spirituality in the health care setting. There is fear that if understandings of spirituality are standardized, it will become exclusive, and not be open to a diversity of experiences and perspectives.

8. Hope In four articles, hope is included in the definitions of spirituality (Berggren-Thomas & Griggs, 1995; Emblen, 1992; Ross, 1994, 1995). Hope is understood both as a will to live and as an ability to come through a crisis and loss of health. Some of these definitions closely connect hope with meaning and purpose (see theme 1) with the explanation that it is a sense of meaning and purpose in life that gives hope.

Overview Some of the themes in the definitions imply a human and individualistic notion of reality (4 and 7), whereas others imply a cosmic or corporate notion of reality (5 and 6). Some imply a cognitive understanding of the self (1 and 8), whereas others imply a wholistic notion of the self

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(2, 5, and 6). Some affirm belief in something beyond the self as the starting point for discussions of spirituality (not necessarily connected with religion) (2, 3, 5, and 6). Others suggest that the starting point is the self (4, 5, 6, and 7) and those conceptualizations that allow the self to continue (1 and 8). The definitions of spirituality in the literature reveal that there is both openness and energy as well as confusion and discrepancy around the topic of spirituality. Spirituality can be discussed, experienced, recognized, and even defined from many different angles. This use of multiple definitions poses some challenges to the research and clinical practice of spiritual care. The diversity of definitions may, to some degree, reflect the cross-cultural, cross-religious, and pluralistic contexts of English-language health journals (primarily in North America and Britain), and it may reflect a plurality in health care disciplines currently engaged in research on spirituality. Some theologians would consider such plurality to be appropriately reflective of the mystery. (See, for example, Kaufman, 1981; McFague, 1982; Rahner, 1989.) As mystery, spirituality in its essence is humanly incomprehensible and uncontrollable. It is of a different order than other things in human experiences and, therefore, cannot be univocally contained and defined by human language; it can only be described. From this perspective, pluralistic dynamism in definitions of spirituality is considered to be the most honest description. However, this perspective may raise more questions than it answers in terms of spirituality and spiritual care. How do we deal with diversity and plurality in our understandings of spirituality and in our practice of spiritual care? In order to reflect meaningfully on this question, we propose that we take a step back and look at the diversity of methodological perspectives out of which have grown the theories and practices we use today. Though this method may be applied to other topics, in the next section we use “spirituality” as the focus for the methodological indicator and consider the findings of this study in the light of the typological perspectives. MAKING SENSE OF PLURALITY— A METHODOLOGICAL INDICATOR

The preliminary typology has grown out of systematic theology over the last number of years. It was the work of Frei (1992, 1993) that first sparked exploration in this direction. The typologies that Frei proposes for understanding modernity and the diversity of perspectives in

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theology grew out of his academic rigour and a deeply held vision of the place of meaning in life. Frei’s typologies, however, are limited by a rigidity that does not allow for plurality (or the possibility of open-endedness) by prioritizing one perspective that effectively shapes the hermeneutical standpoint for all the others. Furthermore, his work falls into the modernist temptation to prioritize method over content and, therefore, does not adequately address the relativism implicit in their presuppositions. We present a methodological indicator with five hermeneutical perspectives, all of which are common among numerous disciplines today. For the most part, these perspectives have grown out of developments in philosophy through the nineteenth century. Not only does this methodological indicator attempt to interpret the findings of the initial study, but it also sets out to categorize epistemological starting points and the goals of research and practice from these five methodological locations. Further, it points to preferences in the definitions of spirituality.

Methodological Indicator The five perspectives presented below represent somewhat different world views, theologies, and anthropologies. They overlap in some instances and are open-endedly incomplete in others, given that they have grown out of Judaeo-Christian and Western contexts and would benefit from greater cross-cultural, cross-religious dialogue. Using “spirituality” as the focus, the five perspectives can be identified epistemologically as follows: spirituality is known practically; spirituality is known phenomenologically; spirituality is known linguistically; spirituality is known in subjective experience; spirituality is an unknowable mystery.

1. Spirituality is known practically In this perspective, spirituality must be practically recognizable and measurable with respect to health outcomes. Language is understood to be a human construct intended to serve the goal of improving human life, and a plurality of definitions for spirituality is not itself a problem. The goal of research is to make these humanly constructed definitions meaningful for appropriate practice and improved health outcomes. Though a singular definition is often the temptation of this practically based model, it is not necessary to have a singular definition of spirituality. However, the plurality points to the need for further research into the practical implications of each of the multiple definitions. Ideally, each definition of spirituality should correspond with a specific prac-

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tice of spiritual care and a specific set of goals for spiritual well-being. In this perspective, there is a measurable internal consistency between definition, practice, and goals in health care. When one of the triad is measurably out of whack, the system needs to be reworked either by reconstructing the definition to make it more meaningful or by reworking the practice or goals so they more aptly correspond to the definition. This perspective is at home in a biomedical model of health care. This perspective would consider the research into systematic reviews to be interesting but not necessarily leading to results that would improve practice. Instead, if categorizing at all, it would prefer to sort out liketermed definitions and consider the implications for the goals and practices of spiritual care and the related parameters for measuring spiritual well-being relating to each of the definitions.

2. Spirituality is known phenomenologically In this perspective, spirituality is understood to have a singular and inclusive reality (shape and structure) of its own that is manifested in phenomena and can be recognized by the human. The language of human experience is one way that the reality of spirituality manifests itself. This model can be most easily grasped in the oft-cited Indian proverb about reality/truth: an elephant is touched and grasped on all sides by different people, all of whom are blindfolded. To understand the elephant better, to begin to grasp it in its entirety, the blindfolded people must communicate and describe to each other their own experience of the elephant (the trunk, an ear, the tail, the back). Such communication gives a truer picture of the inclusive reality/truth and moves them closer to the goal of knowing the elephant as it is. When understanding spirituality through this model, then, the plurality of definitions reflects the variety of ways spirituality is manifested. Further research, of an inductive nature, is required to provide us with a linguistic structure for defining spirituality that reflects the underlying reality of spirituality itself (to articulate the whole of the elephant). The goal of the research would be to move towards an increasingly inclusive definition within which all perspectives are reflected. Greater agreement on a definition for spirituality would lead to improved practice in spiritual care. In this perspective, spirituality is firstly a transcendent constant, an origin or form by which human experiences of and even language for spirituality are manifested. In this interpretive location, the research into the systematic reviews would be considered an excellent first step towards an inclusive defini-

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tion of spirituality that could be used across disciplines, cultures, and so on. The next step would be to construct a definition out of these multiple themes and test it from many different perspectives so as to adjust it appropriately. The agreed-upon definition for spirituality would include its own criteria for measuring spiritual well-being, and would allow different disciplines to develop different practices and goals for spiritual care shaped by the intersection of their discipline with the singular definition of spirituality. This definition would be a starting point for interdisciplinary collaboration on spiritual care.

3. Spirituality is known linguistically In this perspective, language is understood to be that which shapes and gives content to experience. Language is the a priori of human experience. Thus, language is the starting point for research into spirituality and the central means for practice of spiritual care. Language is understood to be about meaning, and meaning is considered to be that which human life most seeks. Diversity in definitions for spirituality is understood to reflect a diversity in narrative constructs that interpret and shape experience. As such, spirituality, however it is defined, is a meaning-making system. In research, theory, and practice, the internal consistency and logical, linear shape is of utmost importance. Narrative therapies are sometimes associated with this perspective, emphasizing language in stories and working towards “re-languaging” our stories. There is variation in this perspective between those who hold a Christian, revelation-based perspective and those who do not. In the former case, God is understood to have revealed Self in the Word. It is the Word (Scripture/Christ), then, that is the context of meaning and the relativizing agent of all words, of all meaning-making systems. In the latter case, it is considered on a person-by-person basis that the better the meaning-making system, the better the health/wellness outcomes. Thus, an individual’s definitions of spirituality are apparent in his/her meaning-making system. Internal inconsistency within this system points to unwellness and provides the shape for the practice of spiritual care. Meaning-making (or internally consistent language) systems are therefore a goal for wellness, relativized only by their own internal consistency (or possibly by external categories that are agreed to be ultimately meaningful, e.g., truth and goodness). In this perspective, the research into the definitions of spirituality in the systematic reviews would be considered to be a good starting point. However, further research would be required to explore the differences

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that are reflected between the dominant narratives in shaping the diverse definitions of spirituality. This could be accomplished in a theme-bytheme basis (however, the fact that many of the themes exist simultaneously within given definitions is a challenging point of departure for this method). The definitions could be categorized in a discipline-bydiscipline basis if it is assumed that each discipline exists out of its own narrative, its own vocabulary and conceptualization of reality. Another possibility for a future research model would be to use a particular disciplinary-based narrative to reflect upon and organize the findings of the study.

4. Spirituality is known in subjective experience In direct contrast to the previous interpretation, this perspective understands that spirituality is considered to be subjective and experiential. Experience is the a priori to expression or communication of experience. It has a shape of its own that is interpreted and reinterpreted by language and the integration of life experiences. Giving voice to one’s experience of spirituality is part of the integrating process. Language and expression have a fluidity that is related to personal experience, though it is not fully definitive of it. Plurality in our understandings of spirituality is necessary given the uniqueness of individual experiences—the uniqueness of human lives. Any totalizing theory of spirituality is considered to undermine the integrity of the ideal/truth of individual experience. In some sense, there may be a take-it-or-leave-it feeling towards research into spirituality in this perspective. Because spirituality is necessarily relativistic, further research, if done, would focus on elaborating upon the vast plurality in the understandings of spirituality, which will ideally vary from person to person throughout the world. As a practitioner, the goal is to understand and to articulate one’s own experience of spirituality, to help the client articulate his/her own experience, and to move towards greater integration within this relational framework. The act of defining one’s own understanding of spirituality is a second step towards reflecting upon experience, and is thereby considered to be a goal of therapy. In this model, the research into systematic reviews would be considered to be good and appropriate because of its acceptance of plurality and its inductive method. The implicit desire to sort out and identify themes evidenced in the research might, itself, require deconstruction so as to more fully determine the unstated bias reflected in the method. Future research would continue to expand the multiplicity of understandings

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of the experience of spirituality/the spiritual life and to consider, through case studies, some clinical examples of how the subjectivity of experiences of spirituality have worked themselves out for the promotion of spiritual care in a patient.

5. Spirituality is an unknowable mystery In this perspective, spirituality is considered to be a mystery, ultimately unknowable through human language or conceptualization. This is the case because it originates from and is the reflection of a transcendent mystery, which is beyond human language or knowing. Plurality and especially contradiction in definitions for spirituality are necessarily indicative of its essence as a mystery. The multiplicity of definitions is of no consequence itself, except as it points beyond itself to mystery. Research into spirituality is appropriate to the extent that it instills a greater sense of awe by consciously celebrating plurality and contradiction that points beyond itself to the reality of a transcendent mystery. For a practitioner of spiritual care, the goal is to develop ways to honour, accept, and celebrate this mystery as it is pointed to through the diversity of created life, including human experiences and expressions of the spiritual. In this model, the research into the definitions of spirituality in systematic reviews would be considered appropriate and accurate primarily because of its acceptance of plurality. The plurality of themes and definitions and the sometimes contradictory data accurately points beyond itself to the utterly transcendent, constant mysterious Other and accurately presupposes difference between that Other and relative creaturely existence. The plurality in the data would be considered to appropriately embody human humility and honesty in the face of mystery. In terms of goals and practice of spiritual care, the move is to establish ways of understanding the experience of spirituality as divinely intended to point beyond itself to the miracle of transcendent mystery and thereby instill a sense of wonder, awe.

Overview In considering these five methodological perspectives, we can see both merits and deficiencies in each one. Certainly the context of care and the health discipline involved in care are important components that help to determine which perspective is deemed most appropriate. This methodological indicator provides a helpful way of continuing the ongoing dialogue about spirituality and for understanding the reasons and necessity for plurality. However, such tolerant pluralism easily leads to

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relativism and nihilism. The fact that each of these methods is judged primarily according to internal consistency in the given method and not according to specified content must raise concern. The problem with this is the fact that ultimately destructive ways of manifesting spirituality (for example) are invited to persist if they are deemed internally consistent or to be a part of an integrated meaning-making system. Furthermore, within the larger context of tolerance (for the sake of tolerance), there are no checks or balances for the content of multiple perspectives. Tolerance, as the conceptualization of the whole within which plurality exists, is dangerous because it assumes that humans are beyond good and evil. In the following section, we elaborate on this critique and propose a way to begin thinking about multiplicity in our North American context within a larger whole of love (instead of tolerance). This proposal seeks to remain open to the plurality in which we live, but resists falling into anti-ethical relativism by contemplating love as that for which humans are fitted. Ultimately, all methods and definitions for contemplating and researching that which is the essence of the human must be judged by the criterion of love. A PROPOSAL

This proposal is inspired by the works of philosophers George Grant (1959, 1965, 1969a, 1969b, 1974, 1986) and Simone Weil (1951, 1952a, 1952b, 1957). In their writings and lives, both were concerned with the extent to which the modern West had conceptually collapsed the horizon of the eternal (the Good, God, love) into the historical and the impact of this upon the way we think and live. With the absence of the horizon by which the limit of the human is conceptualized, both Weil and Grant recognized the manifestation of human freedom as an unbridled will to power, conditioned by nothing outside itself, except perhaps vague notions of supposedly contractual societal values. Further, they recognized that, with the conceptual absence of the Good outside of history, notions of good and evil had become completely subjectivized, true only insofar as an individual self (the subjective “I”) thought or experienced them to be true. The idea of the Good (that is love) had been totally emptied of content and left to individual or social interpretation. Such a reality constitutes a moral abyss wherein humans are unable to know the Good and to do it. One Good, one idea, one perspective is touted as being as good as another. Thus, we see in the postmodern West that tolerance is considered to be the highest way. Though it has

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its good points (relative to other hateful ways of being), the ideal of toleration is premised upon a belief that humans are good and that we know the Good and do it. We need only look around us and see how untrue this presupposition is. In our personal lives and in the life of the world, we can point to many examples that reveal the extent to which humans do not know the Good and do not do it. Furthermore, in this context of moral ambiguity, toleration, as a way of being, assumes tolerance for all things, including the ambiguous and the destructive. Toleration for toleration’s sake presupposes that humans are beyond good and evil. It inevitably spirals towards the meaninglessness of relativistic nihilism. In the foregoing studies, the content of the whole within which plurality is conceptualized is tolerance. It is the ideal of tolerance that holds all the perspectives and all the definitions to be equally relevant and true. This tolerance is based upon a notion of the self as the centre of the universe within a reality in which many selves are the centres of the same universe. Ideally, no single perspective, no single self, should be given greater weight than another. All should be allowed and invited to co-exist within a contractual agreement between all selves based on tolerance. But in reality, not only is this impossible, it is ultimately meaningless because it lacks any content by which to understand one’s life. Instead of accepting tolerance as the content of the whole and the highest Good in which we think and act, we propose that love, as the content of the whole (the Good) and as that to which humans are fitted, be reconsidered to shape our thoughts and actions—our research and practice. In line with Grant and Weil, we propose the conceptual retrieval of the Good beyond being, such that it is known to be that which shapes our thinking about reality and the limits beyond which we cannot move by means of the will. The content of the Good is love. The existence of being is given as the manifestation of this love. The experience of love reflects the mediation of the Good (the eternal) into human life (the historical/temporal). The purpose of being is to live the reality of love, that for which we have been fitted. In this paradigm, diversity in definitions of spirituality would be understood to reflect the particularity of creaturely experience in a larger universality. It assumes distinction between the realm of the eternal (the Good, universal, uncreated, unchanging) and that of the historical (particular, created, changing), in which the latter is relativized and limited by the former. Unlike the methods explicated above, this proposal affirms

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a connection between the particular and universal wherein the ongoing existence of the temporal realm is predicated upon the gift of the eternal. Furthermore, this paradigm presupposes the reality of the mediation of the eternal into the realm of the temporal known in human experience. In this paradigm, spirituality is understood to have specific content that is shaped by the content of the eternal and the reality of its mediation in life. In this proposal, the content gives shape to the method. The content of the universal/eternal is love, love which expresses itself in the ongoing gift of being (or otherness) to creation. Human life is understood to be fitted for love and to hold within it a seed of love that allows for the possibility of seeing glimpses of the eternal by intimation in the particular. In their truest reality, human language and experience are understood as mediators of love, which extends from the eternal. Love is that which is open and receptive to the being of “the other,” resisting temptations to change “otherness.” Love is that which contemplates the beauty of the otherness of the world in all its forms and gives itself over to otherness in a spirit of consent. Love reveals itself in attentiveness. In opposition to love, there is tyranny. Tyranny in the individual and society reigns when the oblivion of the “other” is complete and the Self is the only reality. Tyranny is closed to otherness in all its forms. It is closed to beauty, attentive only to itself. As that which reflects openness to love, and not to tyranny, spirituality must be understood to vary qualitatively among people. Some people have healthier spiritualities than others. Unhealthy spirituality is recognized in the privation of loving, openness, and receptivity to “otherness.” In place of love, power or force is manifested as the way of acting in the world. Power is that which forces the individual will of one (person, perspective, culture, etc.) on the other and thereby denies (and potentially destroys) the being of “the other.” In its worst form, this is tyranny wherein “the other” ceases to be and love is impossible. The tyrant is one who manifests the most unhealthy spirituality, which is really non-spirituality. In this paradigm, the foregoing discussion about the definitions for spirituality would be considered helpful in terms of identifying particularities of this context and the dominant conceptualizations that exist in mainstream Western society. Further, the extent to which they point to openness, to the mediation of love, in human life would illuminate areas of further study and contemplation. The definitions, themselves, would be judged according to the criterion of love as openness and

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receptivity over and against tyranny and the conceptual oblivion of “the other.” The potential for the subjectivization of spirituality in the study would be critiqued as the potential manifestation of individualism, placing the individual human will at the centre of the meaning of life. This paradigm invites deeper reflection on the means of spiritual care and the possibility for the practitioner to support people in the spiritual life. However, this perspective raises questions about the medical model, itself, and the extent to which its denial of the eternal dimension of reality blinds it to its own limits and its potential for self-perpetuating selfaggrandizement. From this paradigm, the five methodological perspectives would be considered in light of love and the extent to which they are given to presuppose and manifest in their form the otherness of love over the tyranny of the Self (the oblivion of “the other”). Indeed, each of the five perspectives invite helpful ways of thinking about spirituality and are best understood together within a larger whole of love (as openness to otherness, receptivity, and attentiveness). It is within such an openended, yet grounded, understanding of the content of the whole that we can enjoy plurality and resist the relativistic nihilism that so easily spirals out of contentless notions of tolerance. CONCLUSION

In this chapter, we have presented the findings of inductive research on definitions of spirituality in twenty-seven health care articles. These findings reflect multiple ways of understanding and experiencing spirituality. We have briefly presented a methodological indicator that outlines five common methodological perspectives so as to examine the results of the initial inductive study, and we have considered the ways plurality can be contemplated within a larger whole. In so doing, the notion of tolerance has been critiqued as the content of the whole, the basis upon which plurality exists. Instead, we propose that love is the content of the whole within which plurality can healthfully exist. The understanding of love as openness, receptivity and attentiveness to “otherness” provides a conceptual framework by which to live and think healthfully in our pluralistic context. Love, when understood as that which attends to “otherness” and opposes tyranny in all its forms, invites us to qualitatively discern the good from the bad— that is, healthy spirituality from unhealthy (or non-) spirituality.

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REFERENCES Bensley, R.J. (1991). Defining spiritual health: A review of the literature. Journal of Health Education, 22 (5), 287–90. Berg, B. (1998). Qualitative research methods for the social sciences (3rd ed.). Toronto, ON: Allyn and Bacon. Berggren-Thomas, P., & Griggs, M.J. (1995). Spirituality in aging: Spiritual need or spiritual journey? Journal of Gerontological Nursing, 21 (3), 5–10. Bradshaw, A. (1996). The spiritual dimension of hospice: The secularization of an ideal. Social Science and Medicine, 43 (3), 409–19. Burkhardt, M.A. (1989). Spirituality: An analysis of the concept. Holistic Nursing Practice, 3 (3), 69–77. Dossey, B.M., & Guzzetta, C.E. (1994). Implications for bio-psycho-social-spiritual concerns in cardiovascular nursing. Journal of Cardiovascular Nursing, 8 (4), 72–88. Emblen, J.D. (1992). Religion and spirituality defined according to current use in nursing literature. Journal of Professional Nursing, 8 (1), 41–47. Feste, C., & Anderson, R.M. (1995). Empowerment: From philosophy to practice. Patient Education and Counselling, 26 (1–3), 139–44. Frei, H. (1992). Types of Christian theology (G. Hunsinger & W. Placher, Eds.). New Haven, CT: Yale University Press. Frei, H. (1993). Theology and narrative (G. Hunsinger & W. Placher, Eds.). Oxford: Oxford University Press. Fulton, R.A., & Moore, C.M. (1995). Spiritual care of the school-age child with a chronic condition. Journal of Pediatric Nursing, 10 (4), 224–31. Goddard, N.C. (1995). “Spirituality as integrative energy”: A philosophical analysis as requisite precursor to holistic nursing practice. Journal of Advanced Nursing, 22 (4), 808–15. Grant, G. (1959). Philosophy in the mass age. Toronto, ON: University of Toronto Press. Grant, G. (1965). Lament for a nation. Ottawa, ON: Carleton University Press. Grant, G. (1969a). Time as history. Toronto, ON: University of Toronto Press. Grant, G. (1969b). Technology and empire. Toronto, ON: Anansi. Grant, G. (1974). English-speaking justice. Toronto, ON: Anansi. Grant, G. (1986). Technology and justice. Toronto, ON: Anansi. Harrison, J. (1993). Spirituality in nursing practice. Journal of Clinical Nursing, 2 (4), 211–17. Heriot, C.S. (1992). Spirituality and aging. Holistic Nursing Practice, 7 (1), 22–31. Kaufman, G.D. (1981). The theological imagination. Philadelphia, PA: Westminster. Levin, J.S., & Vanderpool, H.Y. (1987). Is frequent religious attendance really conducive to better health? Toward an epidemiology of religion. Social Science and Medicine, 24 (7), 589–600. Lukoff, D., Lu, F.G., & Turner, R. (1992). Toward a more culturally sensitive DSMIV: Psychoreligious and psychospiritual problems. Journal of Nervous and Mental Disease, 180 (11), 673–82. Lukoff, D., Lu, F.G., & Turner, R. (1995). Cultural considerations in the assessment and treatment of religious and spiritual problems. Psychiatric Clinics of North America, 18 (3), 467–85.

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McFague, S. (1982). Metaphorical theology. Philadelphia, PA: Fortress. McKee, D.D., & Chappel, J.N. (1992). Spirituality and medical practice. Journal of Family Practice, 35 (2), 201, 205–208. Mickley, J.R., Carson, V., & Soeken, K.L. (1995). Religion and adult mental health: State of the science in nursing. Issues in Mental Health Nursing, 16 (4), 345–60. Miller, M.A. (1995). Culture, spirituality, and women’s health. JOGNN, 24 (3), 257–63. Narayanasamy, A. (1996). Spiritual care of chronically ill patients. British Journal of Nursing, 5 (7), 411–16. O’Connor, T.S., McCarroll-Butler, P., Meakes, E., Davis, A., & Jadad, A. (2002). Review of quantity and types of spirituality research in three health care databases. Journal of Pastoral Care, 56 (1), 227–32. O’Connor, T.S., Empey, G., Fox, K.A., Meakes, E., & O’Neill, K. (1997). Quantitative and qualitative research on a regional SPE program. The Journal of Pastoral Care, 51 (2), 195–206. Oldnall, A. (1996). A critical analysis of nursing: Meeting the spiritual needs of patients. Journal of Advanced Nursing, 23 (1), 138–44. Paton, L. (1996). The Sacred Circle: A conceptual framework for spiritual care in hospice. American Journal of Hospice and Palliative Care, 13 (2), 52–56. Peri, T.A. (1995). Promoting spirituality in persons with acquired immunodeficiency syndrome: A nursing intervention. Holistic Nursing Practice, 10 (1) 68–76. Presti, H.L. (1990). AIDS: The spiritual challenge. Occupational Therapy in Health Care, 7 (2,3,4), 87–102. Rahner, K. (1989). Foundations of Christian Faith. Trans. William Dych. New York: Crossroad. Reed, P.G. (1992). An emerging paradigm for the investigation of spirituality in nursing. Research in Nursing and Health, 15 (5), 349–57. Ross, L.A. (1994). Spiritual aspects of nursing. Journal of Advanced Nursing, 19 (3) 439–47. Ross, L.A. (1995). The spiritual dimension: Its importance to patients’ health, well-being and quality of life and its implications for nursing practice. International Journal of Nursing Studies, 32 (5), 457–68. Smith, E.D. (1995). Addressing the psychospiritual distress of death as a reality: A transpersonal approach. Social Work, 40 (3), 402–13. Swanson, C.S. (1995). A spirit-focused conceptual model of nursing for the advanced practice nurse. Issues in Comprehensive Pediatric Nursing, 18 (4), 267–75. Webster, J. & Schner, G., Eds. (2000). Theology after liberalism: A reader. Oxford: Blackwell. Weil, Simone. (1951). Waiting for God. New York: G.P. Putnam’s Sons. Weil, Simone. (1952a). Gravity and grace. London: Ark Paperbacks. Weil, Simone. (1952b). The need for roots. London: Ark Paperbacks. Weil, Simone. (1957). Intimations of Christianity among the ancient Greeks. London: Ark Paperbacks.


4 Spirituality and Family Medicine Cheryl Levitt

It is important for primary care providers, trained to consider the whole person, to take into account their patients’ spiritual health. The physician need not share the patient’s beliefs, but must understand and respect them in order for treatment to be effective. Family physicians are adept at physical diagnosis and treatment and to a lesser extent psychosocial intervention, but they are usually ignorant of the spiritual component of illness. —Denise McKee and John Chappel (1992)

T

he spiritual side of health is very often neglected in traditional practice and training programs in medicine. We tend to focus on biomedical sciences and behavioural sciences, often forgetting that the cultural context and religious and spiritual beliefs can affect the health of an individual in a fundamental way. Up to 77 per cent of patients would like spiritual issues considered as part of medical care in terminal illness, yet only 10 per cent of doctors inquire about spiritual issues routinely in primary care (Levin, Larson, & Puchalski, 1997). If we believe that spirituality permeates all human experiences rather than being additional to them, we must accept it as integral to health or to a sense of wholeness or well-being (Miller, 1995). The discipline of family medicine is well entrenched in the Canadian health care system. Our system is considered to be one of the best in the world because the model is one which significantly values and supports primary care. Family medicine is the cornerstone of this system, and

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family physicians provide much of the primary care (first-line care, emergency care, acute care, chronic care, preventative care, and continuous care) for all Canadians over their lifetimes. Family medicine emphasizes a holistic, whole-person approach and, therefore, the spiritual aspects of a person should be incorporated into our thinking and teaching. Awareness of the relationship between spirituality and health seems to be increasing. Although spiritual awareness is not necessarily associated with a belief in a supreme being, polls in the United States have consistently shown that most of the population believes in God (Gallup, 1990). In Canada, results of a survey conducted in April 2000 (IpsosReid, 2000) show that eight out of ten Canadians (84 per cent) say they believe in God. Not only do many Canadians believe in God, but twothirds (67 per cent) say that their religious faith is very important to their day-to-day life. Canada is predominantly a Christian country. More than three-quarters (77 per cent) of Canadians identify themselves with a Christian church. One study reported that physicians rarely or never discuss spiritual or religious issues with their patients (King & Bushwick, 1994). However, the literature shows that courses in spirituality and health are becoming very popular, and their popularity is increasing. In 1997, Levin, Larson, and Puchalski reported that there were nearly thirty medical schools in the U.S. that taught courses on spirituality and health; in 1994, there had only been three. There is much debate in the literature about the definitions of spirituality and religion. A good discussion about this occurred in the American Family Physician in 2001, in which the authors, Anandarajah and Hight, explain that some people advocate a universal broad-based definition of spirituality that incorporates religious and non-religious perspectives. Spirituality is thought to be a complex and multi-dimensional part of human experience, which includes cognitive, experiential, and behavioural aspects. Cognitive aspects are the search for meaning, purpose, truth, beliefs, and values that guide individual lives; experiential aspects are emotions one feels, love, connection, inner peace, equanimity, and relationships; and behavioural aspects are the way a person externally manifests his/her individual spiritual beliefs and inner spiritual state. Many people find spirituality through religious behavioural expression, or through a personal relationship with a divine being. Others, however, express their spirituality through a relationship with nature, music, or poetry, through a set of values and principles, or through a quest for truth. A spiritual person chooses a set of values (in humanistic/

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secular terms) which becomes the supreme focus of life around which life is organized. Spiritual distress occurs when individuals are unable to find meaning, hope, love, peace, comfort, or connections in life, or when they experience a conflict between what they believe and what actually happens in their lives. This spiritual distress could have a detrimental effect on an individual’s physical or mental health. Similarly, serious medical illness or terminal illness can trigger spiritual distress (Hay, 1989; Smucker, 1996). PERSONAL EXPERIENCES WITH SPIRITUALITY AND HEALTH

My own personal experiences as a physician and a patient have shed light on the spiritual aspects of health in family medicine. When I first went into practice, as a general practitioner in a small rural community, I was just twenty-four years old. I naturally felt very young and inexperienced. My training had prepared me well for the medical problems and challenges. However, what I was poorly prepared for was playing the role of the priest. I was amazed at what people shared with me, surprised at the profound impact my counsel had on their lives, and awed at their trust in me. I was unsure what my patients expected from me and unable to determine the extent to which I could appropriately become involved in their spiritual distress. There were also times when I didn’t recognize that distress. Early on in my career, a young couple saw me regularly for prenatal care. The husband seemed overly concerned about everything that was mentioned at their visits. I wasn’t aware that he might have had another agenda until it all became apparent to me when, just before his wife went into labour, the husband appeared at my office without an appointment. He was very distraught and I saw him immediately. He explained to me that he and his wife were of the Catholic faith. As such, if anything should happen that would endanger the child, according to his faith, I would be expected to save the child before the mother. This had been distressing him and had been the cause of his concern throughout the prenatal period. He explained to me that even though he and his wife were practising Catholics, he would prefer that, if this became an issue, I would save his wife first, as he could not support the idea of choosing the child over the mother. In looking back, I cannot recall whether I had explored the spiritual and religious background

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with this couple, or whether I was hearing of their faith for the first time at this untimely visit. On a more personal level, I recently went through a difficult time with my mother, who suffered through a long illness before she died. She had always been physically strong and of very sound mind, but developed a terrible lung disease, which made her feel desperate and hopeless. She became dependent on others, and lost her autonomy and her dignity. The things that she valued about life were no longer accessible. She could no longer stand her situation, and wanted to stop all medication and treatment. I was totally unprepared to deal with this as her daughter. I needed help. I needed a caring, supportive person to hear me out, to hear her out, to help her change her mind or help me come to terms with her decision. My mother refused to talk to anyone about it. I called both her family doctor and her rabbi. She refused to see either of them, but I needed their counsel, their spiritual guidance. I needed much more than medical or technical support. FAMILY DOCTORS INQUIRE ABOUT SPIRITUAL HEALTH

Medicine originally developed in religious contexts (Barnard, 1983). Priests were the custodians of public health, and were interested in the whole person. The earliest physicians were clergy, and the church was the first to grant them a medical licence. The development of the scientific basis for understanding illness separated medicine from religion (McKee & Chappel, 1992). When a patient sees a family doctor they share all kinds of information. This “history”taking covers a wide range of life issues, and addresses primarily the patient’s reason for coming to see the doctor. This might be a simple medical complaint, or the doctor might suspect that the problem is far more complicated. In that situation, he/she might delve into many areas: medical facts, family, lifestyle, psychological and spiritual issues. The best doctors are those that can elicit the etiological cause for the presenting complaint and propose a realistic treatment plan based on the information collected. If this information is scanty, or if the information regularly omits an important cause of a presenting complaint, the treatment might be inadequate and the patient will not get well. Inquiring about spiritual health is an important step to a comprehensive and holistic history. Spiritual values might be a supreme life focus for some individuals and might be the root of the illness, an asso-

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ciated factor, or the reason for the failure of traditional medical approaches. Our challenge in family medicine is to find the appropriate tools to glean information about a patient’s spiritual well-being and its importance to him/her. These methods should be acceptable to both the patients and the doctors. Although doctors were historically priests and today’s family doctors should inquire about their patients’ spiritual health, there is a fundamental difference between the support and counselling provided by family doctors and the ministering provided by priests. In this chapter I use the term “priest” to apply to all religious providers, including priests, ministers, rabbis, imams, pastors, monks, nuns, etc. In addition to the impressive range of supporting, counselling, ministering, advising, assisting and providing roles, it is also the role and responsibility of a priest (to a greater or lesser degree) to proselytize, maintain, strengthen, and even direct the faith, beliefs, membership, and adherence of the person to the tenets and dogma of the denomination or religion. The family doctor also provides support, counselling, advice, and assistance to patients. However, this clinical relationship is not based on promoting a religious approach, doctrine, or system of beliefs. Rather, it is based on patient autonomy, consent, respect, and non-judgmentalism. In exploring the spiritual and religious values of the patient and their role in the patient’s life, the physician needs to explore whether these values have any bearing on the complaints and disease of the patient in a context that is free of a religious agenda. The family doctor’s role is to help an ill patient manage his/her illness. When spiritual distress might be the cause or an associated factor in an illness, it is the responsibility of the family doctor to recognize and even understand this link and to appreciate what resources might be helpful. Family doctors are not experts in spiritual matters, and need to know how to access expert resources when required. These resources are bound to be varied in a society of such diverse cultures, religions, and beliefs as ours. This presents a challenge to family doctors and requires that they have at the least a broad understanding of spirituality and religion, and be “in tune” with their own religious and cultural attitudes. SPIRITUALITY AND HEALTH IN A SECULAR WORLD

Although many Canadians are of the Christian faith, Canada has become a very diverse country with people from many different cultures and religions, and the physician population does not yet reflect

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that diversity. Many practising Christians (for example, Aboriginals) have different spiritual attitudes and beliefs. Practising physicians today are likely to come from spiritual and religious backgrounds and cultures that are very different to those of many of their patients. It takes time, training, and a respect for diversity to effectively explore a patient’s spiritual values and to sufficiently inform a doctor’s clinical management. Sometimes, there might be a great synergy between the physician’s beliefs and the patient’s beliefs. However, there might also be a great divide. For example, the physician might be deeply religious and the patient deeply spiritual but a devout atheist. Regardless of the differences, a family physician, in exploring a patient’s history, might discover that spiritual distress is behind the patient’s illness, and would be required to understand the patient’s perspective in order to help the patient address his/her problem. There is no need for the doctor and patient to share the same beliefs; rather, the doctor and the patient can agree that the distress is caused by a spiritual challenge, and together they can explore a course of action. The spiritual distress might be assuaged or helped by discussion and discourse, or by referral to a religious leader or a psychiatrist, psychologist, theologian, or other expert. DEVELOPMENTS IN SPIRITUALITY IN FAMILY MEDICINE

Incorporating spirituality into family medicine is a challenge for even the most accomplished physician. First, a family doctor needs to know how to approach the spiritual aspects of his/her patient’s health, how to broach the subject and take a history, how to analyze the information provided by the patient, and how to counsel the patient effectively. A spiritual assessment might have an effect on medical management in that a physician might plan to do nothing except offer understanding and compassion. He/she might incorporate the patient’s spiritual beliefs into preventative health care: advising the patient to incorporate some behaviours such as prayer, meditation, yoga, t’ai chi, walks in the country, or listening to contemplative or liturgical music. Another approach might be an adjuvant one. The patient might incorporate spiritual practices into medical care: daily walks in country settings, praying while taking medication. Modifying a treatment plan to incorporate a patient’s values might also be undertaken. Examples might include delaying treatment until after a religious holiday, referring a patient to a clinical chaplain, or incorporating meditation into a pain management regime (Anandarajah & Hight, 2001).

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Second, many physicians experience great pain from their own personal spiritual life experiences such as family violence, illness or death. Some suffer spiritual pain through transference in caring for patients with very serious problems, illness and family situations. Family doctors may have to make terrible decisions with and for their patients. In some cases, family doctors may also fear the threat of litigation through human error. There is a traditional lack of support within our own professional environment to address these challenging and painful life experiences. Third, each physician has his/her own personal spiritual beliefs that may, to a greater or lesser degree, guide their lives. How can we help physicians explore their own spirituality? For some, spirituality guides the choice of medicine as a career; for others, it guides the way in which a physician chooses to practise. It might be important for family physicians to reflect on their own attitudes and beliefs and even formally study the broader concepts of spirituality, religion, and health. Finally, physicians are faced with a great diversity of spiritual and religious backgrounds. Not only physicians but also residents and students need help in providing clinical support to patients with differing religious and spiritual beliefs. A greater understanding of the cultural and experiential diversities inherent in their patient population is the first step in gaining this additional knowledge and skill. Fully-rounded family doctors need to know and appreciate that their patients’ religious and concomitant cultural beliefs and practices, which may be playing deep and significant roles in their health or illness, may be very different from their own (as in the vignette above involving the Catholic couple). Physicians need to have a full appreciation of the existence of these divergences, and be informed of a few of the broad details of the spiritual beliefs of their various patient groups. At the very least, this is necessary in order to avoid committing a faux pas or being insensitive, and better still to be aware of the core tenets that may arise in this intercultural context. Although there is a burgeoning interest in spirituality and health, teaching, learning, and incorporating spirituality and health into family medicine is not yet routine and mainstream. However, there have been some interesting new innovations.

The HOPE Questions Some family doctors have explored asking about spirituality as a routine encounter. The HOPE questions have been described as a practical tool for spiritual assessment (Anandarajah & Hight, 2001), and can be used

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in history taking as an approach to a spiritual assessment. The recommended questions explore the following: H– sources of hope, strength, comfort, meaning, peace, love, and connection; O– the role of organized religion for the patient; P – personal spirituality and practices; E – effects on medical care and end-of-life decisions. This approach has been developed as a teaching tool to help medical students, residents, and practising physicians begin the process of incorporating a spiritual assessment into a medical interview. These questions have not been validated by research, but the strength of this particular approach allows for open-ended exploration of the patient’s general spiritual resources and concerns, and it serves as a natural follow-up to discussions of other systems of medical care. It does not immediately focus on the word “spirituality” or “religion.” This is thought to minimize barriers to discussion based on the use of language.

A Collaboration between Family Medicine and Chaplaincy Our medical/health science faculties are committed to ensuring that residents train in an optimal teaching environment. Thus, our clinical teaching units need to be places where people want to come to work daily, where work satisfaction is very high, and where the workplace is attractive and exciting. As well, it needs to be a place where the staff, the health care professionals, and the residents attain spiritual well-being in their work. The Department of Family Medicine at McMaster University is the nesting place for the chaplains of the teaching hospitals in Hamilton, Ontario, with many holding academic appointments in the Faculty of Health Sciences. In this faculty, there is no department of spirituality and health, and traditionally the chaplains have been assigned to the Department of Family Medicine. The chaplains are trained to facilitate an individual’s or a group’s well-being, enable team work, and manage religious spiritual crises. In 2000, as part of a strategic planning process, the chaplains agreed to explore the quality of life in the workplace, and proposed a pilot demonstration program in our teaching family practice units at McMaster, Stonechurch, and North Hamilton. Their services and the program offered the staff a safe place to share their concerns about their workplace, their quality of work life, and their personal concerns and stresses.

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Initially people were concerned that chaplains would “push” religion, or that they would share information with management, or that there would not be limited confidentiality. These concerns demonstrated how important this exercise was; a sufficient number of staff confided in the chaplains in this exploratory phase that we felt we could begin a pilot project to incorporate a chaplain on a more permanent basis into the health provider teams at our family medicine centres. With the help of some initial seed funding from the Hamilton Health Sciences hospital and our department, we placed a chaplain for one day a week in two of our academic teaching units. These units were responsible for eighteen thousand patients, had sixteen family physicians, six nurse practitioners, and about thirty-two residents in family practice. The program was evaluated as a qualified success. Many people on staff shared concerns with the chaplain: personal concerns, workplace concerns, and concerns about patients, and the chaplain also provided counselling to patients in spiritual distress. However, because we could not continue to financially support the program, it did not continue beyond the pilot phase. Clearly, more work needs to be done to prove the value of a service that supports the spiritual well-being of health providers in primary care.

Professionalization and Physician Self-Awareness (PPSA) The third innovation is a new program developed for the Faculty of Health Sciences undergraduate curriculum (Petruccelli, 2002). Many medical schools provide students with sound scientific clinical knowledge and skills in medical practice; however, there is little training in recognizing and understanding how one’s own values and beliefs inform and influence our effectiveness as physicians. Founded in 1999, the Professionalization and Physician Self-Awareness (PPSA) program is a voluntary training program that helps medical students explore their spirituality and achieve balance in their professional and personal lives. The structure includes groups of students meeting regularly throughout their three years to reflect upon their own professional formation and the impact of their own values and attitudes on the care they give to patients. Groups are facilitated by pairing MDs with non-MDs, both of whom are recruited and trained for their ability to foster respect as a role model and provide a safe environment for discussing emotions, encouraging a reflective practice. Developers and supporters of the curriculum believe that self-awareness is central to the “art” of medicine and the promotion of healing.

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Objectives of the curriculum include the following: • To become more self-aware, including how personal behaviour affects patients and colleagues. • To become more aware of one’s values, attitudes, and assumptions and how these affect the practice of medicine. • To recognize the impact of the practice of medicine on oneself as an individual. • To develop skills of communication, conflict management, giving and receiving feedback, group process, problem solving, and so on. Since its inception in 1999, almost two hundred students and thirty-five faculty members have participated in PPSA. The co-planners hope to integrate the program into the students’ core curriculum within three years and to eventually expand it into other settings.

The Kairon Centre According to Greek mythology, Kairon was born of the gods, wounded by them, healed and instructed by them, and then sent out to teach the kings (mankind) in healing, music, and prophecy. He is known as the “wounded healer,” because in spite of his great accomplishments, he suffered from a wound that would not heal. The Kairon Centre was founded in 2001 and is the chosen name for a new program located at the Department of Family and Community Medicine at St. Paul’s Hospital in Vancouver, associated with the University of British Columbia (Thorsteinson, 2001). The Kairon Centre assists practitioners (wounded healers) to resolve the separation of soul and self (restitutions) and put the soul back into medical practice (resilience). It was established to integrate family practice with counselling, medicine, and psychology, and is dedicated to healing the physical, psychological, and spiritual domains. By training practitioners in self-care, they will gain comfort with and skills in treating these domains. Dr. David Kuhl, one of the physicians working at the Centre, interviewed dying subjects as part of his Ph.D. dissertation, and heard about the negative communication that some physicians had with patients. He called this “iatrogenic suffering,” and working with physicians to address this is one of the prime objectives of the Centre. Members of the Centre have ambitious plans to expand their clinical work and their research. They hope to develop educational programs for professionals such as police and firefighters who suffer psy-

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chological and spiritual stress in the course of their work, establish a retreat centre for education and treatment, sponsor external speakers, and financially support a research program. CONCLUSION

Spirituality is an important part of a holistic approach to the “art” of healing, and it should be routinely considered as a cause of illness and distress in patients. There is evidence in the literature that a significant proportion of patients would prefer to have their physician include spiritual considerations as part of their medical assessment. Yet incorporating spirituality effectively as part of a clinical assessment is challenging. Innovative approaches to incorporating spirituality in family medicine have been tried, some of which are described in this chapter. Future developments and further research in this area will offer the promise of an even more comprehensive approach to health, illness, and human suffering. REFERENCES Anandarajah, G., & Hight, E. (2001). Spirituality and medical practice: Using the HOPE questions as a practical tool for spiritual assessment. American Family Physician, 63 (1), 81–88. Barnard, D. (1983). Religion and religious studies in health care and health education. Journal of Allied Health, 12 (3), 192–200. Gallup, G. (1990). Religion in America. Princeton, NJ: Princeton Religion Research Center. Hay, M.W. (1989). Principles in building spiritual assessment tools. American Journal of Hospice Care, 6 (5), 25–31. Ipsos-Reid. (2000, April 21). Canada—A nation of believers. News Release. Toronto: Ipsos-Reid/CTV/Globe and Mail Polls and Research. Retrieved from www.ipsosreid.com/media/dsp_displaypr_cdn.cfm?id_to_view’1019. King, D.E., & Bushwick, B. (1994). Beliefs and attitudes of hospital inpatients about faith healing and prayer. Journal of Family Practice, 39 (4), 349–52. Levin, J.S.M., Larson, D.B., & Puchalski, C.M. (1997). Religion and spirituality in medicine: Research and education. JAMA, 278 (9), 792–93. McKee, D.D., & Chappel, J.N. (1992). Spirituality and medical practice. Journal of Family Practice, 35 (2), 201, 205–208. Miller, A.M. (1995). Culture, spirituality, and women’s health. JOGNN, 24 (3), 257–63. Petruccelli, E. (2002). Professionalization and physician self-awareness: McMaster programme provides “self discovery” tools to help medical students integrate personal, professional lives. Ontario Medical Review, 69 (3), 45–47. Smucker, C. (1996). A phenomenological description of the experience of spiritual distress. Nursing Diagnosis, 7 (1), 10–17.

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Thorsteinson, J. (2001). The development of the Kairon Centre: “…a more comprehensive model of health care; supporting restitution and building resilience.” The Bear Bones (newsletter of the Department of Family Practice Research, University of British Columbia) 1 (2), 7–8.


5 Congregational Life after Abuse Carol Penner

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here do survivors of child abuse turn for support? If they are a member of a religious community, they may turn to their “religious family” for the nurturing that the biological family was unable to provide. Will they find support? It depends. I am not a survivor of child abuse, but for the last number of years I have acted as an advocate for survivors and taught education on family violence to Mennonite congregations throughout Ontario. This chapter draws, in part, on the stories I heard from adult survivors of child abuse about their healing journeys in the Christian church. I have seen church communities become a home for survivors, nurturing them on those journeys. More often, however, I have seen church members revictimize survivors. While most congregations pay lip service to being a supportive community to abuse survivors, the underlying assumption in many congregations is that healing from abuse is a personal issue between the survivor and her therapist, or between the survivor and God. Creating a safe place for the survivor is a challenge that many congregations are not willing to face. In this chapter I use being at home and a safe place as metaphors to explore the topic of spirituality. I believe that religious communities can be a home, or a healing environment, for those wounded by childhood abuse. I begin by providing an experiential definition of being at home, showing the richness of this image as a metaphor for healthy spirituality. Next, I outline how safety at home is shattered for children who experience abuse. The final section discusses why churches fail to be a

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home and conversely, the rich potential for the whole community if the church does provide a home where survivors can experience healing. SAFE AT HOME

Is home a safe place? This is something my young son, and thus our family, is struggling with in a special way this year. He has recurrent nightmares in which he is often in danger. He wakes up and I reassure him, “No, you are not being attacked by a polar bear.” He hears noises on the stairs and is worried that robbers are going to burst into his bedroom. “But our dog would bark if someone came in the house!” I explain. I talk about robbers and how they mostly try to rob houses when no one is home. There are many ways I try to reassure him, but inside I know that I cannot guarantee his safety. Much as I have tried to provide a safe environment, I cannot prevent danger from entering our home. Fearfully, I know that I cannot protect him from abuse, no matter how many locks are on our doors, no matter how much I “streetproof ” him, or talk about good touch or bad touch. We live in a world where bad things can happen to children. Sometimes adults can stop the bad things from happening, but sometimes they cannot. There are no safety guarantees, and yet I try to create a home with my family where there is safety. By this I mean that my partner and I have made a commitment to treat one another and our children with love and respect. We strive to teach our children these values. We work on creating trust; a trust that in our family we will not possess or crush each other but instead rejoice in each other ’s gifts and call each other to growth and freedom (Vanier, 1998, p. 43). This homemaking is an integral part of our spirituality, our connection to a God who calls us to act on this growth and freedom. Can I guarantee that I will always treat my family with mutuality, respecting their differences, protecting them in times of weakness? That is my goal, but unfortunately I cannot guarantee that I will always act lovingly. Home is not a place of perfection, even for the committed. Instead, as Carter Heyward suggests, “mutuality, like everything else, is learned by experiencing it, by trial and effort, by making mistakes and plodding on” (1995, p. 115). Home is not perfect, it is relational. My home relates to other homes—we live in a community that is in a country that is in a world. When I see this context as it really is, and not just as I would like it to be, I see structures of oppression: economic,

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militaristic, racist, sexist. These all conspire to threaten any safety I can create through my own efforts. Am I tempted to turn off the news or close the newspaper? Certainly! It makes me feel uneasy and fearful to see the dangers. Similarly, I have not always wanted to hear the stories of abuse that my job gave me opportunities to hear, because they made me exquisitely aware of how tenuous safety is. Homemaking is a profoundly spiritual issue for me, on both an individual and communal level. Our family is actively involved in a Christian congregation that is trying to create a home, a safe place, for a diverse group of people. We try to embrace those people in our congregation who are hurting and lonely. We care about the homeless people in our city, we worked together to send relief kits to Central America after a hurricane, we raised money to clear land mines in Cambodia. As Christians we have faith in a God who mysteriously, incrementally, is working for healing in a broken world. This Homemaker invites us to make the world a safer place by seeing one another as brothers and sisters and not as enemies or competitors. Being at home and creating a safe place are rich metaphors for spirituality. A healthy spirituality is more than just an inner feeling of peace, it has to do with how we view our embodied selves in relation to the world and its ultimate meaning. Feeling like we belong in our bodies, feeling connected, being in trustful relations with other bodies; all these indicate that we are at home. The experiential definition provided above does not mean always being safe at home, but it can mean that we experience moments of safe space in relationality that carry us through times of unease and danger. Being at home means we have learned to trust the people around us. A troubled spirituality is signified by a sense that we do not belong, that we are disconnected and feel ambivalent or afraid of the world in general; we feel homeless. We have nowhere to turn for safety. Troubled spirituality is often rooted in traumatic experiences that happen to our bodies, particularly when our bodies are young and most vulnerable. THE EFFECTS OF ABUSE ON BEING AT HOME

Childhood abuse profoundly affects a person’s ability to feel at home in their body, in their own home, in their community, and in relation to the divine. The world is experienced as an unsafe place. Jean Vanier talks about the importance of belonging, and how abuse shatters this capacity for belonging: “As a child discovers at certain moments

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her parents’ lack of love, their need to control or possess, and sometimes their violence and abuse, she discovers through her inner feelings of depression, anger, and revolt that belonging is a difficult, even dangerous, reality” (1998, pp. 41–42). Many contemporary writers on spirituality emphasize that healthy spirituality involves an acceptance of and care for the physical body. Childhood experiences profoundly affect whether we feel at home or alienated from our own bodies. During childhood abuse, the body is often the location for pain and suffering. The child learns that her body is not her own, “there is no separateness between her body and that of her abuser” (Blume, 1990, p. 194). For incest survivors, self-hate, shame, and alienation from the body are common attitudes. Survival may involve seeing identity as separate from body, or there may be a desire to be free of the body that puts him/her in danger. Human beings are born with a basic human need to be loved and cherished. The home, whether within a family or a caregiver setting, is the arena where that love is normally given. Childhood abuse often occurs in the home setting by the people who are supposed to love the child. For some survivors, the whole idea of home cannot be reconciled with safe space. The trauma of abuse is long-lasting, for the child has learned “that behind the appearance of love is something different, and not safe at all” (Blume, 1990, p. 243). Abuse can be administered with anger, but it can also be in the guise of love or affection, taking advantage of the innocence of the child. In either case, the child experiences as frightening what should be safe and nurturing. In the face of abuse, the child survivor must find ways to continue primary relationships with those who abuse (Herman, 1992, p. 101). “Therein lies both the real damage of this abuse and the domination that allows it to happen: the child has no choice, not merely because the perpetrator is bigger, or older, or more socially dominant, but because her emotional and physical survival depends on her acquiescence” (Blume, 1990, p. 2). This abuse profoundly affects the survivor’s ability to find and create a new and better home as an adult. Children who are abused do not feel at home in their community. Many survivors struggle with post-traumatic stress disorder. This disorder is most severe when the traumatized person is the only one to whom the event happened. This is often the case for abused children, who must continue their everyday life in their family, their school, and their church, where people treat them as if everything is normal. There is a profound disconnection between the community and the survivor; a

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lack of trust, a feeling that they are not safe. Sometimes abuse becomes amorphized into a vague but consuming anxiety. “Anxiety is an un-fixed fear, a state of apprehension rather than a specific response to a specific thing. For the incest survivor, the world is a dangerous place, period. It is not dangerous at this or that time, or for this or that reason; it is simply unsafe” (Blume, 1990, p. 126). Many survivors feel profoundly alienated from God. This alienation can take many forms. There can be the sense of abandonment because God’s presence was not felt when the abuse took place. There can be anger, that God did not prevent the abuse. There can be despair, that God does not care. Survivors in the church are often encouraged to draw on their Christian faith to restore their sense of safety. However, basic theological tenets can be problematic for survivors, as many feminist theologians have observed. Participation in a basic Christian ritual such as communion can raise red-flag issues for survivors; for example, the belief in a God who sacrificed his own son, communion as symbolic eating of flesh and blood, the call to suffer like Jesus, and the necessity of forgiving others before one partakes. These beliefs can all make the church a very unsafe place. It becomes a home that is full of danger rather than comfort. There are many facets to the woundedness of survivors. Among other things, they feel alone, in danger, and unsafe. In describing traumatized adults who include survivors of child abuse, Herman writes, Traumatized people feel utterly abandoned, utterly alone, cast out of the human and divine systems of care and protection that sustain life. Thereafter, a sense of alienation, of disconnection, pervades every relationship, from the most intimate familial bonds to the most abstract affiliations of community and religion. (Herman, 1992, p. 52)

The road to healing involves creating new homes, finding safe spaces, and discovering new relationships that are trustworthy. Many survivors turn to the church as a haven. Unfortunately, too often the church congregation revictimizes the survivor when he/she does. BETTER HOUSEKEEPING

For many years people within the church refused to admit that child abuse and child sexual abuse happened in church families (Pellauer, 1987, p. ix). My work in the Mennonite church has brought me into direct contact with many communities, and I have found that this

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misconception is beginning to shift. I have heard many church members assert that abuse happens not only “out there” in society but also within church families. There is also a general recognition that child abuse has lasting effects even into adulthood, and that survivors usually need professional support for healing to happen. These are important realizations. When child sexual abuse happens within a congregation, however, the church often fails to be a home for the survivor, in spite of the words that have been spoken in support of survivors. Instead of creating a place of safety, church members often blame the survivor. In spite of an intellectual understanding that abuse happens in the church, when faced with the reality that a respected member of the church has abused a child, there is widespread disbelief and the abusive behaviour is downplayed. The child’s story is doubted or minimized, the caregivers who supported the child in coming forward with the story are treated with suspicion and accused of having ulterior motives. Safety for the survivor is not the highest priority. In these situations, the survivor and his/her supporters often leave the church. For adult survivors who risk sharing a story with the congregation, the initial reaction may be more welcoming. In my experience, this support was most evident when the perpetrator of the abuse was not known to the church. It is easier to be supportive of the survivor without the corollary of having to doubt the morality of someone you know and love. Ironically, however, how the survivor shares his/her story of abuse can be the first arena of conflict with the church. Whose story is it? In some of the situations I saw, details shared in confidence were soon public knowledge. In one congregation, there was a sense that the survivor was obligated to share his/her story with the whole group, otherwise support would not be forthcoming. I witnessed several churches placing strong social pressure on survivors to share their story in large public settings. Mark Yantzi, in his book Sexual Offending and Restoration, cites the following survivor describing her experience: Years ago I told my small group that I had been sexually abused. I showed them the paper I had written that I wanted to use to disclose [the abuse] to the church, and they said, “We can’t allow you to use the words sexually abused.” It would have been acceptable to say perceived sexual abuse. I had to go to a counselor to get some power behind my words. (Yantzi, 1998, p. 141)

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In two different situations, I witnessed church members expressing disappointment about how the survivor chose to tell her/his story. In one case it was “too graphic,” and in another case it was “not clear.” The survivor, of course, should be the decision maker regarding the level of participation in any given community. Thinking that there is a right way to handle abuse in the church, or prescribing a course of action, does not take into account the importance of choice as an integral part of the healing journey for the survivor (Herman, 1992, pp. 15ff). Survivors told me stories of congregations that were initially supportive. The lifespan for support lasted from several weeks to several months, with support ranging from inquiries into how therapy was going to helping out with practical issues such as child care or meals. However, this support soon evaporated as the long-term nature of the problem became evident. Church members expressed their disappointment that therapy was not immediately effective in helping the survivor “get over it.” This lack of long-term support can be explained in a number of ways. For example, people get tired, or they cannot sustain the effort of support. This is particularly the case when the survivor expresses strong emotions like rage or suicidal feelings. Congregations sometimes feel that they have failed. They feel rejected in that they were unable to “fix” the problem, even when they gave support. Too often I heard people blaming the survivor for the slow pace of his/her healing journey. They did this by suggesting that the survivor “doesn’t want to forgive” or “is hanging onto [his/her] pain.” As mentioned earlier, I have seen a growing awareness in the church that survivors need professional help in their healing journey. However, this can become a way for the congregation to foist total responsibility for healing onto the professional caregiver and the survivor. As one writer observes, churches have a tendency “to place the responsibility for emotional well-being on the parent-child dyad, the therapistclient dyad, and the I-Thou dyad of personalistic faith metaphors. In the process we exempt the community and society from responsibility for growth and healing” (Doehring, 1993, p. 11). In one congregation, a survivor who would make passing references to what had happened to her was told that she had to stop talking about the abuse at church, because the congregation was not a therapy group. Most churches I visited did not see themselves as needing to make any changes in order for healing to occur. If healing did not happen, it was the survivor’s fault.

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After observing these patterns of behaviour in a number of different congregations, the metaphor of housekeeping came to mind. In some congregations, survivors were seen as being out of order, or having something wrong with them. People were concerned about this, and they offered support because they wanted to tidy up the problem, perhaps with the help of a professional. More than anything, they wanted everything to be back to normal, the way it was before the disclosure about the abuse. When the survivor was “resistant” to change, then something else had to happen. The something else was usually that the survivor was edged out of the church so that the problem went away. Sometimes the survivor submerged the pain and stayed, but more often than not the survivor had to look elsewhere for a home. What surprised me so often in my work was the vehemence with which people in the church tried to fix what they saw as the problem, and if that failed, the force they would use to shun the survivor. One might expect to see people neglecting or showing indifference to the survivor; instead I saw active revictimization that was at times incredible! We need to ask: What was at stake here? What prompted this reaction? Undoubtedly the answer is complex, but I would suggest that churches are not willing to look at what needs to be changed. By focusing on the survivor as the one who is the problem that can be fixed, they are not seeing the way abuse has damaged the whole community, nor the way the community has fostered the abuse. “A crime such as child sexual abuse is not only a private violation. It represents a tear in the fabric of the community’s integrity and life. Communities of faith who choose to witness truth, accountability, justice, and healing help to restore not only the victim but the integrity of our society itself ” (Ramsay, 1998, p. 221). It is, of course, easier to look at surface issues (housekeeping) and hope that everything can return to normal. For the survivor, unfortunately, life can never be normal again. Life will never be the way it was before the abuse happened. Healing does not mean forgetting about the abuse, it means accepting it, working through the pain, and moving on as a wounded but hopefully stronger person. Why would a congregation refuse to embrace the suffering person as a member of their group? As in the biblical story of the rich man viewing the suffering man Lazarus at his gate, people are afraid: I suspect that we exclude Lazarus because we are frightened that our hearts will be touched if we enter into a relationship with him.

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If we listen to his story and hear his cry of pain we will discover that he is a human being. We might be touched by his broken heart and by his misfortunes…it is dangerous to enter into a relationship with the Lazaruses of our world. If we do, we risk our lives being changed. (Vanier, 1998, pp. 70–71)

Really hearing the survivor’s story would mean that we would have to re-examine the dangers in our community, and admit that we are vulnerable and that our own children are vulnerable. We don’t want to listen to the stories of suffering people because it may mean seeing privilege and disparity. We would have to give up the myth that we live in an egalitarian society. Instead, we would see that our age, the colour of our skin, or our economic status can influence whether we are treated fairly or not. Many people cope with life by blocking out these dangerous realities. Blaming or shunning the victim is one way that we fend off the fear that we are vulnerable to harm. In church settings, there can be even more at stake. Hearing the story of pain, and walking with someone on a healing journey, can help us to re-examine community values. We may find that what we have held dear may in fact be oppressive and hurtful. HOME SWEET HOME!

I have visited churches that do provide a healing home for survivors. I have a vivid image of preaching to a congregation that was struggling with a case of sexual abuse in their midst. So many faces were anguished as I spoke; there was real grief there. It looked like someone had just died. The pain was being felt by so many hearts; it was visible on their faces. In my experience, congregations engaged in homemaking for survivors usually experience upheaval. For some in the church, examining the structures underlying abusiveness led to a critique of both social and theological norms. “Doctrines, ideas and practices that may hitherto have been central to orthodox Christianity, for example, concepts of atonement, forgiveness and so on, may have to be displaced, dismembered, remembered or re-cast if they are to have a role in anti-abusive religion” (Pattison, 1998, p. 39). This process of reconstructing theology can be described as depriving abuse of the “oxygen of theological meaning” (Pattison, 1998, p. 58). There is a change in the congregation as they become sensitized to life with the survivor. They start listening to sermons, prayers, hymns, and Sunday school lessons with the ears of a sur-

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vivor. They ask, “How would this particular statement sound to the ears of someone who has been abused?” (Cooper-White, 1995, p. 250). Upheaval also happened in these congregations because not everyone was willing to take this journey. Some people in the church resisted practical issues: “Why do we need a sexual abuse policy in the church? Why do we need to screen volunteers?” Some preferred to leave, feeling that the “abuse issue” had been blown way out of proportion, and that the church had become a “one-issue” church. Others found the process exhausting, but were committed out of love for the survivor. Most people did not realize at the beginning of the journey how long it would take. Years into the process, people would remark on how they did not realize that the journey would change them so profoundly. In other congregations, the homemaking for survivors was less intense but equally valuable. Some survivors chose not to tell their story to the whole congregation, but instead to a small support group. Healing happened when the support group came through for the survivor, maintaining confidentiality and providing help in practical ways. Homemaking in the church can be a gradual process. In one church, the change began with congregational prayers for survivors of abuse. The minister attended a seminar on abuse. A public announcement about the minister’s attendance led a church member to share with him that she was a survivor of childhood abuse. This led to a Sunday school elective being offered on this issue. Pamela Cooper-White suggests that “a congregation that is educated and sensitized is a powerful witness to the larger themes that affect the survivor’s life. Just having such a context, even if not one word of her individual story is ever told, can be tremendously healing” (1995, p. 249). In this particular congregation, a number of members eventually shared their stories of abuse, some publicly, some privately with the pastor. This only happened after the church had presented itself as a safe space for their disclosures. In another church, practical homemaking was actively implemented. The elders gave money to help for therapy, members of the support group offered child care. Subtle issues were also addressed. The authority and power imbalance symbolized by a huge chair in which the minister sat, compared with the regular pews for laypeople, was problematic for the survivor. When this was brought to the attention of the elders, the chair was quietly removed and replaced with a regular chair. The minister was willing to work creatively with the survivor to create a service of healing for a select group of supporters. I saw many different examples of how this congregation creatively made a safe space for survivors.

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WE’RE GOING HOME

I described spirituality at the beginning of this chapter by using the metaphor of home. I explained that while I am trying to create a safe place for my family, I admit that this safety is not static or guaranteed. It’s relational, it’s open to failure, it’s hard work. In a similar way, creating safe spaces for survivors in congregations is not a straightforward process. Even in congregations that were the most successful in providing a home for survivors, anger, misunderstandings, and hurt feelings remained. Churches create a home not by being perfect but by making a strong commitment to trying to create that home together. Survivors who have been shaped by trauma may feel that they are refugees entering a new country when they begin their healing journey. “They must build a new life within a radically different culture from the one they have left behind” (Herman, 1992, p. 196). The church can be that new home for survivors, but only if members are willing to risk examining their community with new eyes. In the literature about abuse and recovery, the healing process often sounds as though being open to survivors is something that we do “for them.” Although this may sound too one-sided, it is important to look at the transformation that can happen to the congregation’s spirituality. For example, what does it mean to be a community that closes our eyes to the pain of people? How does that diminish us? By closing ourselves off to relationships with people who are hurting, we close off our opportunities to live and grow. A spirituality that is evidenced by homemaking, finding safe spaces for one another, is ironically a spirituality that involves opening ourselves up to pain and danger. “Our vocation can never be simply to create safety but rather to take the risks involved in standing with those in danger, thereby putting ourselves in danger as well” (Heyward, 1995, p. 43). In conclusion, I realize that the reflections in this chapter are qualitative and limited to a relatively small number of congregations in a small Protestant and Mennonite denomination. My own Mennonite theology undoubtedly influences the vision I have of supportive congregations. The literature I read would support the importance of such communities. However, the literature tends to focus its attention on the community created in the healing relationship between the therapist/pastoral counsellor and the survivor. Healing is a miracle wherever it happens; the beauty of survivors being at home in safe and supportive communities is something I would like to see more often! To further that goal, I would encourage both qualitative and quantitative research that

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examines what exactly happens over time in Christian congregations and other religious communities as they interact with survivors of child abuse. REFERENCES Blume, E.S. (1990). Secret survivors. New York: John Wiley. Cooper-White, P. (1995). The cry of Tamar. Minneapolis, MN: Fortress. Doehring, C. (1993). The absent God: When neglect follows sexual violence. The Journal of Pastoral Care, 47, 3–12. Herman, J. (1992). Trauma and recovery. New York: Basic. Heyward, C. (1995). Staying power. Cleveland, OH: Pilgrim. Pattison, S. (1998). Suffer little children: The challenge of child abuse and neglect to theology. Theology and Sexuality, 9, 36–58. Pellauer, M. (1987). Invitations to the reader. In M.D. Pellauer, B. Chester & J. Boyajian (Eds.), Sexual assault and abuse (pp. vii–xxiii). San Francisco: Harper and Row. Ramsay, N.J. (1998). Compassionate resistance: An ethic for pastoral care and counselling. The Journal of Pastoral Care, 52 (3), 357–73. Vanier, J. (1998). Becoming human. Toronto: Anansi. Yantzi, M. (1998. Sexual offending and restoration. Waterloo, ON and Scottdale, PA: Herald.


6 Islamic Spiritual Care in a Health Care Setting Nazila Isgandarova

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am a Muslim woman chaplain and, for the first time in my life, I am working with Christians in a new culture. I am grateful that in my chaplaincy experience I have been welcomed by my peer group and coworkers, and that this has been a positive experience. I am grateful to my supervisors in the Clinical Pastoral Education (CPE) program. In the beginning, I found this program difficult because it originated as a Christian program and even the word “chaplain” sounded too Christian. Many of the Muslim patients I first met assumed I was a Christian. However, when they learned I was Muslim, they came to appreciate the system that offers spiritual care alongside physical care for minorities. Very often members of my peer group and I share stories about our patients. When they recount how they deal with their Muslim patients, I appreciate how, in spite of their differences in faith, they are able to comfort followers of a different faith. I also appreciate that they encourage me to do chaplaincy work with Christian patients because they believe in my skills. This has encouraged me to pursue research into spiritual care in Islam. The purpose of this chapter is to introduce to the Western reader the basic teachings of spiritual care in Islam, since the act of caring in Islam is not widely covered in Eurocentric literature. It is impossible to present the depth and breadth of Islam in this chapter; my intention, therefore, is to provide the average reader with some insights into the subject that will help him/her appreciate the principles for which Islam stands. The chapter begins by briefly distinguishing between chap-

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laincy and the spiritual caregiver. This is followed by three sections exploring the meaning of spirituality in Islam, spiritual care according to the Qur ’an and Sunnah, and spiritual care according to modern Muslim scholars. CHAPLAINCY AND THE SPIRITUAL CAREGIVER

In the West, the Christian word “chaplain” is mistranslated to mean the Islamic word “imam.” In my faith, an imam is similar to a chaplain, but there is a major difference. In my faith only a man can be imam; women cannot be ordained as imams based on reasons in the Islamic literature, and has nothing to do with gender issues. The proper translation of the word chaplain is ruhani khadim (spiritual caregiver) in the Azerbaijan language, or din gorevlisi (religious clergy) in Turkish. I appreciate the very recent development in North America to replace the word chaplain with spiritual caregiver, which is a more inclusive term. In Islam, a woman can be a chaplain, and this has encouraged me to do spiritual work. My main encouragment flowed from the Qur’an, because Islam has granted the idea of equality in creation to men and women and has given women the same spiritual status as men. The Qur ’an declares that whoever, whether man or woman, is righteous and has faith will be given a good and pure life by God, and that God will bestow them with rewards according to their actions (Qur’an, 4:127; 16:97; 33:35). These verses clarify a woman’s obligations under Islam, which are the same as those of a man. One of the obligations is chaplaincy; thus, the Qur’an has endorsed my passion. My growth in the field of health care made me search for the notion of spiritual care in Islam. THE MEANING OF SPIRITUALITY IN ISLAM

In Islamic teaching, the human person is viewed as an entity in which body and spirit are united. Spirituality implies a healthy relationship between body and spirit.

Spirit and Body Every religion, including Islam, deals with the ultimate issue of the Holy Spirit, the Supreme Being. In Islam, the term spirituality means ruhaniyyah. Ruh, which is the root of ruhaniyyah, means spirit and is very often mentioned in the Qur ’an. According to the Islamic scriptures,

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spirit constitutes the immortal part of human existence; the body is healthy if the spirit is healthy, and the spirit is healthy if it is not in conflict with Divine Writ. Bediuzzman Said Nursi says, Spirit is a law possessing external existence, a conscious law. Like the stable and enduring laws of creation, spirit comes from the World of the Pine Command and the attribute of Will. Pine Power clothes it an existence decked out with senses. He makes a subtle, flowing being the shell to that jewel. Existent spirit is the brother of the conceivable law. They are both enduring and come from the World of the Pine Command. If Pre-Eternal Power had clothed the laws governing in the species of beings in external existence, they would have been spirits. And if the spirit banishes consciousness, it still would be an undying law. (1996, p. 292)

In his article “Time to Pray,” Fethullah Gulen writes: The spirit is not an electrical power, but rather a conscious, powerful thing that learns and thinks, senses and reasons. It develops continually, usually in parallel with the body’s physical development, as well as mentally and spiritually through learning and reflection, belief and worship. The spirit determines each individual’s character, nature, or identity. As a result, although all human beings are substantially made of the same elements, each individual is unique. (2003, p. 6–7)

He further points out: The spirit needs our body. The spirit, a non-compound entity issuing from the world of Divine Commands, must use material means to be manifested and function in this world. As the body cannot contact the world of symbols or immaterial forms, the spirit cannot contact this world if there is no human heart, brain, or other bodily organs and limbs to mediate. The spirit functions through the body’s nerves, cells, and other elements. Therefore, if one or more bodily systems or organs go away, the spirit’s relation with them is disconnected and no longer commanded by it. If the failure or “illness” causing this disconnection severs the spirit’s relation with the entire body, what we call death occurs. (2003, p. 7)

In Islam, humans are viewed as entities in which body and soul are united. The soul has its own maladies (like forgetfulness of the Divine presence, greed, jealousy, and so on) and the body has its own ailments, but both are combined in one living entity: the human being. Both act on each other and through each other. This is a unique integration of

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body and spirit, which is linked to the rest of the universe through an elaborate system of levels of reality reaching up to the Divine presence.

Spirituality The term spirituality in Islam is linked to the above view, and is not separable from the awareness of God and from a life lived according to His Will. Thus, the principle of Oneness (al-tawheed, or unity) should be taken into consideration in any study of spirituality in Islam. In Islam only God stands as the very basis of life; without God nothing can exist and function properly. That’s why everything in Islamic civilization, including the health sciences, has come from this fundamental statement. From this perspective, Islamic spirituality is based on three key terms, all of which mean to be safe, integral, and sound. The first is iman, which means faith, but its root meaning is to be at peace, to be safe, or not to be exposed to danger. The second term, Islam, means to be safe, to be whole and integral, and not to disintegrate. The third is taqwa, which is usually translated as piety or being conscious of God, but whose root means to protect from becoming lost or wasted and to guard against peril. In Islam the rational faculty of one’s soul is also known as the mind, and the spiritual faculty is known as the intellect or spirit. They both can contribute to victory over the material faculty known as the body if both mind and spirit are supplied with knowledge from experience and study. Such knowledge makes it possible to discern between good and bad and can bring one closer to God, so that one can know His strength and greatness (Yakun, 1993, p. 33). The Prophet Muhammad praised the marvel of the human mind and spirit in his saying, which was narrated by Tirmidhi: “The greatest dignity bestowed by Allah (God) on His creatures was the human mind and spirit” (Yakun, 1993, p. 33). As we can see, a Muslim’s sense of self is not limited to our identification with the physical body. It means that our identity is not limited even to our intelligence or to our spiritual awareness at the end of our lives—for many people do lose control not only over their bodies but also over their minds in their final stages of life. A Muslim is identified with the choices and actions he/she has made throughout his/her life. The Prophet Muhammad taught that the choices we make freely in this life can affect other people, animals, and even the earth as long as the world continues to exist. As we influence earthly life, even after our physical deaths, it is clear that individual human identity can never be reduced to a feeble mind and body (Mattson, 2002). Even though this is the most

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effective component of our own image, to talk about the spirit is usually limited because of the difficulty in explaining this almost inexplicable aspect of humanity (Qur’an, 17:85). However, Islam does not put the body aside; the body is as important as the spirit (Qur’an, 95:4). Human beings have a superior image that is made up of many components, including the body, the soul, and the spirit. This is a correct view, as maintained by the vast majority of Muslim theologians and endorsed by the scholars of ahl as-sunnah (Ibn Qayyim, 1994, pp. 294–97; al-Kanadi, 1994). Thus, the human body is the visible component of our spiritual identity. The body was created for a noble purpose, therefore the health of our body is the most important favour and one of the greatest blessings that God gives us. The body is a superb creation, and when it is in good health it is an amazing state of existence, even an extraordinary miracle. In the Islamic perspective, health is a blessing, sickness is an examination. Sickness is the messenger of death, and the reminder and announcer of the hereafter. That’s why it is necessary to praise God for the blessings and to show endurance during illness (Cosan, n.d.). Within the context of this perspective, I explore spiritual care in Islam according to the Qur ’an, narrations from the Prophet, and the works of Muslim scholars. SPIRITUAL CARE ACCORDING TO THE QUR’AN AND SUNNAH

In this section, visiting the sick, health and illness, medical treatment, holistic treatment, hospital care, and music therapy will be treated from the perspective of Muslim teaching and practice. In Islam, there are two main words used to denote these concepts. One is shifa, which means spiritual healing, and the other is mualija, which means treatment. The Muslim tradition of spiritual healing or shifa, which is based on the recognition of the effect of spiritual health on the physical body, is one of the interesting tenets of Islam in which the body itself is seen as a mere receptacle for the spirit. As Dr. Muzaffar Iqbal, president of scientific research at the Pakistan Academy of Sciences, has said, “Healing through supplications, prayers, and fasting is a well-established tradition among Muslims” (Iqbal, 1998, pp. 3–5) The Islamic tradition of healing was derived from the Qur’an and from Sunnah (the sayings, actions, and approvals of the Prophet Muhammad), as well as from various teachings of the scholars. Healing aims to create a healthy environment that will have a positive effect on an indi-

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vidual’s physical, mental, and spiritual development. At a physical level, the Qur ’an and Sunnah encourage healthy eating and forbid all substances that cause bodily harm, which include intoxicants, drugs, and so on. The Qur’an and hadiths (sayings of the Prophet) prescribe fruits and vegetables, dates, yogurt, camel milk, natural honey, black seeds, and the like for their nutritious quality and health benefits. Generally speaking, the Qur’an encourages us to eat healthy and good food (Qur’an, 2: 168; 5:4, 91, 93; 2:219). In the Qur’an there are many verses that address various diseases, especially diseases of the heart, which often lead to direct or indirect physical and mental ailments. The Qur ’an also mentions blindness, deafness, lameness, and leprosy, as well as mental disorders that include psychoses and neurotic diseases like sadness and anxiety. However, the primary focus of the Divine message is on moral and ethical diseases. It is one of the main reasons that the Qur’an itself is referred to as a book of healing.

Visiting the Sick In Islamic tradition, visiting the sick and providing spiritual care is a basic duty a Muslim has for another, and is not reserved only for close friends and family. It is actually a basic form of worship to bring one closer to God. In times of distress or illness, the Muslim finds the greatest solace and comfort in the remembrance of God. The severely ill person, who might be distracted by his/her pain, greatly appreciates a companion who can read the Qur’an to remind him/her of God. There are different terms in Islamic literature to express these attitudes. One of them is sohba, a term denoting companionship and presence. It is not used in the secularized context. The effective and fruitful sohba happens when uplifting comfort, inspiration, love, encouragement, strength, exhortation to fortitude, and healing are achieved and affirmed by the Qur’an, the traditions of the Prophet, and Islamic laws (Qur’an, 6:17; 6:151; 4:29; 5:32; 41:44; 39:10; 31:17). In addition, Muslims recite certain chapters from the Qur’an for the purpose of healing, especially sura al-Fatiha, Baqarah, Saad, Falaq, and Naas (al-Hakim al-Tamimi, 1987, pp. 74–75).

Health and Illness The traditions of the Prophet Muhammad also emphasize healing and sickness. He considered health to be one of the greatest blessings to

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have been given to human beings. “There are two blessings which many people do not appreciate: health and leisure….No blessing other than faith is better than well-being” (Sahih al-Bukhari, 1984, Book 81, 1:6412, p. 1232). Imam Bukhari also narrated several hadiths. For example: The first thing every servant of God will have to account for on the Day of Judgment is that he will be asked by God: “Have not I given you a healthy constitution and have not I quenched your thirst with cold water?” No one will be allowed to move from his position on the Day of Judgment when he is asked how he spent his life; how he used his knowledge; how he earned and spent his money; and in what pursuits he used his health.

Through these sayings, the Prophet encourages us to take care of our bodies and not overburden ourselves. Imam Bukhari narrated what the Prophet said: “Bear only what you can cope with,” and “Be keen to do what is of benefit to you” (Sahih al-Bukhari, 1984, Book 81, 1:6412, p. 1232). The Prophet empowered the sick by describing sick people’s sleep as worship and their moaning as litany in praise of God. The sick are rewarded as though they are performing their usual prayers as they do when they are healthy, although they are unable to do so during illness. Their supplications are accepted, their sins are forgiven, all their mistakes and wrongdoings recorded in the Prophet’s book are deleted, and the sick person is told, “Very well, start your new life with an absolutely clean book!” They are encouraged to seek treatment because “there is no disease that God has sent down, except that He has also sent down its treatment.” And we are instructed to “feed the hungry, visit the sick, and set free the captives.” We are also instructed to care for the sick when the Prophet says, “He is not one of us who does not care for others” and “Allah’s Apostle ordered us to accompany funeral processions, visit the sick and greet everybody” (Sahih al-Bukhari, 1984, Book 70, 1:553, p. 1232). When we visit the sick, it is important that we pray with the sick as we comfort them. The Prophet tells us, “When you visit an invalid tell him to make supplication for you, for his supplication is like that of the angels” (Sunan of Ibn Majah). Also, “There is not any Muslim who visits another in sickness, in the forenoon, but the seventy thousand angels send blessings upon him till the evening; and there is no one who visits the sick, in the afternoon, but that seventy thousand angels send

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blessings upon him till daybreak, and there will be a pardon for him in Paradise” (Sunan of Ibn Majah). These quotations remind me of the incarnational theology of Charles Gerkin, who argued that God is already present with the sick. The narration below is an excellent example of this claim: God will say on the Day of Judgement: “O son of Adam, I was sick but you did not visit me.” “My Lord! How could I visit you when You are the Lord of the whole world,” we will reply. God will say: “Did you not know that so-and-so from among my servants (i.e., human beings) was sick, but you never visited him or her? Did you not know that if you had visited, you would have found me there?” God says: “O my servant! Health unites you with yourself but sickness unites you to me.” God also visits the sick and says, “O My servant! Health unites you with yourself, but sickness unites you to Me.” (Yahya ibn Sharaf al-Nawawi, 1997, pp. 15–17)

The Prophet always prayed for the sick when he visited them. He would place his hand on their forehead and pass it over their face and abdomen and say: “O God! Cure him and complete his emigration” (Sahih al-Bukhari, 1984, Book 70, 1:563, p. 1232). Aisha, the Prophet’s wife, narrates, “Whenever God’s Apostle paid a visit to a patient, or a patient was brought to him, he used to invoke God, saying, ‘Take away the disease, O the Lord of the people! Cure him as You are the One Who cures. There is no cure but Yours, a cure that leaves no disease.’” She also narrates that Allah’s Apostle used a Ruqya saying in his treatment, “O the Lord of the people! Remove the trouble. The cure is in Your Hands, and there is none except You can remove it [the disease]” (Sahih al-Bukhari, 1984, 70 1:579, p. 1232). The Prophet also ordered us to comfort the sick by saying, “You will get well and live long.” Although this saying will not prevent what is predestined, it will provide solace.

Medical Treatment In the narrations, this world has been classed as Darul Asbab (a world of means). From this point of view, it is necessary to take medication for one’s illness. The death that results from not taking proper medication or from not seeking treatment is considered suicide, which is forbidden in Islam. There are many hadiths that encourage Muslims to seek medical treatment. For example, Usamah ibn Shirauk wrote: “O God’s Messenger! Should we seek medical treatment for our illnesses?” He replied:

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“Yes, you should seek medical treatment, because God, the Exalted, has let no disease exist without for its cure, except for one ailment, namely, old age.” As well, “Grasp five things before five others: your youth before your decrepitude, your health before your illness, your riches before your poverty, your leisure before your work, and your life before your death.” The Prophet not only instructed sick people to take medicine but also invited physicians to do so (as-Suyuti, 1962). The Prophet always used medicine when he was ill. Aisha narrates that “during the Prophet’s fatal illness, he used to recite the Mu’auwidhaat (chapter al-Falaq and anNaas) and then blow his breath over his body. When his illness was aggravated, I used to recite those two chapters, blow my breath over him and make him rub his body with his own hands for its blessings” (Sahih al-Bukhari, 1984, Book 70, 1:631, p. 1232). Allah’s Messenger said that “Fatihat al-Kitab contains healing for every disease” (Sahih al-Bukhari, p. 131). This is based on the Qur’an where God says, “And We sent down from the Qur ’an that which is a healing and a mercy to those who believe, and it increases the wrongdoers nothing but loss” (17:82). There are also other prophetic sayings in the area of medicine and health, which has developed into an entire discipline known as al-Tibb al-Nabawi (Prophetic Medicine). Only the books of Imam Bukhari, who is the most authentic collector of prophetic sayings, narrates 129 hadiths, which directly relate to medicine, and two books of hadiths are devoted to medicine and patients. Many prophetic statements, for example, “there is no disease that Allah has created, except that He also has created its treatment,” have provided the impetus for Muslim scholars to undertake medical investigations. From the ninth to thirteenth centuries C.E., Muslim scholars made numerous contributions to the field of medicine. These medical scholars and medical practitioners possessed encyclopedic knowledge of theology, law, and philosophy.

Holistic Treatment The Muslim scholars emphasized “holistic medicine” that involved the spiritual, psychological, physical, and moral aspects of being. The essence of Islamic medical tradition was founded on the Qur ’an and on the hadiths, the sayings of the Prophet Muhammad. The fourteenth-century traditionalist and historian Abu Abdallah Muhammad al-Dhahabi wrote: Prayer can cause recovery from the pain of the heart, stomach, and intestines. There are three reasons for this. First, it is a divinely com-

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manded form of worship. Second, it has a psychological benefit. This is because prayers divert mind from the pain and reduce its feeling whereby the power to repel [the cause of] pain is strengthened. Expert doctors try all means to strengthen this [natural] power. Sometimes by feeding something, sometimes by inspiring hope, and sometimes by inspiring fear. Now, prayer [with consideration] combines most of these means of benefit, because it at once instills fear, self-effacing humility, love [of God], and remembrance of the Last Day. (al-Dhahabi, 1961, in Iqbal, 1998).

Rhazes (c. 865–925 C.E.), whose treatise on measles and smallpox is well known in the West, used to treat the maladies of the soul along with those of the body. He wrote a book entitled al-Tibb al-Ruhani (Spiritual Medicine), in which he spoke about the relationship of soul and body, described in detail the moral diseases, and discussed with acute perception how these affect human behaviour. This book was translated into English as The Spiritual Physick of Rhazes, and published in 1950. He devoted twenty chapters to descriptions of various illnesses that can beset the body and soul. Avicenna (980–1037 C.E.), honoured in the West with the title of “Prince of Physicians” and the author of the monumental Canon of Medicine (al-Qanun fi’t-Tibb), was known to have practised the art of healing with the help of spiritual guidance. The Book of Healing (Kitab al-Shifa), Avicenna’s second most important work after the Canon, presents a unique synthesis of the Greek, Persian, Indian, and Islamic practices of healing. Avicenna believed that the human spirit has been constituted with the power of resorting balance in the body, and that the task of medicine is merely to aid this process. He said: “The state of equilibrium which a human being enjoys has a certain range with an upper and a lower limit. The process of regaining health is, therefore, greatly facilitated by the use of practices which produce spiritual healing” (Iqbal, 1998). Ali ibn alAbbas, who lived one thousand years ago, gave a brief definition of health in his book Kamil as-Sina’ah: “Health means that the body is in a state of equilibrium.” In religious medicine the interpretation of human suffering is part of a wider spiritual and ethical framework. Masters of the Sufi orders were traditional religious healers who treated instances of possession and other ailments by recitations of the Qur’an as a prescription of behavioural and ritual instructions. It is said that Moghul emperor Jahangir once suffered from an illness his doctors were unable to cure. Frustrated, he went to the tomb of the Saint Mu’in al-Din Chishti at Ajmer and was

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cured. Afterwards, he wore earrings in the name of the saint as a token of being his follower (Chandpuri, 1969, p. 129). Another Moghul emperor, Babur, prayed for the health of his son Humayun, who was seriously ill and near death. Hence, Babur asked God to spare his son’s life and take his life in lieu thereof.

Establishing Hospitals to Treat the Sick The Muslims not only repeated but also put the orders of the Qur’an and the hadiths into action. In the Muslim world in the medieval times, the ten years (634–644 C.E.) under the rule of the second caliph, Umar ibn al-Khattab, saw many public welfare workers in the Islamic state. The caliph was so concerned for the welfare of the ailing people that he accompanied a team of physicians with the army to Persia. The Ummayad caliph al-Waleed (ruled 705–715 C.E.) was the first to set up institutions for lepers and the blind where servants and guides were employed to help them. But the hospitals began their proper function during the Abbasid caliphate (750–1257 C.E.). Caliph Harun Rashid ordered the establishment of the first hospital in Baghdad. After his hospital was built at the end of the ninth century, a number of hospital foundations were established in quick succession. There were many famous hospitals throughout Islamic history: al-Nuri Hospital in Damascus; al-Salahani Hospital in Jerusalem built by the Crusaders and expanded by Salah al-Din; al-Muqtadir Hospital and al-Adudu Hospital in Baghdad; and al-Fustat hospital in Cairo. Benjamin of Tudela, a Jewish historian who visited Baghdad in 1160, found at least sixty medical institutions there and wrote positively about Sultan Salah al-Din: “All are well provided for from the king’s stores with spices and other necessaries. Every patient who claims assistance is fed at the king’s expense until his cure is complete” (Elgood, 1951, p. 172). In the Islamic model of hospitals, which were based on Greek-Arab medical science, patients of all backgrounds were treated free of charge. In the Muslim world, hospitals were known as bimaristans. Many great hospitals were built by rulers or by private individuals throughout the Islamic world. Hospitals were either constructed for a particular physician or put under the direction of a particularly eminent doctor. Hospitals facilitated the diffusion of Islamic medicine among non-Muslims, had separate wards for male and female patients, and were staffed with nursing and other ancillary staff of the same sex. Only qualified and licensed physicians were allowed to practise medicine. On discharge the patients were given five gold pieces each to tide them over until

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they could support themselves. The hospitals also provided facilities for performing prayers (Syed, 2003). They often had wards for the insane, where drugs, as well as music therapy and Turkish baths, among other things, were used. Since medieval times, some sufi hospitals have specialized in the treatment of psychiatric disorders.

Music Therapy Therapeutic care is based on Greek medicine and religious treatment. Music therapy is one method of treatment. The Qur’an does not mention music directly one way or the other; however, it looks upon melodious voices with favour. Al-Dhahabi (d. 1348 C.E.), author of Prophetic Medicine, wrote, “Singing is the soul’s pleasure, the heart’s delight and food for the spirit; it constitutes part of the most exalted spiritual medicine. It is pleasurable even to some animals. Its moderate enjoyment kindles natural warmth, strengthens the activity of the various faculties, slows down aging, and repels many diseases” (al-Dhahabi, 1961, p. 139–40). In addition, he pointed out that the Islamic ritual prayers, which involve certain changing physical postures, benefit the spiritual, psychological, physical, and moral selves. Prayers can help us recover from pain in the heart, stomach, and intestines; they produce happiness and contentment in the mind; they suppress anxiety and extinguish the fire of anger; they increase love for truth and humility before people; they soften the heart, create love and forgiveness, and encourage a dislike for the vice of vengeance. As well, we can make sounder judgments because we can concentrate on difficult matters and find correct answers to our problems. Prayer helps us remember forgotten things, and helps us discover ways to solve worldly and spiritual matters. Above all, we can effectively examine ourselves, particularly when we strenuously exercise prayer. Abu Nu’aim (d. 1038 C.E.), a theologian and a man of piety, narrated that the Prophet said, “Music beautifies and refreshes the body, apart from the beauty of its words, the soul benefits from its lofty idea.” The Prophet also said to “embellish the Qur ’an with your beautiful voices” (al-Dhahabi, 1961, p. 140). SPIRITUAL CARE ACCORDING TO MODERN MUSLIM SCHOLARS

The Muslim scholars of the past century have made remarkable contributions to spiritual care. Developments in science and technology, including medicine, challenged Muslims to update their knowl-

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edge and information in order to understand modern developments according to the sacred Book of Islam and narrations of the Prophet Muhammad. Bediuzzaman Said Nursi, the famous Turkish scholar of the twentieth century, said that medicine is a science and also an art; medicine relies on the Absolutely Wise One’s Name of Healer, and through its compassionate manifestations in the earth’s vast pharmacy, finds its perfection and becomes reality. He interpreted the verse from the Qur’an (“I shall heal the blind and the leper and I shall quicken the dead, by God’s leave,” 3:49) in this way: The verse “concerns a miracle of Jesus (Upon whom be peace)” (Qur’an, 5:116–120). Just as the Qur’an explicitly urges man to follow Jesus’ (Upon whom be peace) high morals, so too it allusively encourages him towards the elevated art and Dominical medicine of which he was the master. Thus, this verse indicates this: “Remedies may be found for even the most chronic ills. In which case, O man! and O calamity-afflicted sons of Adam! Don’t despair! Whatever the ill, its cure is possible. Search for it and you will find it. It is even possible to give a temporary tinge of life to death.” And in meaning Almighty God is saying through the figurative tongue of this verse: “O man! I gave two gifts to one of My servants who abandoned the world for Me. One was the remedy for spiritual ills, and the other the cure for physical sicknesses. Thus, dead hearts were raised to life through the light of guidance. And sick people who were as though dead found health through his breath and cure. You too may find the cure for every ill in the pharmacy of My wisdom. Work and find it! If you seek, you will certainly find.” Thus, this verse traces the limit which is far ahead of man’s present progress in regard to medicine. And it hints at it, and urges him towards it. (Nursi, 1996, p. 232).

Prayer was brought into modern times as a way to help support the poor and hurt and provide shelter for those in distress. One of the most important scholars in this area was Fethullah Gulen, who provides these instructions about prayer: The inhabitants of the heavens carry along the sincere prayers of such needy people, who are deprived of any other solution. These destitute people, who are in a state of desolation and demise, know what they are asking for and are aware of what they are doing. They turn to Him and unburden themselves of all thoughts. Such prayers would make the heavens burst into tears; hurricanes threatening the world would change its course, waves overturning every-

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thing would calm down, and peace would rise on the horizon. Broken fault lines would surrender to unexpected rulings, and released gases would easily evaporate into the atmosphere. The breeze of such a prayer enlivens Earth and brightens the skies. Hearts beat with exhilaration, and nature rises in order to dance and to send forth smiles. Through prayer, people offer their sacred requests, which are beyond causes, to the Most Glorified One, and acknowledge that God see whatever is hidden or open. Humanity, as well as the jinns and the angels, pray to Him, especially about issues that subjugate their strength and control, and expect a remedy from Him. However, such a remedy is forthcoming only if we take all of the required measures and fulfill all of the necessary conditions. (Gulen, 2003, pp. 13–14)

Dr. Muzammil Siddiqi says that in Islam spiritual medicine can be used to mean two different things, although both are allied and sometimes confused. One refers to the belief in a spiritual, ethical, or psychological cure for diseases that may have physical or spiritual (or psychic) benefits. Thus, a physical illness may be cured, for example, by recitation of the Qur ’an or other prayers (du’a). Most medical professionals in the scientific tradition recognize this belief to an extent. He affirms that volumes of spiritual prescriptions for cure exist in Islam. Dr. Muzammil Iqbal writes that the relaxation response yields many long-term benefits in both health and well-being and can be brought on with salat (five daily prayers in Islam), zikr (divine chanting), and recitation of the Qur’an, which can help us to focus our minds. These practices make us aware of the power of self-care and the healthy things that we can do for ourselves. Our bodies are meant to benefit from exercising our beliefs, values, thoughts, and feelings. Patients who suffer from anxiety and panic after surgery or from a terminal illness have documented that they experience physical solace after making du’a to God. This is the opposite effect of the edgy adrenaline rush we experience during the stress-induced fight-or-flight response. Du’a provides patients with both an emotional and a spiritual balm. This tender comfort restores confidence both in our body and our ability to face the twists and turns of life. Both salat and du’a elicit relaxation responses in patients that can result in achieving mental equilibrium and help patients ward off disease by doing something to calm the body and the fears (Iqbal, 1998).

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The system of spiritual healing is related to the cosmic order of the universe through the basic doctrine that all levels of reality correspond, as Seyyed Hossein Nasr (1987) points out in Science and Civilization in Islam: There is in the Hermetico-alchemical natural philosophy which was always closely tied to medicine in Islam via basic doctrine of the correspondence between all the various orders of reality: the intelligible hierarchy, the heavenly bodies, the order of numbers, the parts of the body, the letters of the alphabet which are the “elements” of the Sacred Book, etc. (120)

Faiz Khan, a member of the Board of Directors of the ASMA Society for Islamic Spirituality, wrote in his article that from the Islamic perspective, there is no essential demarcation between the sacred and mundane, or the secular and spiritual. All of life’s activities are infused with a spiritual dimension, a sentiment that is characteristic not only of Islamic tradition but also of every traditional civilization. Those who visit with and minister to the ill with as much sincerity and presence as they can muster, experience a reciprocal exchange of Divine Grace and Mercy, and through this both parties can be transformed. The fact that both health and illness are seen in Islam as coming from God has closely linked the art of healing to worship. The one who practices the art of healing does this for the sake of God’s pleasure. The physician and the patient are thus united through a spiritual bond. CONCLUSION

From the Islamic perspective, the human being consists of both spirit and body. The spirit is an entity that differs from the physical, tangible body. The spirit is luminous (or light-like), alive and moving, penetrating the limbs and circulating through them. One may reasonably perceive the soul filling and occupying the body; its form, though nonphysical, is moulded into the body’s shape. The soul will maintain its penetration of the physical body and continue to affect its sense, movement, and will as long as the body remains sound. However, if the body is overcome and no longer accepts the forces enacted upon it by the soul, the soul leaves the body and enters the spiritual world (al-Kanadi, 1994). Islamic medicine is based on this concept and is characterized by its overall view of individuals as an integral composite of physiological, psychological, mental, and spiritual components. If something affects

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them, Muslims should seek early medical attention according to the Prophet’s practice and teaching, because our healthy body and spirit are gifts and trusts from God. Such spiritual and religious approaches to disease are interpreted as methods of coping and hope. That’s why for Muslims, the Qur’an, d’ua (prayer), and asking for protection from God are forms of medicine. From the Islamic point of view, a strong faith and trust in God play an important role in the cure of disease, as does eating well in an effort to recover. As the Prophet Muhammad has said: “Make full use of the two cures: honey and the Qur’an.” Muslims acknowledge that we can benefit from both. As Dr. Mehdi Ben Abboud of Morocco has said, Islam prescribes both ways of treatment without excess in the former or neglect of the latter, as individuals are an integral composite of body and spirit. We are encouraged to feed our souls as we feed our body, through prayer and continued worship in our daily lives. God has also promised to respond to whoever calls on Him, provided the call emanates from a pure heart: “When my servants ask you concerning me, I am indeed close (to them): I listen to the prayer of every supplicant who calls on me” (Qur’an, 2:186). The role of others is to comfort the patient. It helps the patient not to feel isolated and gives him/her a sense of companionship. Visiting the sick is a staple of Islamic morality and is common to most traditions. We have seen how the Prophet visited the sick and offered them prayer and words of comfort. He also encouraged healthy people to ask the sick to pray with them. These are, indeed, sources of blessings, as Islam teaches us. For a CPE student, it is similar to the incarnational theology of Gerkin, who insists that God is already present with the sick (O’Connor, 1998, pp. 42–43). In concluding, I’d like to mention that one of the main concerns of the Qur’an and the life of the Prophet Muhammad was the psychology, sociology, and law of humanity. According to Islamic texts, their purpose should be to build proper moral guidelines (Ahlaq), because only through this can human beings attain healthy personalities and characters, healthy societies, and just states. REFERENCES al-Dhahabi, Abu ‘Abd Allah Muhammad ibn Ahmad ibn ‘Uthman. (1961). al-Tibb al-Nabawi (Prophetic Medicine). Cairo (n.p.). al-Kanadi, Abu Bilal Mustafa (Ed.). (1994). Mysteries of the soul expounded. Jeddah, Saudi Arabia: Abul-Qasim.

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al-Razi, Abu Bakr Muhammad ibn Zakariyya. (1950). al-Tibb el-ruhani (The spiritual physick of Rhazes). (A.J. Arberry, Trans.) London: John Murray. al-Tamimi, al-Hakim. (1987). Khawass Al-Qur’an (Miraculous properties of the Qur’an). In Fazlur Rahman, Health and medicine in the Islamic tradition. New York: Crossroad. as-Suyuti, Jalalu’d-Din Abd’ur-Rahman. (1962). Medicine of the Prophet. London: Ta-Ha Publishers. Athar, S. (1993). Health guidelines from Qur’an and Sunnah. In Shahid Athar (Ed.), Islamic perspectives in medicine. Indianapolis, IN: American Trust Publications. Chandpuri, A.K. (1969). Attiba-i Ahd-i-Mughliya (Doctors of the Moghul period). Karachi, Pakistan (n.p.). Cosan, M.E. Health and sickness according to Islam. From a pamphlet published by the Islamic Science, Culture, and Art Association, Auburn, Australia. Elgood, C. (1951). A medical history of Persia. Cambridge: Cambridge University Press. Gulen, F. (2003). Time to pray. The Fountain, 42, 13–14. Ibn al-Qayyim. (1994). Kitâb ar-Rûh (Book of the spirit). In Abu Bilal Mustafa alKanadi (Ed.), Mysteries of the soul expounded (p. 296). Jeddah, Saudi Arabia: Abul-Qasim. Iqbal, M. (1998). Islamic medicine: The tradition of spiritual healing. Science & Spirit, 9 (4), 3–5. Khan, F. (2002, June 14). Faith and care of the patient: An Islamic perspective on critical illness. Yale Journal for Humanities in Medicine. Retrieved from http://info.med.yale.edu/intmed/hummed/yjhm/spirit2003/faith/fkhan1/htm. Mattson, I. (2002, July 17). Dignity and patient care: An Islamic perspective. Yale Journal for Humanities in Medicine. Retrieved from http://info.med.yale.edu/ intmed/hummed/yjhm/spirit/dignity/imattson.htm. Nasr, S.H. (1987). Science and civilization in Islam (2nd ed.). Lahore, Pakistan: Suhail Academy. Nursi, B.S. (1996). The words. Istanbul, Turkey: Sözler. O’Connor, T.S. (1998). Clinical pastoral supervision and the theology of Charles Gerkin. Waterloo, ON: Wilfrid Laurier University Press. Pickthall, M.M. (1970). The meaning of the glorious Koran. New York: Mentor Books. Syed, I.B. (2003). Efficient hospitals: Islamic medicine’s contribution to modern medicine. Journal of the International Society for the History of Islamic Medicine, 1 (1): 3, 20–23. Yakun, F. (1993). To be a Muslim. Burr Ridge, IL: American Trust Publications.


Part 2 Spiritual Practices in Health Care


7 Communication in Spiritual Care among People with Dementia Ellen Bouchard Ryan Lori Schindel-Martin Amanda Beaman

Garden Blossoms I was lost in the Garden of my mind, A tangled confusion; My thoughts flitted with no aim. What was I just remembering? Where was home? Where were the others? She tends the garden of my mind, Widens the crooked pathways, Darts to the very best flowers, Creates stepping stones from one to the other, Writes snapshots for me to hold. She shines the sun of her listening upon me, and My spirit blossoms. — E.B. Ryan

I

nterpersonal connections are especially important to older adults with dementia for maintaining their spirituality. Spiritual wellbeing arises from one’s relationships with the self, others, God, and nature (Ellor, 1999). However, cognitive losses can mean that relationships with God, self, and the environment may be experienced only through meaningful relationships with others.

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DEMENTIA AS A THREAT TO PERSONHOOD AND COMMUNICATION

Dementia refers to a progressive and irreversible deterioration of the cognitive-functional capacities of the brain in older adults. Increasing confusion, memory loss, and communication difficulties are hallmarks of this condition, which are caused by such progressive neurological disorders as Alzheimer’s disease. The prevalence of dementia in the population over age sixty-five has been estimated to be approximately 8 per cent (Canadian Study of Health and Aging Working Group, 1994). Alzheimer’s disease (AD) is the most prevalent condition associated with dementia, making up 55 to 65 per cent of its incidence. These figures are clearly significant for communities who offer spiritual support to aging individuals. The literature typically describes Alzheimer’s disease and related dementias as occurring in three stages: mild, moderate, and severe. Over a period of fifteen to twenty years, the person with dementia loses first the complex, abstract executive functions of the cerebral cortex, followed by changes in motor functioning that results in the loss of the ability to walk, eat, and swallow. In addition, the person with AD experiences profound changes in memory, so that once-familiar faces become unrecognizable and the purpose and application of specific objects are forgotten. Table 1: Memory and Communication in Dementia Abilities Best Preserved Life-time memories Non-verbal comprehension and expression of emotions Speech pronunciation Grammar Abilities Deteriorating Progressively Short-term and recent memory Ability to learn new information Intentional access to life memories Word knowledge Pragmatics (contextually appropriate language)

Table 1 outlines the memory and communication skills that are seriously affected by Alzheimer’s disease and related dementias (Lubinski, 1995; Orange & Ryan, 2000; Ripich, 1991; Santo Pietro & Ostuni, 2003). As well, the table identifies skills within these domains which are main-

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tained until very late in the disease. In particular, recent memory and new learning are seriously impaired by the progress of the disease, yet longterm memories are preserved. The individual experiences significant losses in linguistic expression and comprehension, while maintaining abilities for expressing and understanding emotions non-verbally. It is useful to describe the stages of Alzheimer’s disease, since it is the most prevalent form of dementia and many of its symptoms are common to other dementias. In each of the three stages of AD progression, changes impact significantly on an individual’s ability to communicate and interact with other people. The communication changes that are unique to each stage of the disease require specific adaptation so that individuals can participate in activities that are spiritual in nature. During the mild stage, individuals exhibit word-finding difficulty, use semantically empty words (i.e., thing, stuff), and may have difficulty following complex or abstract language. However, most are able to get by adequately in social situations. By the moderate stage, their awareness of their difficulties may have diminished, and the word-finding problems and empty utterances become more severe. Increased difficulty in understanding conversations may lead to less initiation of conversation and a withdrawal from social situations. Despite these difficulties, individuals retain their ability to understand emotional meaning. People in the late stage may become very disoriented to time and place and may be unaware of what is expected of them during conversations. Their inability to understand word meanings or form new memories causes partial or complete withdrawal from social interaction (Ripich, 1991; Santo Pietro & Ostuni, 2003). Knowledge of the different stages can be a useful reference, but it is important to remember that each person affected by dementia experiences it differently. Furthermore, symptoms may originate from, or be exacerbated by, a social environment that does not encourage or recognize remaining capabilities. For example, an individual in early stage dementia may seem increasingly withdrawn or uninterested in social interaction. While this behaviour may be a sign of a worsening condition, it could be indicative of depression associated with being aware of cognitive losses (Lubinski, 1995). Unwarranted assumptions about decline into the moderate stage could lead to further, unnecessary withdrawal. The cognitive declines of dementia can have the effect of assaulting one’s personhood, as many of the cherished activities and meaningful conversations that previously confirmed the older person’s sense of self no longer take place. Indeed, as an individual progresses through the

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stages of dementia, daily activities and interactions may become increasingly centred around the many “custodial” tasks that caregivers must perform in order to meet their physical needs. Norberg (2001) states that the gradual loss of communication ability associated with dementia results in feelings of being disconnected, disintegrated, and not at home. Norberg suggests that communication with people with severe dementia is essential for both connectedness and integrity, and that it should be based on a consoling communion with caregivers. While individuals with dementia clearly have greater physical needs than normally aging adults, the mere presence of these needs negatively alters the way they are perceived and treated by others in their social environment. Norberg (2001) states that certain behaviours typical of dementia have become stigmatized to the extent that they are seen only as problems, rather than as attempts at maintaining interpersonal connectedness. Similarly, Kitwood and Bredin (1992) describe this process as the problematizing of the dementia sufferer; “they” are labelled as “deficient” and categorized separately from “us,” the normal and “undamaged” individuals. The Communication Predicament Model of Aging (Ryan, Giles, Bartolucci, & Henwood, 1986) provides a useful framework for understanding how this labelling process is detrimental to the personhood of individuals with dementia. The model posits that a label such as “demented,” and/or behaviours characteristic of dementia, trigger stereotyped expectations of incompetence from people in the social environment. Based on these lowered expectations, people modify their behaviour towards the individual (e.g., reduce conversation with them), resulting in constrained opportunities for the older person to reveal her/his “self.” In terms of learned helplessness theory (Lubinski, 1995), over time the dementia sufferer learns to stop responding if he/she feels his/her efforts are futile. The individual may still be capable of responding, but gives up due to social and physical cues in the environment that suggest he/she is inadequate. It is critical to distinguish between innate helplessness, an individual’s actual reduction in abilities due to dementia, imposed helplessness, and diminished performance due to a poor social environment (Lubinski, 1995; McWilliam, Brown, Carmichael, & Lehman, 1994). Thus, dementia is associated with an excess disability caused by the inappropriate reactions of others (Dawson, Wells, & Kline, 1993; Kitwood, 1997; Kitwood & Bredin, 1992; Sabat & Harre, 1992). For example, religious communities such as congregations engaged in worship may assume that someone with dementia is receiving no benefit from attending a

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religious service because of a recent diagnosis or because of behaviours such as dozing, wandering, or agitation. The perceptions of the congregation may be internalized by the family caregiver, who then decides that the person is no longer capable of religious participation. This decision would further reduce the older person’s opportunities for social interaction and regular stimulation, causing an overall decline in his/her responses. It is clear that assuming that individuals with dementia are totally incapable will make it very difficult for caregivers to affirm the personhood of cognitively impaired older adults. Alternatively, a perspective that focuses on the remaining competencies builds a personhoodenhancing social environment. FOSTERING SPIRITUAL WELL-BEING IN PEOPLE WITH DEMENTIA

Because of these cognitive changes, individuals with dementia become especially dependent on social partners to maintain their spirituality (Kitwood & Bredin, 1992; McCurdy, 1998). Harrison (1993) argues that the personhood of individuals with dementia can be revealed by taking a life narrative approach, considering each individual’s unique past roles, relationships, and experiences. Thus, a personhood-centred caregiver will devise strategies that help the older person maintain meaningful social interactions and emphasize his/her individuality. Such an interpersonal approach will move the caregiver-recipient dyad past the stigmatizing label of dementia to enable spiritual well-being. The Communication Enhancement Model (Ryan, Meredith, MacLean, & Orange, 1995) illustrates how recognizing individuality can foster spiritual well-being. According to the model, a positive feedback loop ensues once the characteristics unique to each individual are acknowledged by caregivers. Based on individual cues, caregivers may modify their behaviour in order to meet the specific needs of the older adult. Moreover, the increased awareness of the “individual” leads caregivers to respect and promote the older adult’s remaining competencies (e.g., singing of hymns embedded in long-term memory). The model also highlights the role of the environment in facilitating or hindering an older adult’s conversation and participation. For example, agitated or aggressive behaviours associated with dementia can be reduced by removing triggers in the environment (e.g., turning off the television). An important intervention study has demonstrated that when teaching

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staff in nursing homes provide explicit social reinforcement for residents’ independent behaviours, they can break the negative-feedback cycle that creates dependence and encourage a return of independence (Baltes, Neumann, & Zank, 1994). Older adults whose “person” has been recognized feel empowered and are better able to exhibit their communication abilities, further fuelling others’ perceptions of them as competent. When we confirm the remaining competencies of individuals with dementia, we are better able to search for creative ways to foster their spiritual well-being. Table 2 presents the spiritual needs of persons with dementia (Cole, 1999; Davis, 1989; Ellor, 1999; Goldsmith, 1996; Kitwood, 1997). Although the list is based on universal human longings, some needs become stronger as one’s personhood is threatened (such as affirmation of self-worth and a sense of hope), while others are more difficult to address because of the disease’s impact on communication and thinking (such as feeling connected, validation of feelings, and remembering experiences of beauty). Table 2: Spiritual Needs of Persons with Dementia Self

God

Community

Nature/ Environment

Being known as a person Feeling competent Being useful and successful A sense of hope Acknowledgement of life story Validation of feelings Affirmation of worth Assurance of God’s love

Support for prayer and worship Opportunity to express and share grief Dealing with hope/ fears about death Participating in rituals and religious services

Feeling connected Able to share Feeling loved Offering love Sense of belonging Communication with others Giving to others

Experiencing beauty and wonder Remembering such experiences Belonging to God’s creation

USEFUL PERSONHOOD-AFFIRMING STRATEGIES

In this section, we present a variety of approaches for communicating with older persons suffering from dementia that will sustain their spirit. Our focus is on specific communication strategies, connecting through life stories, and facilitating religious participation.

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Communication As one attempts to communicate with a confused individual, it is important to maintain a focus on the person within that individual despite their diminished access to memory and their diminishing ability to express intended meanings and follow a conversation (Bourgeois, 2002; Hoffman & Platt, 1990; Kaplan & Hoffman, 1998; McCallion, Toseland, Lacey, & Banks, 1999; Rau, 1993; Santo Pietro & Ostuni, 2003; Souren & Franssen, 1993). Some key strategies are outlined in Table 3. Table 3: Strategies for Communicating with a Person with Dementia Type

Strategy

Environment

Choose a private, quiet, well-lit location Minimize distractions Approach within the person’s visual field Use calm tone of voice Maintain eye contact Use reassuring facial expressions, touch, gestures, and body postures Take time for a conversation, with long pauses as necessary Listen for the person’s perspective and the feelings being expressed Use simpler but adult grammar Avoid technical terms and jargon Communicate one idea at a time Ask questions with two alternatives from which to choose Beware of fatigue-reducing communication performance Recognize individual as a person Validate the person’s emotions and reassure her/him Negotiate by taking into account preferences, needs, and anxieties Collaborate by working together and by responding to an expressed desire or need Facilitate accomplishments, by providing the missing steps between intention and completion

Non-verbal

Verbal

Interpersonal

Source: Adapted from Kitwood, 1997; Lubinski, 1995; Orange & Ryan, 2000

Communication begins with optimizing the environment by choosing a quiet, private location with good lighting and a minimum of distractions. Given the importance of non-verbal comprehension and expression in dementia, it is useful to focus on the underlying message by attending carefully to non-verbal cues, especially tone of voice, eye

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contact, timing, facial expressions, gestures, body postures, and touch. For example, pausing between utterances can enhance comprehension, and waiting a long time for responses can make the difference between a monologue and a conversation. A calming tone of voice and a smile can do much more to reassure an agitated person than any choice of words. Other strategies include active listening/watching, getting the person’s attention before beginning a conversation, providing information one item at a time, and asking questions with two alternatives from which to choose. From an interpersonal point of view, Kitwood’s (1997) personhoodoriented strategies consist of the following: recognizing an individual’s identity, negotiating preferences and activities, collaborating jointly on specific tasks, validating emotions without agreeing to a disoriented sense of reality, and facilitating intended actions to compensate for the disease-based loss of ability to follow through on one’s own. By enabling the person with dementia to be successful in this way, a spiritual adviser or other caregiver can help reduce symptoms such as withdrawal, agitation, and aggression. These strategies can empower the person with dementia to exhibit remaining strengths, to achieve some of their goals within the conversation, and also to participate more fully in daily life.

Connecting through Life Stories The practice of storytelling has identified numerous advantages for encouraging reminiscences and the sharing of stories (Clark, 1996; Hepburn, Caron, Luptak, Ostwald et al., 1997; Randall & Kenyon, 2000; Ryan, Pearce, Anas, & Norris, in press; Rybarczyk & Bellg, 1997; Thorsheim & Roberts, 2000; Usita, Hyman, & Herman, 1998). These activities can be especially beneficial for the person with dementia, given the greater retention of memories from long ago as compared with more recent, present-day memories and the increased opportunity for a satisfying communication encounter when the topic is the individual’s early life. Conversational remembering can be rewarding in that the older person enjoys the storytelling activity and the opportunity to contribute to the conversation; in addition, the life story’s content can remind him/her of past achievements and joys. The conversational partner can develop a bond with the individual and then identify new ways to affirm personhood in future conversations. Recording life stories as a legacy for the family can provide a gift of immeasurable meaning when the teller is progressively losing connections with these memories. Recorded stories

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can also assist formal caregivers to understand the personal identity of the client and connect with him/her more effectively. Remembering Boxes. We have begun working in the community and in long-term care with individualized Remembering Boxes, which can stimulate conversations about lifetime memories despite cognitive impairment. More than a decade of research by Michele Bourgeois and her colleagues has demonstrated the effectiveness of memory aids to enhance communication between staff members and nursing home residents with cognitive impairment (Bourgeois, 1990; Burgio, Allen-Burge, Roth, Bourgeois et al., 2001). Remembering Boxes include writings (e.g., letters, stories, poems), pictures, and meaningful objects from a person’s life. Collecting materials to create a Remembering Box in the early stage of dementia can be a rewarding activity for both the person with dementia and the family members who collaborate. This activity generates opportunities for the loved ones to review the older person’s life in a meaningful way. The making of a Remembering Box during this stage allows the individual to make his/her own choices and to contribute stories that may not be spontaneously retrieved later on in the disease. The box then becomes an invaluable communication resource in the later stage as communication skills are lost and if the older adult is moved to a nursing home. In the later stage, the preparation of a Remembering Box can be done by family members or close friends with consultation, when feasible, with the individuals themselves. The meaningful writings and items act as external memory aids to elicit rich stories and generate satisfying conversations. Working with Remembering Boxes readily encourages the use of Kitwood’s interpersonal strategies (as outlined in table 3): recognizing the value of the individual’s life memories, negotiating which items to discuss, validating the emotions arising from re-experiencing a life event, collaborating in the reconstruction of a story, and facilitating the recording of a newly elicited story about old times. In long-term care we have also been working with Remembering Boxes as a concrete tool that staff can use to engage in frequent, often short but meaningful conversations, despite a person’s cognitive impairment (Hagens, Beaman, & Ryan, in press). The materials in the Remembering Box, as well as the ongoing conversations, increase the caregivers’ knowledge of and comfort with the individual, thereby activating the positive-feedback loop of communication outlined by the Communication Enhancement Model (Ryan et al., 1995).

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The objects and stories that were collected from family members for the Remembering Boxes have offered interesting information about the residents to staff and visitors. Staff have found that using the Remembering Box during conversations has increased the likelihood of the older person elaborating on topics in response to questions. Residents who had typically exhibited withdrawn, dependent behaviour during conversations took some control of interactions with the aid of their Remembering Boxes. The meaningful items in the box have also been used by staff to calm an agitated resident or to spark a conversation in the night when a particular resident was unable to sleep. Thus, the information contained in the box broadens the repertoires of questions that can be asked by caregivers, eliciting richer responses from the person with dementia. Meaning-rich responses deepen conversations, further augmenting the caregivers’ knowledge, and they leave the older person feeling increasingly competent, valued, and connected to life. Lucy Tailor’s Story. Biographical stories can be an important resource for providing care in a long-term facility. As outlined above, enabling the resident to share life stories and experiences in the form of a biography is one way to help the resident and caregiver establish a relationship of meaning and purpose, making the resident’s capacity clearer to the caregiver. An example is the case of Lucy Tailor, pseudonym for a resident of Shalom Village Nursing Home, a Jewish home for the aged in Hamilton, Ontario, which is affiliated with McMaster University as a teaching nursing home. Mrs. Tailor’s dementia experience was fraught with fear and anxiety. She sought comfort through an active search for her mother, someone with whom she had had a close and deeply satisfying relationship as a young child. Mrs. Tailor would often become inconsolable while searching for her “Mother.” The staff recognized that the search for “Mother” was symbolic, and that while the search would never result in “Mother ” in the material sense, a biography might recapture the “essence” of “Mother.” Staff members at Shalom began recording a biographical account of Mrs. Tailor’s mother as a result of conversations with her during calmer moments. She described her mother’s physical characteristics (beautiful, thick, curly, raven-black hair), her dreams and inspirations (coming to Canada from Hungary as an immigrant), her worries (being separated from her husband when he immigrated to Canada to prepare the way for the family, and caring for the needs of four children), her feelings for her mother (she was my “dear heart”), her

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mother’s pet name (Charnala), and how others saw her (a wise, respected woman whose advice was sought by others in the village). The fragments of Mrs. Tailor ’s mother ’s biography were pieced together like a beautiful quilt (see Jones, 1999; Moore & Davis, 2002; Shenk, Davis, Peacock, & Moore, 2002). The biography was read to her during those moments when she was inconsolable and seeking out “Mother” in an agitated fashion. The story was available to all members of the clinical team caring for her, and was used frequently with success. She would usually become immediately engaged by the story, and add new “threads” to it. She was often given a printed copy of the story to carry with her. This intervention was very helpful in affirming something that had deep and profound meaning. Her mother was given back to her symbolically through the reading of the story, and this gave her great spiritual comfort. It also assisted the staff members caring for Mrs. Tailor to stop feeling helpless in the face of her agitation. Reading the biography aloud was a simple, accessible, and effective way for the staff to connect with her and to feel that they had contributed to her positive memories and her self-affirming life story. It is important that staff be given concrete, practical, and creative tools with which to respond to the resident in spiritual distress. The biographical activity described above can be initiated and implemented by anyone, including family members, and disseminated for use by all members of a clinical team. In addition, pastoral care workers who are visiting with congregants either in their own homes or in a nursing home could use a biographical story to offer comfort and to reconnect people to significant stories that represent their life journey.

Facilitating Religious Participation Pastoral care for persons with dementia involves making an interpersonal spiritual connection through an emotional and symbolic plane. O’Connor (1992) suggests that the spiritual care for the person with dementia can facilitate a balance between the elements of Erikson’s developmental stage of integrity and despair (see Erikson, Erikson, & Kivnick, 1989). The pastoral care worker enters the individual’s world, working in the here and now to mirror affective behaviour, thereby creating a bond. The focus of pastoral care becomes presence and being, rather than progress and doing. The reciprocity of the relationship between pastoral care worker and person with dementia is the key to promoting an interpersonal competence and mastery that, in turn, promotes spiritual well-being.

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Participation in religious life can involve a number of activities. Helping the person with dementia to join in on familiar chants, prayers, and songs can facilitate an experience of the feeling-oriented aspects of spirituality and worship. Richards and Seicol (1991) suggest that pastoral care workers can help the person with dementia maintain a spiritual connection to God through memories, life stories, and sharing in music, prayers, sacraments, symbols, and rituals that are familiar. Clayton (1991) suggests using the metaphorical strength of familiar parables and psalms to assist persons with dementia to discover the meaning behind life events, or to take comfort in particular words and rhythms. Davis (1989), in his autobiographical work that describes his personal experience of living with Alzheimer’s disease, outlines some of the simple, yet profound ways in which congregants and family members helped to ease his wounded spirit. For example, hearing psalms such as Isaiah 43:2, “Should you pass through the sea, I will be with you; or through the rivers, they will not swallow you up,” gave him great comfort (The Jerusalem Bible). The abilities of even the most severely affected individuals to experience God must not be underestimated. For example, individuals who are disoriented, in respect to person, place, and time have frequently been seen participating positively in the singing of hymns, reciting parts of well-known prayers, or performing ritual gestures during religious services, as well as having an uncanny sense of when it is the Lord’s Day. The work of McFadden and Hanusa (1998) suggests that spirituality and meaning in the nursing home is co-created through the dynamic reciprocal relationship between the staff and the residents. They recommend that nursing assistants be taught to interpret their everyday duties as the means through which residents find meaning in the events of day-to-day life and connect to what is holy. This interpersonal relationship contributes to everyday spirituality in the nursing home. Everett (1996), a chaplain in a long-term care facility in Alberta, suggests that even the most severely affected individuals can experience God’s presence through sensory experiences of life that are richly symbolic: the aroma of freshly baked bread, the smell of the earth on a crisp autumn day, or the caress of a warm summer breeze not only stimulates the senses but also celebrates and honours the relationship with God and the universe. The pastoral visitor should recognize that spiritual ministry includes taking the person afflicted with dementia to the neighbourhood park or to the courtyard of the nursing home. Sitting quietly while the person enjoys this experience constitutes a ministry of presence.

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It is also important that pastoral care workers look for and recognize the many opportunities available for persons with dementia to experience self-worth, purpose, and hope. Creativity and flexibility can assist the pastoral care workers in fulfilling the needs of the spirit. Shalom Village has undertaken to adapt religious services and all aspects of spiritual life to accommodate those who are cognitively impaired. During Sabbath, memorial services, and high holidays such as Passover, the religious leaders move throughout the congregants, helping them participate in chants and sing familiar religious texts. The written materials read during services have been simplified. Those leading the services are careful to read slowly, using gestures, vocal pitches, and rhythmic speech patterns that bring meaning and comfort to those with dementia. Should a congregant begin to chant out of context, the religious leaders will follow, leading others in the congregation to honour the individual’s contribution to communal worship. Congregants are not prevented from leaving the service if it is clear they need to wander or have momentarily lost interest. They will continue to be welcomed each time they enter the place of worship, which might happen frequently during each service. In other words, behaviours that might be viewed as unacceptable are understood and accommodated. At Shalom Village, family members and volunteers from a variety of congregations in the community assist with the services as well. The high number of spiritual facilitators ensures that nursing home residents will have their needs met quickly, for example, being given help turning pages in religious texts or simply being offered fellowship or reassurance during the service. It also enables those persons with dementia to participate actively in parts of the religious service where they typically would not be engaged. For example, pastoral care workers and volunteers have stood with persons with dementia at the front of the congregation in a place of honour as the religious script is read, representing their participation “by proxy.” Spiritual life can be enhanced when the pace and focus of the religious service is adapted to encourage participation by all members of the congregation, including those who are cognitively impaired. CONCLUSION

Building upon and facilitating the use of enduring abilities among individuals with dementia can help them meet a variety of spiritual needs. Spirituality is based on a relationship of honourable reciprocity between the person with dementia and her/his caregivers

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(McCurdy, 1998). Pastoral care workers, community religious leaders, family, volunteers, and professional care providers all have a role to play in enhancing spiritual well-being in persons with dementia. Participation in activities, ranging from the religious to the most ordinary daily-care tasks, engage the person with dementia, thus maintaining a spiritual connection to what is “holy.” When caregivers learn to affirm the personhood of individuals with dementia, they are better able to help individuals reconnect with their sense of self, and with others, their environment, and their God. Moreover, pastoral care workers and other caregivers can also benefit spiritually from establishing a relationship that is often deeper than words and more focused on the present moment. Educational programs that enhance nurturing skills in professional caregivers of people with dementia can decrease their own stress and increase their overall well-being (Bell & Troxel, 1997; Kaplan & Hoffman, 1998). Caregivers can foster spiritual well-being by helping persons with dementia exercise every opportunity to engage in activities that have symbolic meaning, thereby making them feel valued and cherished. It is true that sharing a hug or a smile, swaying to the beat of music, or savouring a meal are simple interactions. However, these are profound ways for caregivers to ensure that persons with dementia continue to feel accompanied on their journey through life, while refreshing their own spirit. To paraphrase the introductory poem, You shine the sun of your listening upon me, and Our spirits blossom. ACKNOWLEDGEMENTS

Reprinted with permission from The Journal of Pastoral Care & Counseling, 59 (1–2, spring/summer 2005), 43–55. The authors gratefully acknowledge the financial support of the Social Sciences and Humanities Research Council of Canada and the assistance of Ann Anas and Hendrika Spykerman. REFERENCES Baltes, M., Neumann, E., & Zank, S. (1994). Maintenance and rehabilitation of independence in old age: An intervention program for staff. Psychology and Aging, 9, 179–88. Bell, V., & Troxel, D. (1997). The best friends approach to Alzheimer’s care. Baltimore, MD: Health Professions.

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Bourgeois, M.S. (1990). Enhancing conversation skills in patients with Alzheimer’s disease using a prosthetic memory aid. Journal of Applied Behavioral Analysis, 23, 29–42. Bourgeois, M. (2002). Where is my wife and when am I going home? The challenge of communicating with persons with dementia. Alzheimer Care Quarterly, 3, 132–44. Burgio, L.D., Allen-Burge, R., Roth, D.L., Bourgeois, M.S., Dijkstra, K., Gerstle, J., et al. (2001). Come talk with me: Improving communication between nursing assistants and nursing home residents during care routines. The Gerontologist, 41, 449–60. Canadian Study of Health and Aging Working Group. (1994). Canadian study of health and aging: Study methods and prevalence of dementia. Canadian Medical Association Journal, 150, 899–913. Clark, P.G. (1996). Communication between provider and patient: Values, biography, and empowerment in clinical practice. Ageing and Society, 16, 747–74. Clayton, J. (1991). Let there be life: An approach to worship with Alzheimer’s patients and their families. Journal of Pastoral Care, 45, 177–78. Cole, E. (1999). Still a person. In J. Ellor, S. McFadden, & S. Sapp (Eds.), Aging and spirituality (pp. 101–106). San Francisco, CA: American Society on Aging. Davis, R. (1989). My journey into Alzheimer’s disease. Wheaton, IL: Tyndale House. Dawson, P., Wells, D.L., & Kline, K. (1993). Enhancing the abilities of persons with Alzheimer’s and related dementias. New York: Springer. Ellor, J.W. (1999). Spiritual well-being defined. In J. Ellor, S. McFadden, & S. Sapp (Eds.), Aging and spirituality (pp. 40–43). San Francisco, CA: American Society on Aging. Erikson, E.H., Erikson, J.M., & Kivnick, H.Q. (1989). Vital involvements in old age. New York: W.W. Norton. Everett, D. (1996). Forget me not. Edmonton, AB: Inkwell. Goldsmith, M. (1996). Hearing the voice of people with dementia. London: Jessica Kingsley. Hagens, C., Beaman, A., & Ryan, E.B. (2003). Reminiscing, poetry writing, and remembering boxes: Personhood-centered communication with cognitively impaired older adults. Activities, Adaptation, and Aging, 27, 97–112. Harrison, C. (1993). Personhood, dementia, and the integrity of a life. Canadian Journal on Aging, 12, 428–40. Hepburn, K.W., Caron, W., Luptak, M., Ostwald, S., Grant, L., & Keenan, J.M. (1997). The Family Stories Workshop: Stories for those who cannot remember. The Gerontologist, 37, 827–32. Hoffman, S., & Platt, C. (1990). Comforting the confused. New York: Springer. Jones, J. (1999). A life-cycle approach to ministry with the aging. Journal of Pastoral Care, 53, 323–31. Kaplan, M., & Hoffman, S.B. (Eds.). (1998). Behaviors in dementia. Baltimore, MD: Health Professions. Kitwood, T. (1997). Dementia reconsidered. Philadelphia, PA: Open University Press. Kitwood T., & Bredin, K. (1992). Towards a theory of dementia care: Personhood and well-being. Ageing and Society, 12, 268–87.

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Lubinski, R. (Ed.). (1995). Dementia and communication. San Diego, CA: Singular. McCallion, P., Toseland, R.W., Lacey, D., & Banks, S. (1999). Educating nursing assistants to communicate more effectively with nursing home residents with dementia. The Gerontologist, 39, 546–58. McCurdy, D.B. (1998). Personhood, spirituality, and hope in the care of human beings with dementia. The Journal of Clinical Ethics, 9, 81–91. McFadden, S.H., & Hanusa, M. (1998). Nourishing the spirit in long-term care: Perspectives of residents and nursing assistants on sources of meaning in residents’ lives. Journal of Religious Gerontology, 10 (4), 9–26. McWilliam, C., Brown, J., Carmichael, J., & Lehman, J. (1994). A new perspective on threatened autonomy in elderly persons: The disempowering process. Social Sciences and Medicine, 38, 327–38. Moore, L., & Davis, B. (2002). Quilting narrative: Using repetition techniques to help elderly communicators. Geriatric Nursing, 23, 262–66. Norberg, A. (2001). Communication in the care of people with severe dementia. In M.L. Hummert & J.F. Nussbaum (Eds.), Aging, health and communication (pp. 157–75). Mahwah, NJ: Erlbaum. O’Connor, T. (1992). Ministry without a future: A pastoral care approach to patients with senile dementia. Journal of Pastoral Care, 46 (1), 5–12. Orange, J.B., & Ryan, E.B. (2000). Alzheimer’s disease and other dementias and patient-physician communication. In R.D. Adelman & M.G. Greene (Eds.), Communication between older patients and their physicians. London: W.B. Saunders. (Reprinted from Clinics in Geriatric Medicine, 16, 153–75.) Randall, W.L., & Kenyon, G.M. (2000). Ordinary wisdom. Westport, CT: Praeger. Rau, M.T. (1993). Coping with communication challenges in Alzheimer’s disease. San Diego, CA: Singular. Richards, M., & Seicol, S. (1991). The challenge of maintaining spiritual connectedness for persons institutionalized with dementia. Journal of Religious Gerontology, 7 (3), 27–40. Ripich, D.N. (1991). Language and communication in dementia. In D.N. Ripich (Ed.), Handbook of geriatric communication disorders (pp. 255–84). Austin, TX: PRO-ED. Ryan, E.B., Giles, H., Bartolucci, G., & Henwood, K. (1986). Psycholinguistic and social psychological components of communication by and with older adults. Language and Communication, 6 (1), 1–24. Ryan E.B., Meredith, S., MacLean, M.J., & Orange, J.B. (1995). Changing the way we talk with elders: Promoting health using the Communication Enhancement Model. International Journal of Aging and Human Development, 41, 89–107. Ryan, E.B., Pearce, K.A., Anas, A.P., & Norris, J.E. (in press). Writing a connection: Intergenerational communication through stories. In M.W. Pratt & B.H. Fiese (Eds.), Family stories and the life course. Mahwah, NJ: Erlbaum. Rybarczyk, B., & Bellg, A. (1997). Listening to life stories. New York: Springer. Sabat, S., & Harre, R. (1992). The construction and deconstruction of self in Alzheimer’s disease. Ageing and Society, 12, 443–61. Santo Pietro, M.J., & Ostuni, E. (2003). Successful communication with persons with Alzheimer’s disease, (2d ed.). St. Louis, MO: Butterworth-Heinemann.

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Shenk, D., Davis, B., Peacock, J.R., & Moore, L. (2002). Narratives and self-identity in later life: Two rural American older women. Journal of Aging Studies, 16, 401–13. Souren, L., & Franssen, E. (1993). Broken connections: Alzheimer’s disease: Part II— Practical guidelines for caring for the Alzheimer’s patient. Berwyn, PA: Swets and Zeitlinger. Thorsheim, H., & Roberts, B. (2000). I remember when. Forest Knolls, CA: Elder Books. Usita, P.M., Hyman, I.E., Jr., & Herman, K.C. (1998). Narrative intentions: Listening to life stories in Alzheimer’s Disease. Journal of Aging Studies, 12, 185–97.


8 Spirituality and Addiction Lori Edey

THE PROBLEM

As a society, we are seeing the increasing polarization of working hours. On average, full-time employees are working more hours and part-time employees are working fewer (Canadian Council for Social Development, 1999). Many people are working more hours per week than they did in the latter part of the twentieth century, in spite of the many technical advances that promised to make life easier and provide more leisure. It is interesting to notice how the self-help books and magazine covers of the 1990s have moved into the new millennium reflecting a desire for even more simplicity! A Statistics Canada study has also linked longer working hours with increased health risks, illustrating how one addictive behaviour can lead to another. Women who work longer hours are more than four times as likely to increase the amount they smoke as women who work shorter hours. They are twice as likely to increase their rate of alcohol consumption, and 40 percent more likely to decrease their level of physical activity and to experience an unhealthy weight gain (GPI Atlantic, 2002). These observations of human nature have led many to conclude that all people in the Western world are addicts (Miller, 1987). Others have spoken to the theological nature of addiction. Undoubtedly, our creation as human beings includes components of temptation and attachment (May, 1988, p. 91). Therefore, understanding the nature of addiction is difficult because it is impossible for clinicians to detach from the impact of addiction in their own lives when addressing addiction’s

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impact in the lives of their clients. In order to provide spiritual care to those who suffer from addiction, clinicians must continually reflect on their own lives as well on the lives of their clients. This chapter contributes to this broad and complex discussion. Peter VanKatwyk articulates the magnitude of the concept of spiritual care: The term spiritual care is made up of two impossible words: each simultaneously connecting persons to, and disconnecting them from, their lives in the world. The idea of caring is simple enough yet overwhelming in its implications: feeling responsible not only to take care of one’s own life but also to care about what happens in the lives of others and in the life of the world….Similarly, the term spiritual connotes a concept that seems to both place and displace humans in the world of daily living. (VanKatwyk, 2001, pp. 126–27)

The difficulties implicit here are exponentially increased when considering the spiritual care of an addicted person or system. Recovery at the spiritual level involves an ongoing process that simultaneously defines individuals as having clear boundaries, yet interconnecting with others. Murray Bowen’s concept of family systems offers another way of understanding this paradox: individuals must engage in the process of becoming differentiated so that they can balance their experiences of individuality and togetherness (Bowen, 1985). The clinician joins the system when he/she engages with the addicted client.

Addressing the Problem Spirituality cannot be spoken of without referring to one’s relationship with self, others, or a power greater than oneself (often referred to as “God”). The basic text in Alcoholics Anonymous (1976) states clearly that a spiritual foundation is fundamental to a meaningful recovery from chemical dependency. Therefore, this chapter begins by describing a therapeutic relationship model that is based on an understanding of a spirituality that honours the relational and systemic nature of addiction and recovery. After developing the therapeutic model, I discuss the nature of addiction to demonstrate how it relates to spirituality in recovery. Both practical and philosophical suggestions for appropriate spiritual interventions in the treatment of addicted clients are offered. When the clinician engages with another in treatment, he/she becomes part of a system. When clinicians work as part of a team pro-

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viding care, each member of the team becomes part of a system. When a clinician works within institutions, professional colleges, and community contexts, each individual clinician is part of each of those systems. Therefore, to work with addicted clients is to become engaged with an addicted system. This complexity deserves respect and attention. Furthermore, it requires an acknowledgement that individuals are never fully “recovered”; rather, clients and clinicians alike engage in the “process of recovery.” However one understands one’s own addiction, it is helpful to see and embrace that part of oneself when caring for addicts. The image of the fellow journeyer upon this road to spiritual awareness /wholeness/salvation/serenity/health becomes more real when clinicians are able to do this. Their care is more likely to offer healing and hope and to possess greater theological integrity. The spiritual care of addicts from a Christian faith perspective calls on the caregiver to engage with others as Christ did. The Christian faith perspective is the one I have chosen to reflect my theological orientation. Hopefully, it will encourage readers to reflect theologically upon the relationship between their own faith orientation and the spiritual care they provide to others. Such reflection engenders both stability and accountability in their caregiving. Just as God became present in human existence through the person of Christ, clinicians need to embrace their humanity in order to provide incarnational ministry and care to the addicted people and systems upon whom they are called to serve. Clinically, this relational approach gives the clinician a better chance of developing and maintaining a therapeutic alliance that encourages healing. A THERAPEUTIC RELATIONSHIP TRIANGLE: YOUR STORY, MY STORY, GOD’S STORY

Therapeutic relationships can happen only in dialogue between individuals and those with whom they form relationships in order to respect the holy ground upon which the relationship is called into being. This is in keeping with Martin Buber’s “I–Thou”stance (1958). When clinicians and clients are mindful of the holy ground, they are aware of a power greater than either of them that is part of the relationship. Thus, the relationship becomes an expression of both the client’s and the clinician’s spirituality. The model that grows from these assumptions is reflected in the therapeutic relationship triangle, “My Story, Your Story, God’s Story”

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(see figure 1). “My Story” refers to the life experience and self-awareness of the person using the model, in this case, the clinician. “Your Story” refers to the experiences and ways of understanding the life of the “other,” in this case, the client. (Sometimes, “Your Story” may refer to the collective or institutional life, for example, a hospital, church, family, or community organization.) “God’s Story” refers to the values held by the individual (either the client or the clinician). Sometimes “God’s Story” is represented by a collective body of values, for example, in the case of a religious or other institutional mission. Finding a dynamic balance among these three parts opens up the possibility of a spiritual foundation being built into the relationship—whether it is personal or professional. This model also provides the foundation for a therapeutic relationship. Figure 1: A Therapeutic Relationship Triangle

Currently, emphasis is being placed on the importance of narrative therapy as a significant component of healing (Frank, 1998; Wear & Castellani, 1999; Back & Arnold, 2000; Greenhalgh & Hurwitz, 1998; Charon, 2001; McWhinney, 1998). Kurtz and Ketcham write that “stories are the vehicle that moves metaphor and image into experience” (1992, p. 17). Acknowledging the systemic nature of a healing relationship, this triangle honours the traditional stories of old and allows space for the creation of new stories. Commitment to such a spiritual foundation constitutes a place for accountability and challenge, support and nurture on both personal and professional levels. Clinicians must continually visit and revisit their

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own story (i.e., “My Story”), thereby increasing their self-awareness as to how one’s own story affects others, which is reflected in the lines that join “My Story” to “Your Story” and to “God’s Story” in the triangle. For example, if clinicians recognize that the alcoholics with whom they are engaging therapeutically remind them of their brother or first husband or cousin or next-door neighbour, those stories of their lives will significantly affect the relationship they have with their clients. (The nature of how that works is fodder for another discussion!) A commitment to hearing “Your Story” allows the other to separate from his/her “My Story.” After being present to witness the story of the other, the model invites the listener to reflect upon how one’s own story interfaces with the other’s story. This identification is illustrated by the line that joins “My Story” to “Your Story.” This model is applicable whether or not the “you” is singular, representing a relationship between two individuals, or plural, representing a relationship between an individual and an institution, agency, or group. After hearing that “Your Story” is separate from “My Story,” clinicians must then listen for the values, attitudes, and assumptions that could be illuminated in the client’s “God’s Story,” indicated by the line that joins “Your Story” to “God’s Story.” Say, for example, that your current client is a father who doesn’t have any sense of his life’s direction. He has recently been downsized at work, is suffering from the breakup of his relationship, and is afraid of not being able to support his children. The “God’s Story” for this client may be reflected in the values of having a job that gives him self-esteem and an opportunity to contribute meaningfully to the world. It could include a desire to provide his children with a security that he enjoyed as a child, and may lead him to believe that he is a poor role model and would be more helpful to his children if he disappeared from their lives. The use of alcohol may remove these feelings of inadequacy that overwhelm him as he thinks about the father he wanted to be for his children and the father he sees himself as being. The clinician’s own “God’s Story” could reflect that he, too, bases his self-worth and how valued he is to his children by taking into account his daily presence in their life and whether or not he is able to provide for them with the economic fervour he intended. Clinicians need to be clear about how their values are similar to those of their clients, and how they differ. Being clear about “God’s Story”—the ability to articulate and claim one’s own values—comes from ongoing reflection that teaches us how to discern these differences. This reflection can take many forms, includ-

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ing prayer or meditation, with or without a structure. One example of structured reflection is offered by Wayne Muller ’s (1997) four simple questions that are intended to “reveal the beauty and meaning of our lives”: Who Am I? What do I love? How do I want to live knowing I will die? What is my gift to the family of creation? As individuals listen to a greater number of “Your Stories,” their own “God’s Story” is enriched. This is as true for the client as it is for the clinician. The more this model of therapeutic relationship is used in various medical and clinical contexts, the more apparent it is that most people can recognize which elements of the triangle are most familiar and comfortable for them and which may be more difficult to access. There are a number of ways to enhance both the comfort and access levels in this model. Activities such as journalling, systematic identification of feelings, enhancing sensual awareness, and renewed focus on self-care strategies can strengthen the “My Story” component. “Your Story” can become stronger through reflecting upon valued relationships in the past or present, finding and nurturing relationships with valued individuals or organizations, listening to the stories of others whose lives are different than “My Story,” and enhanced boundary work. Strengthening “God’s Story” may come from prayer, meditation, spiritual readings, music, developing and nurturing a variety of images of God, or finding and engaging with a community of people who share similar values. Some people find that they need to actually change the name of this point in the triangle in order to separate their understanding of spirituality from prior religious wounds or indifference (Edey, 2002). Religion and religious understandings of the holy, referred to as “God,” may enhance some people’s understanding of their values, offering both support and direction. However, others’ experience of religion may be destructive to their understanding of spirituality and “God’s Story.” Those for whom religion is helpful are encouraged to use it as a tool—in addition to other tools—to enhance their awareness of this point on the triangle. Those for whom religion is unhelpful or destructive are encouraged to separate that experience so that they are able to identify their values unfettered by this discussion. Many addicts choose to tangentially focus on this argument so as to take away attention from the task at hand. This is part of the disease. Providing clear boundaries and permission to separate the concepts are important clinical interventions. Sometimes, after engaging their understanding of “God’s Story,” people in recovery return to religious practice or are attracted to it in new ways. It is important to note, however, that religious behaviour without

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spiritual underpinnings could become be an addiction unto itself (Booth, 1991). Engaging the therapeutic relationship with this model in mind deepens and enriches the whole system as each of its parts becomes healthier. WHAT IS ADDICTION?

There are many definitions of addiction, ranging from being a moral problem to a medical illness. It is significant to note that in the latest version of the widely used and accepted American Psychiatric Association’s (2000) Diagnostic and Statistical Manual of Mental Disorders (DSMIV), addiction is included as an illness. In describing the criteria for substance-related disorders, the DSM-IV (Behavioral Criteria 3–7) differentiates between addiction, tolerance, and dependence, defining addiction as (1) a preoccupation with acquiring alcohol and drugs; (2) compulsive use (continued use despite adverse consequences from alcohol and drugs); and (3) a pattern of relapse to alcohol and drugs over time, despite the reinstitution of adverse consequences. Although these criteria are meant only to speak of a person’s use of substances, the same descriptors can be used to describe some people’s use of behaviours. Someone who gambles, is a compulsive overeater, sex addict, or workaholic, who continues these behaviours in spite of their adverse consequences, and who repeats the same behaviour expecting a different outcome, can also be considered as being “addicted.” These behaviours are often referred to as process addictions (Schneider & Irons, 1997, p. 225). Therefore, as the introductory discussion suggests, there are no limits to the variety of external influences to which one can be addicted. Generally, these influences are grouped into two categories: chemicals (including alcohol, nicotine, and prescription and street drugs) and behaviours (including gambling, work, sex, relationships, religious activity, compulsive overeating, etc.) Although these addictions clearly manifest themselves in different ways, the use of chemicals or expressing negative behaviours is often referred to as one of the symptoms of addiction. WORKING WITH DENIAL

In addition to the use of drugs or reliance on adverse behaviours, another symptom of addiction is denial, often presenting itself as minimization and rationalization (Miller, Gold, & Smith, 1997). Minimization can be expressed as “I only drink with others, so I’m not an alcoholic,” or “I only use prescription drugs, so I’m not really an addict.”

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Rationalization can include such statements as “If I didn’t have such a stressful job, I wouldn’t need to blow off steam so regularly. Everybody needs to let down and I do it at the casino.” Or, “If I was really appreciated at home, I wouldn’t need to seek excitement elsewhere. Besides, what’s it going to hurt? She’ll never know.” Despite the symptom of denial being present, it is helpful if the clinician does not label a client an “addict.” This is not a malicious or intentional oversight, in spite of the fact that some clinicians become angry and frustrated that a client does not easily claim the label of “alcoholic” or “addict.” (This is another example of how the clinician’s “My Story” can influence the therapeutic relationship.) Sometimes, clients do not know or admit that they are addicts because they are in a state of “denial.” At other times, clients have become so disconnected from others as their disease has progressed that they deeply fear the intimacy of being so clearly understood that another might get to know their “story”: “If you really knew me, would you love me?” might be their underlying fear. Paradoxically, this is the very thing for which they yearn. Waiting until the client is ready to claim the label “addict” or “alcoholic” as part of his/her “My Story” (or the clinician’s “Your Story”) is one way of honouring the therapeutic values of dignity and respect for the person. (These values are elements of the clinician’s “God’s Story” and “My Story,” and are thereby reflected in the line joining these two points on the triangle.) When a clinician assesses a client for addiction, it is important to use objective tools in order to maintain a therapeutic alliance rather than create a power struggle. Some of these include simple screening instruments like the CAGE (Kahan & Wilson, 2002, p. 11), an acronym for the four key traits or symptoms presented in the four questions the client is asked: C: Have you ever tried to CUT DOWN or CONTROL your drug or behaviour of choice? A: Do you feel ANGRY when others comment about it? G: Do you feel GUILTY regarding your use or consequence of using? E: Have you ever had a morning EYE OPENER?

Other valid screening instruments include the Michigan Alcohol Screening Test (MAST) or the Drug Abuse Screening Test (DAST) (available online at www.ncadd-svf.org/symptoms/mast_test.html and www.schick-shadel.com/drug-test.html). Both of these instruments are

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designed to be self-administered by the client. The questions allow clinicians to discuss the consequences of drug use choice with clients. Another option is to use the “working definitions” as suggested by the DSM-IV. The clinician may invite the client to reflect upon his/her own behaviour or chemical use, thus seeking help from the therapeutic alliance that will result in a shared understanding of the role of addiction in the client’s life. These working definitions are (1) persistent behaviour (or chemical use) in spite of negative consequences, and (2) repeating the same behaviour (or chemical use), expecting a different result. Using all of these methods promotes a therapeutic alliance between the client and clinician because they are working on the same “side” as they explore the client’s life together. These methods derail attempts by the client to “prove” to the clinician that he/she is not an addict because he/she does not have many of the mythical behaviours associated with addiction. For example, clients may say, “I’m not an alcoholic because I never drink alone,” “I’m not an addict because I never miss a day’s work,” or “I’m not an alcoholic because I don’t get hung over.” If the clinician were to say to the client something like: “I’m not sure whether or not you are an addict, but there are a couple of working definitions that people have used that might help us explore the place of addiction in your life,” the client might recognize that his/her friends have changed over the years, because those who nag him/her about his/her alcohol use have made way for those who drink just as much. He/she might also recognize that he/she has been passed over for a promotion at work and doesn’t feel as “into it” as he/she once did. The client might acknowledge that although he/she doesn’t “waste time” with hangovers, he/she spends a great deal of time planning the next party and social engagement and no longer has any interest in his/her old hobbies. Whether the beginning stages of the therapeutic relationship involve sharing stories from an individual or group of individuals, the invitation to reflect upon various areas of the clients’ lives—work, home, relationships, finances, legal status, group affiliations—often helps clients discover and claim the ways in which they repeat their behaviours in spite of negative consequences or because they expect different results. Whether or not this leads to an adoption of the label “addict” is not important. Rather, it provides the clients with an avenue they can use to explore the values in their lives—that is, their “God’s Story.”

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THE DISEASE MODEL

Some argue that addiction is a moral problem, believing that to acknowledge it as a disease would take away the sense of responsibility from the individual. Addicts would simply blame their behaviours and consequences of using their behaviours or drugs of choice on “their disease.” Recovery treatment for these people is often manifested in such admonitions as “just stop” or “pull yourself up by the bootstraps,” suggesting that recovery from addiction is a matter of self-control. As discussed above, the publication of an actual diagnosis in the DSM-IV has evoked a general acceptance among members of the medical community that addiction is a disease. As in many other medical situations, individuals are responsible for complying with treatment after being diagnosed with the disease of addiction without being responsible for having the disease in the first place. Addicts are no more responsible for having this disease than diabetics are responsible for having diabetes. However, both diabetics and addicts have the responsibility of making the decision to seek out and comply with appropriate treatment. The disease of addiction is progressive, chronic, and fatal. The following model (figure 2) illustrates its progressive nature through the addiction’s physical, mental, and spiritual dimensions. Just as the disease is progressive, so is recovery. The left side of the diagram describes the disease’s progression, or relapse after entering a period of recovery; the right side follows the journey of recovery. Figure 2: The Progressive Nature of the Disease of Addiction

Once clients accept the diagnosis of addiction, the physical use of drugs or reliance on behaviours needs to be addressed and a treatment found. In the case of chemicals, this usually means total abstinence from the drug of choice. (The term “drug of choice” is used through this chapter to include alcohol since alcohol is a drug.) Sometimes this involves the administration of another drug to achieve medically safe detoxifica-

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tion. Treatment interventions vary depending on the drug or behaviour of choice. For alcohol or drug addiction, physical intervention needs to be administered under the care of a qualified physician. Behaviourally, this physical intervention usually means structuring and defining appropriate use. For example, people suffering from compulsive overeating cannot simply abstain from food. However, making a list of chosen foods and sticking to it may be the physical intervention. Sex addicts may choose to abstain from sexual relations with anyone other than their own partners as a “bottom line,” thereby addressing the physical manifestation of this addiction. Once the physical intervention takes place, clients often recognize some manifestation of the mental aspects of the disease. These are often irrational thinking patterns that include rationalization and minimization: “I only drank on weekends!” “I never use alone.” “I never bought the stuff myself.” “Everyone used.” At this stage of recovery, cognitive behavioural interventions are often helpful. When addicts recognize the gaps between the mental distortions under which they live and the values they hold, a tremendous amount of guilt is often evoked: “I can’t believe that I actually thought my boss would buy my excuse about the traffic jam so many times when I was late to work.” “I’m so ashamed that I can’t even remember what grades my kids are in.” Such statements speak to the spiritual dimension of the disease, which is the foundation to recovery. That is, individuals recognize that as their disease progresses, they begin to separate from the things they value. Consider the example of Roger Snowden, a busy physician who struggles between his commitments to patients and his desire to be engaged in family life. He finds that his workload consistently increases and he is home less and less. The guilt he feels when going home is increased as he sees the disappointment in his son’s eyes because he missed yet another hockey game; as he hears the frustration in his partner’s voice as she laments that he missed yet another time when he was scheduled to drive and she had to fill in; as he feels the disconnection of his daughter’s presence because she is always reading a book. The shame of feeling like such a rotten husband and father is almost too much to bear. He recognizes that he is separating from his values (his “God’s Story”) in three dimensions: 1. Within himself—he no longer sees the behaviours he would ascribe to being a “good husband and father ” reflected in his own behaviour.

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2. With others—lately, it seems that the most common interaction between him and his wife is arguing, and he seems to have lost touch with the kids and their lives (other than the fact that he is always supposed to be driving them somewhere). 3. With his sense of purpose and direction—he is trying to be a good doctor and trying to be a good family man. How can he do both when they each demand so much? It seems that these days he is good at neither one of them. These are the symptoms of spiritual disease. Roger becomes increasingly isolated from his personal values, his connection with others, and his sense of purpose and direction (see figure 3). Figure 3: The Dimensions of Spirituality

Roger begins to feel quite defensive and has no trouble reminding his family that if it weren’t for his hard work and good income, there wouldn’t be such great hockey equipment or such a comfortable house or the wonderful holiday they had last summer…or was it two summers ago? Increased guilt and shame leads to more mental gymnastics. He rationalizes, minimizes, and blames others for the state in which he finds himself. After pouring himself a drink, he discovers that the pain is dulled. This intervention offers relief and is therefore repeated. As he becomes physically addicted to alcohol, he becomes more creative in justifying using it: “If we weren’t so underserviced in medicine, I would have more time to spend with the family. They just don’t understand the pressure on me and why I need a few drinks to unwind.” Or “I put in a

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good day’s work. I deserve to have a reward at the end of the day.” Or “I can’t sleep without it and I need my sleep to function the next day.” Inevitably, these mental gymnastics lead to further alienation and isolation, and Roger discovers he has not only one addiction, work, but now he has another, alcohol. Recovery for Roger begins with physical interventions: stopping the use of alcohol altogether (with medical detoxification if necessary), and finding a “bottom line” for his behavioural work addiction. This may involve a complete leave of absence for a period of time, with a modified re-entry as his recovery journey progresses. Support during this time is crucial. This may take the form of residential or outpatient treatment, depending on how long Roger has had these addictive behaviours and the severity of their consequences. The support offered from residential treatment provides a relatively safe environment but, more important, a community of people who suffer from the same disease. Roger can participate in such a community through a twelve-step program or support group as an outpatient or an in-patient. This community becomes something outside Roger that is a power greater than himself. If Roger were to simply stop drinking and working compulsively, he would only address the physical part of the disease. A common maxim among alcoholics is that the disease is 20 percent alcohol and 80 percent “ism,” which speaks to the lifestyle changes that are required in order to develop a solid recovery. As Roger ’s physical symptoms diminish, he inevitably sees more clearly how his behaviours and their consequences have affected his life and those around him. He is likely to feel bad about the ways in which he has hurt himself and others about whom he cares in both his personal and professional life. Again, the support of a community—a power greater than himself—allows Roger to experience acceptance and care in spite of what his behaviours have cost him and others. The clinician is an important part of this community, providing that incarnational presence through the therapeutic relationship triangle. The line joining the client’s “My Story” and “God’s Story” represents this incarnational relationship. Each time Roger chooses to share with another person (a clinician, a fellow peer in recovery, or a significant person in his life), he makes a connection, thereby breaking out of the isolation that characterized the spiritual part of his disease. His confidence grows as he is more able to live out of those spiritual values that embody his “God’s Story.” Only after living out of this part of himself for a period of time is Roger

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encouraged to look into the past. His experiences of being loved unconditionally in the present become the foundation upon which he can best understand ways that the disease manifested itself in the past. This foundation is often not built solidly enough, as the recovering addict is anxious to “clear away the wreckage of his/her past” (Alcoholics Anonymous, 1976, chapter 5). However, a solid foundation can be maintained through daily spiritual reflection and opens up ways to do further spiritual work: giving and receiving forgiveness, completing unfinished grief work, and developing a new way of life that is based on living more consistently out of one’s values (“God’s Story”). The process described in the twelvestep programs offers a structure for those just beginning and wisdom from those who have achieved a solid recovery. It is important to note that recovery is lifelong work; one is never “recovered.” Alcoholics Anonymous talks about this as “progress, not perfection” (Alcoholics Anonymous, 1976, p. 60). This new way of life, based on a healthy spirituality, offers the addict many different ways to keep the addiction in check, just as monitoring insulin levels can help a diabetic keep the diabetes in check. The fruit of such recovery is often reflected in a commonly heard statement: “I’m grateful that I have this disease. It has provided me with a new peaceful way of life I would never have known otherwise.” For clinicians, the privilege of working with addicts in this way reaps similar rewards, because they are challenged to live with the same kind of integrity they expect from their clients. CONCLUSION

This chapter has touched on the very complex discussion of spiritual care for addicts. After acknowledging the complexity of spiritual care, I attempted to amplify the difficulties by reminding clinicians of the systemic nature of addiction. Therefore, clinicians are not exempt from the throes of this disease in either their personal or professional systems. In caring for this special population, clinicians must be prepared to recognize how this pathology affects them. In order to begin to work with addicts, clinicians must understand that addiction is a disease that plagues most people (including themselves) to some degree. By recognizing their own “stories,” clinicians can see how similar their lives are to their addicted clients’ lives, rather than the differences that separate them. Therapeutic alliances can be based on the values of dignity for other human beings, and on the awareness of self and of “others” as described in the therapeutic triangle.

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Using this basis of treatment, all elements of the system will be changed, including the clinicians. Clinicians working in this area must be prepared to deepen their own self-awareness, recognizing where the disease continues to grow in them and where they live in connectedness with their “God’s Story.” It is this area of clinical work that can provide clinicians and clients alike with opportunities to deepen spiritually, recognizing the fruits of that growth in all areas of their lives. REFERENCES Alcoholics anonymous (3rd ed.). (1976). New York: Alcoholics Anonymous World Services. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Back, A.L., & Arnold, R.M. (2000). End-of-life narratives. Medical Encounter, 15 (3), 1. Booth, L. (1991). When God becomes a drug. Los Angeles, CA: Jeremy P. Tarcher. Bowen, M. (1985). Family therapy in clinical practice. New York: Aronson. Buber, M. (1958). I and thou (2nd rev. ed.). (W. Kaufmann, Trans). New York: Charles Scribner’s Sons. Canadian Council for Social Development. (April 1999). Work, family and community: Key issues and directions for future research. Prepared for the Labour Program Human Resources Development Canada. Charon, R. (2001). Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA, 286, 1897–1902. Edey, L. (2002). Professionalization and physician self-awareness (PPSA). Doctoral dissertation, St. Stephen’s Theological College, Edmonton, AB. Frank, A. (1998). Just listening: Narrative and deep illness. Families, Systems and Health, 16 (3), 197–212. Genuine Progress Index (GPI) Atlantic. (2002). Measuring sustainable development. Atlantic Centre of Excellence for Women’s Health, IWK Health Centre, Halifax, November 27, 2003. Greenhalgh, T., & Hurwitz, B. (1998). Narrative based medicine. London: BMJ. Kahan, M., & Wilson, L. (Eds.). (2002). Managing alcohol, tobacco and other drug problems. Toronto, ON: Centre for Addiction and Mental Health. Kurtz, E., & Ketcham, K. (1992). The spirituality of imperfection. New York: Bantam. Mark, L. (1988). Stairway to serenity. New York: Harper Hazelden. May, G. (1988). Addiction and grace. New York: Harper and Row. McWhinney, I.R. (1998). The physician as healer: The legacy of Michael Balint. In J. Salinsky (Ed.), Proceedings of the Eleventh International Balint Congress, 1999 (pp. 63–71). Miller, K. (1987). Sin. San Francisco, CA: Harper and Row. Miller, N.S., Gold, M.S., & Smith, D.E. (Eds.). (1997). Manual of therapeutics for addictions. New York: John Wiley.

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Muller, W. (1997). How, then, shall we live? New York: Bantam. Schneider, J.P., & Irons, R.R. (1997). Treatment of gambling, eating and sex addictions. In N.S. Miller, M.S. Gold, & D.E. Smith (Eds.), Manual of therapeutics for addictions (pp. 225–45). New York: John Wiley. Wear, D., & Castellani, B. (1999). Conflicting plots and narrative dysfunction in health care. Perspectives in Biology and Medicine, 42 (4), 545–58. VanKatwyk, P. (2001). Reconciliation and forgiveness: A practice of spiritual care. In A. Meier & P. VanKatwyk (Eds.), The challenge of forgiveness (pp. 125–39). Toronto, ON: Novalis.


9 Spirituality in Occupational Therapy Sue Baptiste

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he occupational therapy profession in Canada has been engaged in an active debate for many years concerning the centrality of spirituality as a core construct of practice. If, indeed, occupational therapy is to follow its mission of focusing on an occupation-based mandate within health promotion and health care environments, then it is critical to “take the bull by the horns” and define our terms clearly in order to understand and be able to discuss and explain the central tenets of why we do what we do. The occupational therapy program at McMaster University in Hamilton, Ontario, offers an entry level master ’s program, and has undergone a major curriculum development process over the past five years. The curriculum remains a two-year experience, and is built upon principles of problem-based, learner-centred, self-directed learning. The previous model (based on impairment, disease populations, and developmental stages) has been replaced by a model that reflects the very nature and processes of practice. Consequently, students within the new curriculum are introduced immediately to the underlying theories of occupational therapy practice. They grapple with the current seminal debates within the discipline very early in their professional preparation. Spirituality as the centre of unique meaning in everyone’s life is one of the most critical of those debates. In this chapter, I will outline the history of occupational therapy as a discipline, highlighting the emergence of “spirituality” as a core concept and the evolving definition of “spirit”; provide key definitions of

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occupational therapy and spirituality, from the perspective of Canadian occupational therapists; identify particular elements of the current debate within the discipline; and propose some important questions that need to be addressed. BACKGROUND

The early origins of the importance of meaningful occupation and health, the roots of the occupational therapy profession, can be traced back to ancient Egypt and Greece. These basic concepts and philosophies continued to develop in other parts of the world over many centuries. In Canada, occupations were used as treatment during the nineteenth century; however, occupational therapy as a discipline began to take shape in response to the needs of soldiers wounded in the First World War (Friedland, Robinson, & Cardwell, 2001). From this early stage, the belief existed that the mind, body, and spirit interacted through therapeutic activity and contributed to health and well-being (Health & Welfare Canada, 1983). Because it is rooted in the concepts of social justice, the profession values all individuals as members of the community with the right to participate in meaningful occupations (Townsend, 1993). In its initial development, the profession held these beliefs at its core but, over a number of decades, the influence of reductionism and the medical model changed the direction and focuses of occupational therapy practice (Baum & Christiansen, 1997). In the late 1970s, occupational therapy practitioners in Canada recognized the need to take the focus away from addressing the component parts of people and return it to its humanistic, holistic, occupation-based roots (Health & Welfare Canada, 1983). The document Guidelines for the Client-Centred Practice of Occupational Therapy (1983) resulted from this refocusing. This Canadian approach to the practice of occupational therapy was unique throughout the occupational therapy world in its reinclusion of the spiritual component of the individual. Today, these initial guidelines have developed into the Canadian Association of Occupational Therapists’ publication Enabling Occupation: An Occupational Therapy Perspective (1997), written to provide guidance and leadership in keeping the focus of practice congruent with the profession’s values and beliefs. The Canadian Model of Occupational Performance (CMOP) and the Canadian Occupational Performance Measure (COPM), both stemming from the Enabling document, have gained international recognition for being client-centred and for placing spirituality at the core of their process.

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THE CANADIAN MODEL OF OCCUPATIONAL PERFORMANCE (CMOP)

The Canadian Model of Occupational Performance (CMOP) illustrates the fundamental considerations guiding an occupational therapist in Canada. The model, as represented in figure 1, shows the dynamic relationships between persons, the occupations in which they engage, and the environments within which they function. Figure 1: Canadian Model of Occupational Performance

Source: CAOT (1997), 32.

At the centre of the occupational therapy process is the person, underscoring the strongly client-centred approach to therapy where the client is supported in defining the occupational performance issues to be addressed in partnership with the occupational therapist. The environment surrounds the person, and occupation is emphasized as the element connecting the individual to the environment(s) in which he/she interacts. It is accepted that all three will affect one another and any change, whether within the person, the nature of the occupation, or the environment, has the potential to affect the quality, purpose, and meaning of life. The CMOP places spirituality at the centre of the person,

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with the nature and state of an individual’s personality viewed as influencing the environment and infusing meaning into the occupation. A key concept in the practice of occupational therapy (OT) is occupational performance. It is at the level of occupational performance that OT interventions are aimed. Occupational performance is defined by the Canadian Association of Occupational Therapists as “the ability to choose and satisfactorily perform meaningful occupations that are culturally defined, and appropriate for looking after one’s self, enjoying life, and contributing to the social and economic fabric of a community” (CAOT, 1997, p. 45). Occupational performance results from the interplay of the person, the occupation in which he/she is engaged, and the environmental context within which the occupation is accomplished. In order to capture and depict explicitly the concept of occupational performance, the Person-Environment-Occupation Model (PEO) was developed (Law, Cooper, Strong et al., 1996), as shown in figure 2. Figure 2: Person-Environment-Occupational Model

Source: CAOT (1997), 61. Adapted from Fearing, Law & Clark (1996), 18.

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The transactive nature of the PEO model assumes dynamic, interdependent, inseparable relationships between person, occupation, and environment. The point at which the interlocking circles intersect is considered the point of occupational performance. This is not just the sum of the interplay of the three factors, but in gestalt tradition, represents something much more: the ability to choose and perform occupations of personal meaning. The degree that the three components overlap, and thus the potential for successful, meaningful occupational performance, evolves over the lifespan and varies according to situation, skill level, and preparedness. Although spirituality could be considered part of what influences the interaction of person, occupation, and environment to exceed the sum of its components, it is not explicitly depicted within the PEO model. WHAT IS OCCUPATIONAL THERAPY (OT)?

One formal definition of occupational therapy is as follows: Occupational therapy is a health discipline aimed at promoting, restoring and maintaining health through occupation. Occupation consists of a balance between the three spheres of self-care, productivity and leisure. Occupational therapists work with people who are disabled by illness or injury, emotional disorder, congenital or developmental disorder or the ageing process. Occupational therapists practice in a variety of rehabilitation environments including community health care settings, acute, continuing or long-term care institutions, schools and the workplace, correctional facilities and people’s homes. (Queen’s University, 2001)

In translation, then, occupational therapy (OT) can help anyone who is having difficulty doing the activities that are important to them. Occupation is everything that one does each day, including self-care (e.g., getting dressed, bathing, cooking, eating); leisure (e.g., engaging in hobbies, sports, social activities); and productivity (e.g., paid or unpaid work, housework, schooling). Occupational therapists are university-taught, regulated health professionals whose unique training enables them to understand not only the medical and physical limitations of a disability or injury but also the psychosocial factors that impact on an individual’s ability to participate in activities that are meaningful to him/her. Their approach is based upon research demonstrating that an individual’s ability to engage in a fulfilling occupation increases his/her health and well-being over the life course.

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Figure 3: Cumulative Experience across an Occupational Life Course

Source: CAOT (1997), p. 48.

Since Queen’s University developed the definition cited above, the roles of occupational therapists have expanded to encompass a much broader scope of practice. They can be found working with individual clients in health care, social service and community agencies, placing their focus on enabling an individual’s occupation and participation in life. Similarly, occupational therapists provide consultation, assessment, and intervention services to individuals, groups, companies, agencies, and governments through the public and private sectors. DEFINITIONS OF SPIRITUALITY

The official CAOT definition of spirituality was the result of many hours of painful searching, reflection, and discussion among occupational therapists from around the country over a two-year period. Even following this extensive consensus-seeking process, the result seemed less than optimal or even acceptable to many who participated in this exhausting yet energizing exercise. Therefore, in the eyes of that particular group, spirituality is: “A pervasive life force, manifestation of a higher self, source of will and self- determination, and a sense of mean-

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ing, purpose and connectedness that people experience in the context of their environment” (CAOT, 1997, p. 182). This definition is currently being debated among OTs in Canada and was the impetus for a much more active participatory dialogue than had happened in previous years. Following the publication of Enabling Occupation in 1997, a special edition of the Canadian Journal of Occupational Therapy on spirituality was published (CAOT, 1997). This issue, written by members of the profession and others, included articles that encompassed many aspects and views of spirituality and the centrality of individual meaning and purpose. Egan and DeLaat (1997), for example, have proposed a working definition of spirituality that makes explicit the importance of meaning that is derived from relationships with ourselves, other human beings, other inhabitants of the earth, the earth itself, and, for many individuals, a higher power or Creator. These authors also suggest that acknowledgement of the spirit, which is an aspect of each person, is required in order for recognition of spirituality to exist. Since then, many other articles have been published by occupational therapists within their own as well as within other journals and publications. One of the main milestones of this continuing debate was the presentation by Mary Ann McColl of the keynote address at the annual occupational therapy convention focusing on spirituality. She provided a very thoughtful and different view of the whole issue (McColl, 2000), proposing that spirituality is a sensitivity to the presence of “spirit,” where “spirit” exists independently of humans, and is “the force that animates the body of living things” (McColl, 2000). In the transpersonal psychology literature, Stanislav Grof, known for his research on holotropic mind states, avers that “spirituality involves a special kind of relationship between the individual and the cosmos, and is, in its essence, a personal and private affair” (Grof, 2000, p. 211). Given the differences within the definitions shared, there are many active elements of disagreement and lack of clarity and understanding within the occupational therapy discipline. Some of the points still being debated include whether to shy away from the religious/secular argument; how to embrace the potential breadth of meaning; if it is okay to delve into meaning that individuals give to their lives and the roles and occupations within that life which they value and celebrate; and when we should send for the chaplain.

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QUESTIONS FOR DEBATE

I would like to pose the following six questions as a way to help focus the debate. What are other definitions of spirituality? While occupational therapy has tended to steer away from definitions steeped in religious or faith-based reasoning, this is perhaps a hangover of the secular forces that guided the profession during the formative phases of thinking around this topic. The timing may well be right to reintroduce the notions inherent within world beliefs. Can spirit be shared or do only individuals possess it? This question has crystallized most particularly since the emergence of New Age thinking and the address given by McColl (2000). Is spirituality about transcendence or introspection? Can it encompass both? There has been much thought put into framing this particular question. Again, this may be best approached from the two perspectives of the religious and the secular. Is spirituality responsible for the connections between people? The notion of a community of souls, which has been present in many world religions since the beginning of thought and reintroduced to Western thinking most recently through the New Age movement, has led to a clearer insight that leans in this direction. Jung (1959), for example, describes a collective unconscious which may be experienced through the transpersonal experiences described by Grof (2000). Do we need meaningful activity to sustain our spiritual well-being? This question encapsulates the essence of the whole occupational therapy profession; since many Canadian occupational therapists believe this to be so, it is probably one of the key spindles around which the next phase of theoretical development will revolve. To what extent should occupational therapists be involved with their clients in their spiritual development? Occupational therapists work with diverse groups of cultures and traditions, which have different views of spirituality. Lukoff et al. (1995) recognize that some people undergoing spiritual or religious experiences can be hospitalized if misdiagnosed as mentally ill. As occupational therapists, it is important to be able to make a differential assessment between psychopathology and spiritual experiences in order to enable optimal occupational performance for our clients.

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CONCLUSION

The past decade has revealed fascinating glimpses of a profound search for core meaning and purpose for the occupational therapy profession in Canada and, indeed, more widely around the world. The centrality and importance of the construct of “spirituality” has taken centre stage as the key philosophical discussion needed to be undertaken in order to move the discipline forward in building foundational knowledge and understanding. As conversations happen and understanding grows, the importance of this debate gains clarity with particular relevance to the historical underpinnings of the profession. In order to continue along this path, it becomes imperative that occupational therapists broaden their dialogues, engaging with colleagues and contacts from many other areas of practice and learning. Relationships need to be expanded so that they embrace social and cultural models of practice and service delivery and become more inclusive of other sciences and arts, such as human geography and divinity. This is a fascinating time; this is a time that can become the next important milestone in furthering our understanding of meaningful occupation and its complex connections to the individual in the context of health, ill health, and the search for a long-term quality of life. REFERENCES Baum, C. & Christiansen, C. (1997). The occupational therapy context: Philosophy-principles-practice. In C. Christiansen & C. Baum (Eds.), Enabling function and well-being (pp. 26–45). Thorofare, NJ: Slack. Canadian Association of Occupational Therapists (CAOT). (1997). Enabling occupation: An occupational therapy perspective (E. Townsend, Ed.). Ottawa: CAOT Publications/ACE. Egan, M. & DeLaat, M. (1997). The implicit spirituality of occupational therapy practice. Canadian Journal of Occupational Therapy, 64, 115–21. Fearing, V.G., Law, M., & Clark, J. (1997). An occupational performance process model: Fostering client and therapist alliances. Canadian Journal of Occupational Therapy, 64, 7–15. Friedland, J., Robinson, I., & Cardwell, T. (2001, January/February). In the beginning: The CAOT from 1926–1939. Occupational Therapy Now, 3 (1), 5–18. Grof, S. (2000). Psychology of the future: Lessons from modern consciousness research. Albany, NY: State University of New York Press. Health and Welfare Canada. (1983). Guidelines for the client-centred practice of occupational therapy. Ottawa: Ministry of National Health and Welfare. Jung, C.G. (1959). The archetypes and the collective unconscious. New York: Routledge and Kegan Paul.

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Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy, 63, 9–23. Lukoff, D., Lu, F., & Turner, R. (1995). Cultural considerations in the assessment and treatment of religious and spiritual problems. Psychiatric Clinics of North America, 18 (3), September, 467–85. Townsend, E. (1993). Occupational therapy’s social vision. Canadian Journal of Occupational Therapy, 60, 174–84.


10 Using a Labyrinth in Spiritual Care Ingrid Bloos

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growing number of people are rediscovering the ancient labyrinth and sharing in the rapid revitalization of its use as an aid for facilitating spiritual growth and human awareness. The labyrinth is based on the spiral pattern that is found throughout history and across disparate cultures. It is an archetypal pattern that symbolizes the cyclical nature of life, and could be used as a complementary facilitative tool in a contemporary health care context. Different individuals can use it for many different purposes. Labyrinths are relatively simple to make and can be adapted to a variety of contexts. These are the ideas that form the basis of this chapter’s discussion. WHAT IS A LABYRINTH?

In its most basic form, a labyrinth is a spiral pattern that is followed repeatedly. This “following” represents action, that is, the eyes follow the labyrinth pattern, or the fingers trace it, or the body walks or dances it. Labyrinths have traditionally been used to facilitate spiritual connection, integration, and growth (West, 2000; Artress, 1995). Labyrinths vary in size and proportion, are both permanent and portable, and simple or intricate in their design. For example, the eight-hundredyear-old tiled-floor labyrinth at Chartres Cathedral, France, is twelve metres in diameter and can be walked, whereas the pictorial labyrinth located on the outside wall of St. Lucca Cathedral, Italy (circa ninth century), is approximately forty-five centimetres and is traced with the fingers (Artress, 1995). 149

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Figure 1: Chartres Labyrinth

At this point, the term labyrinth should be distinguished from its conceptual counterpart, the maze. Scholars typically agree that labyrinths are not mazes (Artress, 1995; Bord, 1976). They are distinguished from one another by their path and intention (Westwood, 1997; Artress, 1995). The path of a labyrinth is unicursal while the path of a maze is multicursal. This means that the labyrinth has one direct path from the entrance to the centre and back out again. The centre is always visible from any point along the path. There are no structural tricks, traps, puzzles, or dead ends. The intention of the labyrinth is to clarify, deepen, and connect. Both the philosophy inherent in the spiral symbol and its physical manifestation in the labyrinth reflect an emphasis on wholeness. By contrast, the multicursal path of the maze contains numerous twisting and winding paths with many puzzles and dead ends along the way. There are many ways in and many ways out. However, none is either straightforward or immediately apparent. The intention of the maze is to tease, confuse, frustrate, obstruct, or trap the walker at each step. Mazes are often found in puzzles and games designed to challenge the cleverness of the player. Accordingly, it is only the labyrinth with its emphasis on wholeness rather than fragmentation, and on connection rather than separation, that emerges as a tool that can be used to promote spiritual growth and healing.

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WHERE DOES IT COME FROM?

The spiral pattern from which the labyrinth is derived is an opened form of the circle, the oldest symbol known to have been drawn by humans (Purce, 1974). Believed by many to represent the Ultimate Feminine, the circle is considered the perfect form that is symbolic of unity and the form within which all others are held. When the line of a circle is opened up and continued, it becomes an ever-expanding and deepening spiral. This continuous movement is understood as the universal symbol for creation (Purce, 1974). Its pattern embodies concepts of cyclical movement from birth to death, from form to formless, from known to unknown. As such, the spiral pattern taps into our archetypal knowing (gnosis) and resonates at a deep and often unconscious level (Jung, 1964). It metaphorically captures the mysteries of life and serves as a cosmic symbol for transformation, change, and wholeness. These themes are found throughout history in nearly every culture and almost every place in the world. From prehistoric cave drawings and petroglyphs dating back more than ten thousand years, through the ancient Egyptian and classical Greek and Roman periods, into medieval and early modern times, some form of this concept is consistently expressed in artifact, practice, or theory. For example, in the Dordogne Valley, France, cave drawings depict the spiral form as a part of fertility and passage rites. In ancient Egypt, archaeologists have excavated the remains of a magnificent labyrinth that purportedly served as the administrative centre for judicial, ritual, and sepulchral matters (Matthews, 1970). The spiral has also been found on Egyptian, Greek, and Roman artifacts, including pottery, armour, paintings, coins, and the clothing of royalty (Hooke, 1935). Labyrinth remains have been found in churches in Algeria, Italy, Great Britain, and France. Ancient forms outlined in stone, carved into stone, or marked as large stone arrangements have been found in parts of northern Europe, Scotland, and Scandinavia dating back to the neolithic period. Turf labyrinths—mounds of earth covered with grass—have been found in Germany and Scandinavia and are earlier forms of the garden and hedge labyrinths prevalent in England during the seventeenth and eighteenth centuries. The spiral pattern has always symbolized understandings of movement, change, and connection. The labyrinth stands as an “emblem of transformation,” as a road map towards new possibility, and, on a more ordinary level, as a puzzle that reflects the natural human fascination with enigmas (Dooling Draper, 1992). Our drive to search for the “missing

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Figure 2: Cretan Labyrinth

piece” that will present the “whole picture” challenges the limitations of our physical being and intellect. The two forms of the labyrinth that are common today are the Cretan and Roman labyrinths. The Cretan labyrinth is known as the classical style, and dates back nearly four thousand years (Matthews, 1970). It is simple in its design, as it has only seven concentric circuits to its centre (see Appendix 1). This particular style of labyrinth, named after the Island of Crete in Greece, serves as the context for a renowned heroic journey. The myth of Theseus, Ariadne, and the Minotaur reflects the mortal challenges of the existential struggle (Downing, 1980). In this myth, the labyrinth’s architect, Daedalus, lures the king’s son, Theseus, to the labyrinth where he must enter and encounter the deadly Minotaur. This hideous half human/half beast, to whom Athenian youths and maidens are ritually sacrificed, waits in the labyrinth’s centre ready to destroy anyone who dares to enter. Theseus undertakes the challenge of encountering the Minotaur to free Athens of this obligation and to further his own journey. He makes his way to the labyrinth’s centre and ultimately slays the Minotaur only to face the next challenge, that of finding his way out of the labyrinth. This he does only through the help of the maiden Ariadne. The singular golden thread that she holds connects her to Theseus and ultimately leads him to freedom and safety outside. The mythology contained within the pattern of the Cretan labyrinth continues to serve as an allegorical reflection that captures many of the

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challenges and struggles presented to each of us in some way along our own journey. Complications and difficulties challenge our perspective to see, know, or remember a different way—a way that incorporates support and connection. In these moments, we may literally and symbolically delve into our own centre, grappling to find the “golden thread” or the connection that will lead us away from fear and isolation. Experiential images of birth as entering the journey, life as travelling through the journey, and death as a learning or completion of the journey correlate to the process of moving through the labyrinth. As such, it is the simple movement embodied within both form and story of the ancient Cretan pattern that captures the complexities of this archetypal experience (Conty, 1992). The second type of labyrinth popular today is based on the Roman labyrinth, which evolved approximately two thousand years after the Cretan labyrinth. Designs based on the Roman pattern were incorporated into the labyrinths common to the medieval Christian Church. The floor labyrinth at Chartres Cathedral, France, is the best surviving representation of the Roman design (see figure 1). The circuitous path is organized into four quadrants by lines that form a cross (Artress, 1995; Matthews, 1970). The lines not only give form and order to space that could otherwise appear as chaos but they also intersect at the centre to form a position thought to represent the symbolic place of the Sacred or Divine (Westwood, 1997; Artress, 1995; Conty, 1992). For example, the curvilinear lines of the Chartres labyrinth form the singular path towards the labyrinth’s centre, giving both literal and symbolic method to what initially appears to be an aimless pattern. The lines intersect at the centre and provide balance and symmetry. The most remarkable feature of this labyrinth is the invisible thirteen-pointed star radiating outwards from its centre. While the early medieval Christian Church associated the labyrinth with its teachings, archival records indicate that the mythologized preChristian figures of Theseus and the Minotaur were often incorporated into the labyrinth’s centre. The myth symbolizes recurring themes of struggle, confusion, despair, and disorientation as well as a metaphorical way or direction to reorient oneself (Baker, 1992; Coomaraswamy, 1992). The path of the labyrinth reminded Christian followers of the circuitous course waiting ahead for those who surrendered to temptation; thus, the allegorical depiction of the struggle between good and evil remained a typical feature of medieval labyrinths. For the French, the design and structure of the labyrinth was commonly known as chemin

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de Jerusalem, meaning the “way of the pilgrim,” which conceptualized the labyrinth’s winding path to its centre as the devout Christian’s symbolic road to Jerusalem. This idea captures an ideology of challenge, perseverance, and commitment to religious purpose. After the Crusades, when the journey to the Holy Land was often too dangerous or impossible, the labyrinth was used to make a token pilgrimage (Artress, 1995; Doob, 1990). Other uses of the church labyrinths included acts of penance, accomplished by walking the labyrinth’s path on one’s knees, as well as the diocese’s use of the labyrinth to commemorate Christ’s death and resurrection at Easter by recreating parts of the events through elaborate ceremony and dance. Whether literal or figurative, walking the labyrinth’s path came to illustrate the symbolic journey taken in life—from the entry place or the place known as birth, along the single winding path to the centre where integration occurs, and to the point of completion or death. What is especially important to a contemporary understanding of the labyrinth as a facilitative tool is the notion of the creativity inherent in its structure as symbolic of the Divine Feminine (Artress, 1995). This association was influenced by beliefs from surrounding medieval pagan cultures and was ultimately incorporated into various forms of Christian ritual and worship. Aspects of such cultures came to focus less on struggles between good and evil and more on motifs of change. An interpretive and ideological shift away from images depicting the Theseus-Minotaur mythology to that of the continuous connection of Ariadne’s “golden thread” manifests creativity as a force of continual movement: change and constancy, regardless of conscious awareness. Essentially, the labyrinth consists of opposing spirals arranged around two perpendicular axes, an arrangement that gives the structure its power by capturing the simultaneously connected positions of motion and stillness. As a religious path, the labyrinth pattern provides guidance to enduring the complexities of life in the face of constant change (Conty, 1994; Coomaraswamy, 1992). One example of the motion, stillness, and connection embodied in the Divine Feminine is found in the Chartres labyrinth’s centre in the form of a six-petaled rose known as the rosette. The rose was typically associated with the Virgin Mary and embodied similar notions of Divine love, and the rosette’s six petals symbolized the six stages of creation and planetary evolution (Artress, 1995). The path of the Chartres labyrinth demonstrates that the Roman form is comparatively more complex than its simpler Cretan predeces-

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sor (Artress, 1995). In terms of construction, labyrinths of the medieval period were built to embody both the arithmetic and geometric principles of the now largely lost art of “sacred geometry” (Artress, 1995; Lawlor, 1982; Pennick, 1980; Purce, 1974). Rudimentary forms included the circle, triangle, and square, and their properties provided the basis upon which further division or extrapolation became possible. According to the principles of “sacred geometry,” form captures the simultaneous unity and diversity of the cosmos and endeavours to capture aspects of unity or the Divine (Conty, 1992; Lawlor, 1982). It is important to remember that medieval architecture, like its art, was not merely an aesthetic expression but an intellectual virtue; there was no divorce of science from art (Coomaraswamy, 1992). Freemasons and master artisans commonly devoted their entire lives to their craft. In this way, their works served as a testament to the builders’ devotion to the Divine, and promoted the hope that there was something beyond material existence (Gustafson, 1979). HOW HAS IT BEEN USED?

The spiral pattern has always symbolized understandings of movement, change, and connection. As a derivative form, the labyrinth has attempted to capture the deep mysteries of life. Historically and cross-culturally, labyrinths have assumed many configurations. The symbolic eternal movement imbedded in the spiral pattern transcends cultural and religious limitations and taps into our deepest knowing and our unconscious awareness (Downing, 1980). For example, within Native traditions, the labyrinth pattern is reflected in forms of a sacred spiral symbolizing the unity of all creation. For many North American Natives, the medicine wheel is a physical expression of this knowledge. Based on the number four, it represents birth and rebirth, the tunnel or vortex of “eternal return” invariably leading to the centre, and symbolizes personal vision and enlightenment during the often dangerous journey through life. The Hopi Indians of Arizona called the labyrinth the “Mother Earth” symbol. Its association to sacred underground sanctuaries reflects the Hopis’ evolution through three previous worlds to the present fourth world. It is believed that the lines and passages of the sacred spiral integrally form the universal plan of the Creator (Purce, 1974). The Pima and Papago Indians of Arizona and New Mexico incorporate a similar belief system, which is illustrated through intricate basket weavings in

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the famous symbolic form of the “Man in the Maze.” Themes of balance and harmony are important and widely reflected throughout the traditions of Native North Americans (Coomaraswamy, 1992; Bruchac, 1992). Within Jewish kabbalistic mysticism, the sephirot is an elongated version of the labyrinth pattern and is based on the number ten (Artress, 1995). More commonly known as the Tree of Life, the sephirot represents the “branches” that describe the qualities of the Divine and of the archetypal human being. The sephirot is understood as a vortex of the spiral that expands from, contracts, and then returns to its Divine Source. Meditation on the interaction of the hierarchical arrangement of the branches directs the human spiritual path and supports the search for deeper meaning in the words of the Torah (Ellwood, 1995). The balanced arrangement of the branches metaphorically represents “things of the right hand and those of the left…the opposition of the paired motions that inhere to the totality of the world extended in time and space” (Coomaraswamy, 1992). The Tibetan Sand paintings of the Buddhist tradition, a commonly recognized mandala form dating back thousands of years, are also based on the spiral pattern. The word mandala comes from the Sanskrit and simply means “circle.” These circles contain patterns intended to capture the unity, diversity, and movement of the universe. These mandalas are not walked; the spiral circles drawn into the sand are used for contemplation. This practice of meditating on the spiral pattern quiets the mind and helps to centre the self (Purce, 1974). Disciplines within Islamic mysticism, such as the whirling dervishes of certain Sufi orders, incorporate specific, repetitious, rhythmic spiral movements of dance into elements of their spiritual practice in order to reach higher states of consciousness. The belief is that the paired repetitious motion of clockwise and counter-clockwise movements around its own axis invokes for the Dervish a “stillness of heart” and a connection to the Divine Source (Purce, 1974). The labyrinth has served as the context for the choreography of the spiralling movements of dance for many cultures over thousands of years. In its literal form, the lines of the labyrinth naturally invite movement and encourage dance. As a metaphor, the circling movements mirror the journey or “dance” of life. As a facilitative construct, the labyrinth, comprised of opposing directions around a single shared axis, harmonizes energy by connecting movements of involution and evolution (Conty, 1992; Jeanes, 1979; Purce, 1974).

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WHAT GIVES THE LABYRINTH ITS POWER?

We have come to see that there is an energetic connection between outer pattern and inner movement. The act of moving through the labyrinth’s path involves the action of repeatedly curling inward towards a centre place and then moving back out—a movement that arguably resonates with some primordial part of our being. Some suggest that what we receive from dancing, tracing, or walking a labyrinth will largely be influenced by our perspective or direction of orientation within the structure (Baker, 1992). That is, because a labyrinth is based on two opposing spirals arranged around a common axis, if movement is oriented away from the labyrinth’s centre outward, then the movement is centrifugal, whereas if it is oriented from the outside inward towards the centre, it is centripetal. A centrifugal orientation suggests that the walker may be seeking a symbolic “way out” or an external solution, while a centripetal orientation suggests a way into the centre or some form of an inner solution. Ultimately, movement through the labyrinth’s path involves both centrifugal and centripetal motions that will inspire a more balanced redirection of perspective, thought, and emotion. From a physical and kinesthetic perspective, we understand that movement shifts energy. It is our biochemical, electromagnetic energy system that responds with an electrical stimulus each time a muscle is moved. Furthermore, the simple act of moving through the path of the labyrinth requires a certain amount of concentration. The activity engages both the left and right sides of the brain and, as such, both creative and analytic aspects are called upon to function conjointly (West, 2000; Purce, 1974). From the simple physical perspective, movement helps to adjust the body’s electrical frequency, and at a profound level, movement through the labyrinth’s path resonates with aspects of our collective imagination and resourcefulness. This makes sense given what we also understand about the spiral pattern. From a metaphorical perspective, Jung recognized the spiral pattern of the labyrinth as part of the collective unconscious—a transcendent part of our being. The pattern as a universal symbol for change, transformation, and wholeness is an archetype deeply embedded into our human psyche. It appeals to our pattern-seeking mind. The spiral is a soul-recognition pattern moving towards a deeper aspect of self that seems to share the essence of both mythologized beliefs and archetypes of the collective (Jung, 1964). We come to see that the process of movement and the spiral pattern combine to create a reverberation that is powerfully compatible at phys-

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ical, emotional, intellectual, and spiritual levels. The mathematical properties inherent in the geometric form of the labyrinth are thought to facilitate the transkinaesthetic properties necessary for balance and its attributes. HOW CAN THE LABYRINTH BE USED IN A HEALTH CARE CONTEXT?

We know that the pattern of the labyrinth can serve as a physical construct for ritual and prayer. Within medieval and pagan contexts, its winding path was drawn, walked, traced, danced, prayed, contemplated, and meditated upon (West, 2000; Artress, 1995; Jeanes, 1979; Purce, 1974). The labyrinth forms a theoretical framework attempting to capture and express that which is undefinable. In medicine, there is growing awareness of and appreciation for comprehensive models of health and health care to promote the perspective of wholeness. This is appropriate given the variety and complexity of contemporary health care considerations. The labyrinth’s inherently inclusive and organic nature supports its use as a multi-functional tool that could be helpful within many phases of care and for all groups of people—patients, health care providers and support staff, family members, and visitors. Simply put, the labyrinth can be a useful tool for anyone in a position of experiencing, supporting, or trying to understand their current situation. For example, for the person receiving care, it can be helpful for making choices about treatment; for family and friends, it can be walked as a distraction or to provide a context within which private thoughts or struggles can be clarified. Walking the labyrinth may be particularly helpful for staff, physicians, or others who work in increasingly stressful environments. The labyrinth could be easily incorporated into the clinical health care environment. A labyrinth’s physical construction can be suited to accommodate available space and resources. Labyrinths can be made as either simple or aesthetically intricate forms. Typically, portable labyrinths are popular, and can be constructed from painted fabric, arranged stones, drawings on paper, or by taping the pattern onto the floor or carpet. Some institutions may choose to build more permanent labyrinths by using floor tiles in an interior space or by using plants in a garden setting. Limitations of physical resources need not dictate the incorporation or use of the labyrinth. Theoretically, tracing a small finger labyrinth can provide the same emotional, physical, and spiritual

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opportunity as walking an expansive floor design. The path of the large floor labyrinth can be made to accommodate specific individual needs and can be adapted to accommodate wheelchairs and so on. For example, people with physical limitations may be assisted in their walk. Labyrinth walks can be taken alone or can be accompanied by a trained facilitator. While it does not seem necessary for its effectiveness to be witnessed or monitored, it may be helpful to offer guidance and support both before or after moving through the labyrinth. The act of walking a labyrinth has been known to have a deep, lasting, and residual affect on the user (West, 2000; Artress, 1995). Issues that arise may require further discussion or attention, and supportive measures may include access to a counsellor, chaplain, or therapist, or to someone familiar with labyrinth work. Other possible supportive methods may involve some expression of the experience through various art forms such as drawing, painting, writing, and sculpting. Because the labyrinth, as a facilitative tool, heightens awareness and conscious connection, some form of expression or articulation of the experience may extend the therapeutic benefits. USES

The characteristics of the labyrinth that promote its use as a spiritual tool translate easily and naturally into the health care context. Moving through the labyrinth engages both mind and body, as it requires a certain degree of attention to negotiate the path and its many turns towards the centre. The kinesthetic aspect of the movement engages our physical and logical self, while the pattern of the movement walked calls forth our intuitive nature. These aspects combine to promote a greater sense of wholeness and connection and, as such, substantiate the labyrinth’s use as an adjunct to any ongoing treatment and care. While the use of a labyrinth in no way presumes to replace or eliminate other forms of prescribed treatments, the incorporation of its use can assist in addressing a variety of needs. For example, the labyrinth is currently being used by a psychiatric hospital in the treatment of patients with schizophrenia. For these people, walking the labyrinth has had a calming and integrative effect on their thoughts and behaviours. More generally, the labyrinth acts as a metaphor that mirrors back to us our own process. It can reveal where we are in our thoughts, actions, and feelings, and offer insight into the next step.

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Walking for Clarity The labyrinth is a helpful tool when clarity is needed or when there is a sense of being overwhelmed or confused. Walking with a question in mind may be particularly useful in health care contexts for patients and health care workers alike. The physical movement of walking stimulates biochemical shifts. Merely moving along the labyrinth’s path can be calming and help to alleviate stress, by simply offering a change of pace and scenery. It can help the walker shift awareness inward to focus on self in a more compassionate and holistic way. When we are in our thoughts and mind too much, physical movement facilitates the restructuring of the body’s energy and can free up stifled resources. In this way, physical balance helps the walker draw upon broader aspects of his/her being and supports decision-making abilities. As a multi-functional tool, the labyrinth can be used for meditation, for praying for direction or guidance towards a sense of peace, comfort, calm, or acceptance. It may be used to pray for greater connection to self or to another in a time of increased physical, emotional, intellectual, or spiritual vulnerability and disconnection. Such challenges often touch the core of who and how we are in the world, triggering fears of isolation, confusion, and abandonment. For the patient, a health challenge is often associated with a sense of deep grief, vulnerability, and powerlessness. In this context, walking the labyrinth provides a place for the person to grieve. It can serve as a place where a person can reclaim lost or forgotten aspects of self. This becomes particularly relevant in situations involving illness, palliative care, and death. People in advanced stages of illness can experience intensified stress or vulnerability on many levels. Often during such times, there is a heightened need to connect with God or a source of Higher Power. The labyrinth can provide a calm, compassionate, and sacred place where no questions, feelings, thoughts, and experiences are ever too much to be held, experienced, or expressed. The labyrinth can also serve as a physical tool to support play, to celebrate, to expand, and to be creative and hopeful.

Walking with Intention There is no right way to walk a labyrinth. There are probably as many ways as there are people who walk it. What is important, however, is to find a way that works on a personal level. Once an individual has decided to take the journey, he/she simply enters and follows the path to the centre and then takes it back out again. While not necessary, facil-

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itators suggest walking the labyrinth’s path at least three times in order to quiet distractions, diminish self-consciousness, and allow the experience to expand. What does it mean to walk with intention? Intention means having a plan of action or an aim that guides some action. When we have an intention, we have in mind a clear direction or specific purpose to what is being engaged. While it is not necessary to define an intention or question, focusing on what is needed or wanted from the labyrinth experience tends to enhance the experience (West, 2000). Intentions can be powerful because they can focus and direct our physical, intellectual, emotional, and spiritual resources. Intentions call forth the energy within us and around us to clarify our thoughts and support our movements. Intentions need not be complicated or precise. An intention can be as simple as walking with openness. It is more important that the walker begin to clarify what he/she is asking for or what he/she needs in the moment. As such, an intention makes the walker more aware of his/her innermost needs and begins to move these needs forward towards conscious awareness. Intentions best support the labyrinth walk when they are put into the form of an open-ended question or phrase. This creates more space in which responses can occur. As with many spiritual quests, it is best to walk with an openness of heart and mind, to try to put the ego to the side as it often has a way of being invested in a particular outcome. Attachment to a particular outcome might hinder or obscure what emerges. The key, as well as the challenge, of the intention is to simultaneously carry a plan for what is needed and an openness for what comes.

Examples What follows are some examples of how a labyrinth could be used over the course of an ordinary day in a health care facility. Most of these ideas can be used with a floor labyrinth located in a large space that is moderately private and easily accessible. Some of the reasons that bring a person to walk the labyrinth might include the need for preparation before medical treatment, physical movement, distraction, meditation, relaxation, clarity, or guidance. For example, an outpatient walks the labyrinth before a dialysis or chemotherapy appointment to emotionally prepare for treatment. Another patient walks because she is struggling with decisions about courses of treatment and is hoping to find greater inner clarity. In these ways the path of the labyrinth may serve multiple purposes of guiding, calming, and clarifying.

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In other instances walking the labyrinth may merely provide the context for physical movement or distraction. A pregnant woman heeds her physician’s suggestion and walks the labyrinth’s path to accelerate labour. A laboratory technician walks simply for some physical exercise and to re-energize during his break. For parents with a young child who are spending considerable time with a hospitalized parent, the labyrinth provides a place for a much needed break and an interesting pattern on which the child can play. Another young family with their newborn move through the labyrinth with friends and family in celebration of their joy. A physician walks the labyrinth out of curiosity. A wheelchairbound patient needing a creative change of scenery rolls through the labyrinth, while a post-operative patient needing to increase physical mobility manoeuvres the labyrinth on crutches with the help of her physiotherapist. Other reasons to use the labyrinth focus on gaining a particular perspective or tackling a specific conflict. For example, a nurse walks to help her figure out how to deal with a particularly difficult patient. A chaplain needing to prepare for an upcoming presentation uses the labyrinth to become calm and centred; an intern walks to shake off the demands of a long shift; an administrative assistant walks with his ambivalence as he is thinking about his partner’s job transfer. The palliative care unit is another area where the labyrinth could prove to be quite beneficial, because palliative care is directly concerned with issues of dying and death. The historical tradition of the labyrinth is predicated upon systemically addressing the questions of beginnings and endings and ultimately of cosmic wholeness. As such, it is an applied tool that can offer help throughout the challenges of the dying process. Some examples include a person in palliative care who moves along the labyrinth’s path seeking greater spiritual connection. A grieving husband who is visiting his dying wife walks in hopes of finding understanding and guidance. The pediatric staff arrange to walk as a group as they mourn the loss of their young patient. Family members use the labyrinth as an arena for group prayer as they gather to pray for their loved one. Mobility need not determine how the labyrinth is used. Labyrinths drawn onto ordinary sheets of paper can easily be traced and shared. Two-dimensional finger labyrinths that are carved into wood are becoming increasingly popular and are readily available. The process of drawing and creating a labyrinth can offer many of the same benefits. In these ways, labyrinths can be used in a variety of creative ways. For

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example, a visiting chaplain brings pictures of several labyrinth styles to a bedridden patient, encouraging choice and conversation in the process. Several young adolescent patients spend the afternoon designing and creating a labyrinth as they recount experiences of their illnesses. While these examples do not assume to be an exhaustive account of applied uses, it becomes apparent that the labyrinth can be easily adapted to the health care environment and used in a myriad of creative ways. CONCLUSION

The place and use of the ancient spiral pattern, upon which the labyrinth is based, is consistently found across many cultures throughout history, symbolizing the understanding of perpetual movement and creative change as experiences of birth, life, and death. With an inherent emphasis on wholeness, we have come to see the labyrinth as a facilitative tool that assumes a comprehensive cross-cultural application for spiritual expression in forms that include both theory and practice which can be easily transported into our contemporary multicultural, multi-faith environments. We also see that from a biochemical perspective, the labyrinth, as construct, serves as a kinaesthetic tool. The process of movement through the labyrinth is powerfully compatible at physical, emotional, intellectual, and spiritual levels and harmonizes energy. Integration of these qualities supports the perspective and experience of greater balance and wholeness. With our growing awareness of and appreciation for models that are appropriate to the variety and complexity of contemporary health care issues, the labyrinth is becoming an affordable, accessible, multi-functional tool that may be helpful within many phases of care in increasingly stressful environments. Its incorporation and use does not presume to replace or eliminate other forms of prescribed treatment; rather, its use as a compatible adjunct to continuing interventions can address a variety of additional needs. Ultimately, moving through the labyrinth reflects a commitment to becoming more conscious of moving through life as an active participant. It makes us active rather than passive beings, and wholly supports us in the process. APPENDIX 1: CONSTRUCTING A CRETAN LABYRINTH

The lines of the classical seven-circuit Cretan labyrinth can be made of tape, marker, paint, stones, plants, or any other material. It can be made to be permanent or temporary, and can be arranged on surfaces

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like floors, canvas, paper, grass, soil, and sand. Once the basic idea of the seven-circuit labyrinth design is understood, replicating and transferring it to other sizes and contexts is simple. The movement of creating labyrinths is often, in itself, a creative and therapeutic process. See West (2000) for extensive instructions on constructing the eleven-circuit labyrinth. Figure A.1: Constructing a Cretan Labyrinth

REFERENCES Artress, L. (1995). Walking a sacred path. New York: Riverhead. Baker, R. (1992). A modern metaphor. Parabola, 17 (5), 83–87. Bord, J. (1976). Mazes and labyrinths of the world. London: Anchor. Bruchac, J. (1992). Waw Giwulk: The center of the basket. Parabola, 17 (4), 52–53. Conty, P. (1992). The geometry of the labyrinth. Parabola, 17 (4), 4–14. Coomaraswamy, A.K. (1992). The one thread. Parabola, 17 (4), 26–33. Doob, P. (1990). The idea of the labyrinth. Ithaca, NY: Cornell University Press. Dooling Draper, E. (1992). Focus. Parabola, 17 (4), 3. Downing, C. (1980). Ariadne, mistress of the labyrinth. In J. Hillman (Ed.), Facing the gods (pp. 135–49). Dallas, TX: Spring.

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Ellwood, R.S. (1995). Medieval and modern Judaism. In R.S. Ellwood (Ed.), Many peoples, many faiths (5th ed.). New York: Prentice Hall. Gustafson, J.F. (1979). Full circle commentary. Parabola, 4 (2), 90. Hooke, S.H. (1935). The labyrinth. New York: Macmillan. Jeanes, R. (1979). Labyrinths. Parabola, 4 (2), 12–15. Jung, C.G. (1964). Man and his symbols. New York: Dell. Lawlor, R. (1982). Sacred geometry. London: Thames and Hudson. Matthews, W.H. (1970). Mazes and labyrinths. New York: Dover. Pennick, N. (1980). Sacred geometry. London: Turnstone. Purce, J. (1974). The mystic spiral. New York: Thames and Hudson. West, M.G. (2000). Exploring the labyrinth. New York: Random House. Westwood, J. (1997). Sacred journeys. New York: Henry Holt.


11 A Wholistic Approach to Healing: An Individual, Family, and Community Model Calvin Morrisseau

MY PERSONAL JOURNEY

The healing that took place in my family reminds me of a Hopi prophecy of 1830 which read: Our people are in their midnight We will come into the daylight and become leaders When the eagle lands on the moon. Many of us believe the process of healing for Aboriginal people also began in 1969, when Neil Armstrong’s lunar vehicle touched down on the moon for the first time and sent the message that the Eagle had landed. In our family, this process started with my mother over twenty years ago. For us, my parents’ entry “into daylight” was as important as Neil Armstrong’s historic landing on the moon. It did not receive any press coverage, but for us it symbolized a new life destined to improve the lives of many people, including those yet unborn. From one seed sprang new generations of siblings who spoke of healing and growth instead of denial and shame. Both my parents were alcoholics. I believe strongly if it had not been for the alcoholism both would have been excellent role models. In the same manner, I believe there are many other parents who could be great parents if they, too, did not become consumed with the substance abuse and addictions associated with growing up in a family organized around pain.

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To deal with the pain of rejection and feelings of inadequacy, by the time I was twelve I was abusing the chemicals which eventually led to my alcoholism. At age twelve, my choice of chemical was gasoline because it was easily accessible, and the “high” I experienced allowed me to forget who I was and where I lived. I can remember seeing my father working at the sawmill. All ten of us children were very proud of the fact that he worked every day. In those days, I spent a great deal of time with my friends. In many ways, they were also my family. I relied on them for the caring I did not receive when my mom and dad were drinking. Like many other kids, we spent every summer swimming, playing ball, and just goofing off. Unlike many other kids, we also spent a lot of time throwing rocks at cars, drinking, and sniffing gasoline. Most weekends were spent wondering what kind of weekend it would be. Would it be one of those sober weekends where we would be like a normal family, or, would it be a drunken weekend where everything and everyone seemed crazy. I remember the inconsistency being the worst feeling in the world. It felt like we were either going to be in hell or in heaven. It was those sober weekends that meant the most to me. Those were the times when my father would take the family to our little shack on Haymarsh Bay. As a family, we usually spent those weekends swimming and fishing. More important, it meant my parents would be spending the weekend with us. I loved it when my parents were home. I guess that is why it hurt so much when they were away drinking. When they drank, it meant that we had to deal with the fighting, crying, screaming, and terrifying sounds of drunken partying. It also meant I would spend a better part of the evening worrying. I worried because my parents were not home, and then worried because when they did come home other drunks usually came with them. I was never really sure what was worse, waiting and worrying or listening to the sounds of the drinking. During the times my father was sober, he was very quiet. When he drank, he became the opposite. At night, when I would be trying to sleep, he would come and talk to me. It was a type of father that I could not truly appreciate. Yet despite his drunkenness, it was at those times I learned about women, the world, sports, and the way he really felt inside. He talked about his fears, dreams, failures, and frustrations, and tried during these talks to give me some direction for my own life. It was the only time when my father could actually say he loved me. As I look back today, I

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can see how it was the only way my father could express his true inner feeling. But a child doesn’t really understand those things; instead of trying to accept my father’s need for intimacy, I learned to resent his midnight intrusions. My mother was a product of the Catholic school and my father the product of the residential school system. Instead of learning appropriate discipline, my parents were taught to use corporal punishment as a means of control and discipline. At that time, spankings were not considered inappropriate discipline. In fact, the religious community considered you a bad parent if you did not discipline your children by “spanking.” The not too silent code of spare the rod and spoil the child was very much a society value. In my earlier years, I didn’t see anyone trying to teach my parents new parental skills. What I did see was the confirmation that hitting was allowable as an appropriate means of discipline. But regardless of society values or the intentions, the feeling associated with the spankings remained the same. It always made one feel humiliation and indignity. This was reinforced at school, where corporal punishment as a means of control and discipline was also the choice. For the slightest infraction of the rules, you would be disciplined with a wide range of tactics, ranging from shaming rituals, in which children were forced to stand in the corner of the room for long periods of time, to being ridiculed in front of the class by having to sit on a stool, or being sent directly to the principal’s office. Being sent to the principal’s office usually meant getting strapped with a leather strap with a texture similar to a beaver’s tail. I could never decipher if the violation was consistent with the punishment. It was more likely the degree of punishment coincided with the mood of the principal. I did know that I was always deeply afraid of being punished. Yet I always did my best to put on a brave front. I did not want anyone to think I was a cry baby. You might feel a hatred for the teacher; however, being brought up Catholic meant you were the one who was bad. No matter what people did to me, I was apparently the one who was in the wrong. I was taught to believe I was born defective, with original sin on my soul. Of course, that meant all I had to do to be bad was to be born. It was not very helpful in trying to develop some kind of sense of self-worth. My self-worth had to come from outside myself. School was supposed to be a place of learning, growth, and development, but for me it only presented a different set of problems. The only

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similarity between home and school was the feeling of anger it generated because I was not as good as the other kids. My clothes usually had patches, my lunch consisted of mustard sandwiches, and my body usually was dirty. Being called a “dirty Indian” brought forth anger and hatred for the system that was supposed to teach me. Because of this, I never really developed a commitment to education. My education came from home, and I was a prize pupil. It was not surprising to have all kinds of drunks come to my house after the bars closed. From my bed at the back of the house, I could tell by the voices whether violence was going to break out. I still feel sadness when I think of my mother, who was too drunk to protect her children from those who came there, yet I know this was all part and parcel of the drinking. It was her alcoholism that dictated whether she could or would do anything about the drunks who came into the room. Most people I knew never drank for just a single night. Instead everyone I knew drank for the entire weekend. Those weekends I usually ate raw porridge mixed with water while stepping over and watching the drunks who were passed out half-clothed. By Saturday the house was a mess, with beer and wine spilled all over the floor. Mixed with the dirt from people’s shoes, it made the floor sticky, so sticky that my socks would stick to the floor. I remember a great deal of violence. I remember drunks fighting drunks, brothers fighting brothers, women fighting other women, men beating their wives, and wives beating their husbands. I watched the fights. I saw the blood spilling from the faces of drunks. I watched until all the action was over, and then I would go back to bed as if nothing happened. I prayed no one would hurt my dad and was at the same time afraid he would hurt someone. I was always afraid something bad would happen and I would end up being alone. It was a feeling that never left me. I hated my parents’ drinking. I became confused and thought that meant I hated them. I couldn’t imagine what kind of child would have the boldness to hate his parents. I thought there must be something wrong with me. Maybe if I could be a better son, a better brother, or a better student, things would change. In my confusion, I trusted a boy who was six years older than the eight I had already lived. His name was Marcel, and he was also the only older person who paid genuine attention to me. Marcel often gave me snuff, making me feel grown up and special. Snuff was a tobacco product you placed between your gum and lower lip. Instead of smok-

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ing cigarettes, snuff gave you the effect of smoking without actually smoking. I hated the taste of snuff, but I loved the acceptance it gave me. The bad taste was a small price to pay for the attention of someone I admired. I pretended to enjoy it. Marcel was a sexual perpetrator, but at that time I did not think of him as an abuser. I cared deeply for Marcel. I guess that is why it hurt so much when later in life I realized what he had done had left me damaged. The abuse happened on a Friday evening when my parents were out drinking. I remember feeling sad because I knew my father would be drinking for the weekend, which meant our fishing trip would be cancelled. I went over to see Marcel, who always seemed happy to see me. The one thing I knew about Marcel was that whenever he said he would do something I knew he would do it. We sat around and talked for about an hour. He asked me if he could rub my back because my muscles were tense. As he was massaging my back, he reached around and touched my penis. I jumped up from the floor and started to pull my T-shirt back on. He reached over and grabbed me, kissing me on the lips. I wanted to run away, but he placed his hand on the back of my head and held it to his chest. I started to cry, and as he tenderly stroked my head, the tears came from my eyes. I thought I would never be able to stop crying. After I cried, I also felt a great comfort. For the first time in my life, I felt someone other than my brothers and sisters, someone older, cared about me. It was at that time that I decided that I would do almost anything to feel the way he made me feel. I never felt shame or remorse, but I knew that if anyone found out I would be ridiculed. Almost daily throughout that summer, I was a willing participant with Marcel. No matter how painful the sexual abuse was, it could not be as painful as believing my friends would think me defective, different, or damaged. So the abuse continued until Marcel and his family moved away. It was a dichotomy: in some ways, I was sad to see him go, but I was also happy to see the end. I wanted Marcel to love and care for me, and I did anything to make sure he did. I found it difficult to face my friends, and I prayed that no one would ever find out about what had happened, that this secret would go to the grave with me. I loved to swim and run logs down by the sawmill with my friends. There was a group of us whom my sister would fondly refer to as the Four Musketeers. So it was, the four of us standing in our little world, constantly dreaming of leaving and finding a better life. There were

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many times when we would lie on the dock at the sawmill dreaming those visions of fame and fortune. Individually we dared not, but as a group we dared to dream about being something other than held to the reserve. I was sexually abused for the second time when I was ten years old. One of my cousins and I were collecting pop bottles to sell at the air base located near the residential school. At that time, the residential school was being torn down to make room for a new one. The school was abandoned. The workers who were to tear it down had yet to arrive. As we were walking by, a man I knew offered to buy the pop bottles from us for more money than what we would have gotten at the air base. He told us to put the bottles inside one of the abandoned classrooms, which we quickly did. Just as we were about to leave, the man grabbed me and told me to stay. All of a sudden, more people entered into the room and formed a circle around us. What happened next was almost beyond belief. They told us to take off our clothes. We did so, and suddenly one of the men grabbed me and forced me face down onto one of the old tables placed against the wall. He then undid his pants and began his sexual assault. I remember feeling powerless. I also remember a fear so terrifying it felt like I was about to die. When he was finished, another man grabbed my hair and pulled me towards him. He whispered to me that he would kill me if I didn’t do exactly what he said. He undid his pants and told me to put his penis in my mouth. I almost vomited because I was so disgusted by what was happening. Yet fear caused me to do exactly what he asked. I must have blacked out— because the next thing I remember was my cousin and me walking away from the building. Neither of us mentioned this incident to anyone. The experience left a lasting impression on me, an impression that would last a lifetime. I walked away disgusted with myself. By the time I turned twelve years old, I was still emotionally numb. Everything that happened in my life served only to validate my mistrust. I lived in fear that someone would find out about me. I felt that somehow I was touched by the hand of the devil himself. It was becoming more difficult to live with what happened. I found my escape in solvent. I discovered the fantasy and disassociation sniffing gas can bring. I relished this escape. I sought it as often and as much as I could. For me, sniffing gas represented freedom from my pain. I did not care about anything but getting caught. Gasoline became my greatest friend, one that brought me gifts, the gifts of fan-

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tasy and escape. It was my first love, and I loved it with all my heart. I sought its relief and planned my life around it. I remember the day that would shape my life forever. It was 1 July 1967, Canada’s one hundredth birthday, and some friends and I were looking forward to ending the celebrations by sniffing gas in an old abandoned car. Our parents were also out celebrating, and we knew their drinking would last a couple of days. After spending the day in Fort Frances, we returned to the reserve. We stole five gallons of gas from the tractor at the lumber mill on the reserve, hiding the gasoline in the car. We then went for a swim and agreed to meet after dark. Around 9:00 that evening, I left for the old car. As darkness approached, my friends and I found some old cans which we used to hold the gas. All we had to do then was sniff the gas and enjoy the hallucinations. I am not sure how a candle got into the car, but in my stupor I remember looking up and thinking how pretty it looked with its light dancing on the dashboard. Around 11:00 that night, I went home, leaving two of my friends still sniffing gasoline. As I came around the front of the car, I saw the two faces looking out at me. I waved goodbye to them. Around midnight the car exploded from the buildup of gasoline fumes and the candle. My two best friends died, killed as a direct result of sniffing gasoline. It left the families and community trying to determine what went wrong. It was an experience that would shape the rest of my life. The following days were like a fog. I fought to hold back my tears. As the days passed, I remember the funeral. The coffins were closed, and in my childlike mind I believed my friends were not in them. For days after the funeral, I would go search for them. I went to all the places where we used to play, down to the old sawmill where we spent hours and hours playing cowboys and Indians, then up to the sawdust pile, the old swimming hole, and finally to their homes. No matter where I looked, the day always ended in the same way. I walked silently home. On my birthday, only eleven days after my friends had died in the car, my sisters, out of their love and concern for me, held a birthday party. This was the first real birthday party I remember having—and the only guests who came were my brothers and sisters. Right after my thirteenth birthday, I was subpoenaed to the courthouse to testify at the inquest into their deaths. Nothing I could possibly think of could have prepared me for what was about to happen. As

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I entered the courthouse, I found a large, cold place. I began to feel afraid, wondering if they thought I had killed my friends. As the proceedings went on, I was finally called to the witness box. Although the inquest laid no guilt, I walked out of that building condemning myself. In my thirteen-year-old mind, I believed I had killed both my friends. I walked away wishing I had died in the car. I never really recovered from their deaths, and carried the burden of guilt far into adulthood. For the following four years, my life remained the same, with the exception that I was beginning to grow up. By the time I had reached seventeen, the effects of that experience were buried deep inside me. I don’t recall much about those years other than a great deal of sadness and aloneness. I later remember coming out of my gigantic fog. It was as though someone had erased most of my life. I also remember my fear. It is the one feeling I can describe easily. But that fear changed the day I had my first drink of alcohol. I’ll never forget how I got started. I was seventeen, in high school, and heading into the washroom when another student, a friend of mine from Manitou Rapids reserve, asked me if I wanted a drink of lemon gin. I first didn’t think it a good idea. I had seen what alcohol had done to my parents. In spite of my apprehension, I’ll never forget the feeling I had when the gin took effect. Although I disliked the taste, the feeling spreading through my body was unmistakably pleasant. From the first time I took a drink, it seemed as though my whole world had suddenly changed. At last, I had found a friend and did not feel as though I was alone any more. My fear subsided, and I felt I had a kind of control over my life. For the first time, I did not feel apprehensive. I was able to talk to people. I went up to a girl and initiated a conversation. I was amazed at the ease with which I spoke. Increasingly, I found my conversation flowed quite easily—I was even witty, charming, charismatic. I am not sure if others noticed my change in personality, but I sure felt it. I was confident and thought I could take on the whole world. My new-found confidence was only because the alcohol had made me feel brave, yet I did not care what caused it. I only wanted to continue feeling that way. At first I thought drinking a lot of fun. I found companionship with the other teens who drank, and they seemed to understand me. I was finally part of a group, a feeling I had not experienced since I was thirteen. Alcohol helped me forget about all the things that had happened to me. But by the time I was twenty, I had attempted suicide a number of times. Somewhere along the line, alcohol had stopped making me

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feel good. I would wake up in the morning not knowing what I had done the night before. I hated not knowing what I was doing, but the numbness alcohol provided outweighed the consequences. Somehow I just rationalized that things would improve—all I had to do was find the right combination of drinks. In my attempts to normalize my drinking, I tried many forms of geographical cures. I moved to the city of Thunder Bay, Ontario, and back to Fort Frances when it didn’t work out there. The problem was that no matter where I went, I always took myself with me. Slowly it was beginning to dawn on me that perhaps I was the problem. As my drinking progressed, I became increasingly demoralized. I felt like there was no way out. Even my best friend, King Alcohol, no longer provided relief. With the added burden caused by the shame over the things I did and the people I hurt while I was drinking, I felt no reason to continue living. Whenever I looked into the mirror, I knew I had become what I had never wanted to be—one of the drunks who used to frequent my home. I knew I was in deep trouble when I woke up one morning with a loaded rifle in the bed with me. As I thought back to the night before, I vaguely remembered putting the gun to my head, pulling the hammer back, releasing it, and starting the process all over again. Sometime during the night, I finally fell asleep with the gun still in a firing position. I knew if I didn’t do something about my drinking, I would die. While I was going through this, my mother found sobriety, through a twelve-step, self-help program. As she learned to appreciate sobriety, she began to practise tough love on my father. After her return from treatment, she had left my father, who was still drinking. It worked. Once my father realized my mother was serious about her sobriety and that he might lose her, he agreed to pursue treatment. The dream of every child of an alcoholic is to have his parents sober, but I was still very sick and could not appreciate what they had done. Having acquired two sober parents, all of my visits back home consisted of them warning me about the “disease” called alcoholism and encouraging me to get treatment. They believed that I, too, was an alcoholic. I disliked what they were telling me and interpreted what they were saying as evangelism. But despite my resistance, it wasn’t long before I began to see how most of my present problems had come from my drinking. Each time I saw my parents, they seemed happier than I ever remember. It was through their example that this recovery stuff began to interest me.

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THE INDIVIDUAL’S ROAD TO ASSUMING RESPONSIBILITY

One night in July of 1977, everything seemed to fall apart. I found myself constantly drinking in spite of my parents’ attempts to make me see the light. I was getting so drunk that I would lose my memory after only three beers. This was followed by feelings of depression, hopelessness, and fear of impending doom. I knew that if I continued along that path I would eventually kill myself. One night I’d had enough and called my father to come pick me up. All I remember was having the last bit of alcohol I had poured down the drain. That night my father didn’t preach to me and tell me things that I already knew; instead he told me he understood. A friend of his came and talked to me for most of the night, and for some reason that particular night I believed what this man was telling me. For the first time in my life, I began to trust someone. The following week, I started attending a few self-help meetings. I unfortunately did not find myself remaining sober for very long. But finally in September 1977, after countless failed attempts to stay clean and sober, I entered a drug and alcohol treatment centre in Thunder Bay. I found my way out of the chaos because someone in my family had found a way to end the cycle of addiction in their own life. In other words, by watching my parents enjoy sobriety, I began to believe there was hope for me. If alcoholism is generational, then it only stands to reason that recovery can also be generational. I had to begin to accept responsibility for my own alcohol and drug use. No longer could I blame my parents. No one had forced me to drink. It was I who held the bottle to my lips and tilted it back. The first step in this recovery process was accepting the fact that I had worked very hard to get myself sick enough to not even value my own life. I sought self-esteem by finding acceptance among those whose drinking was also problematic. In the end, the one I hurt the most was myself. Yet I did hurt other people, too and I had to accept responsibility for that by making amends and by becoming a positive role model for others. To this very day, I haven’t taken a drink. I owe a great deal to my parents, whose support and encouragement allowed me a second chance at life. It was a relief to have someone in my life who had already been through the difficult things we have to face when we try and “get sober ”—paying some long-overdue bills, repairing lost or damaged friendships, rebuilding self-respect and broken, tattered lives.

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This process of recovery continued within our family. Soon another family member found sobriety, then a sister, followed by four more of my siblings. The recovery process took over ten years, yet it all began with a single family member wanting to change their life. In spite of virtually non-existent programs to help people who needed and wanted recovery, a few community members walked towards sobriety and remained clean and sober. From that small number, many of our community people are now in recovery and are receiving ongoing support from the same self-help program that had saved my life. It all started with just a few people who shared the same vision of sobriety. I don’t believe I would be here today were it not for those few people who had the dedication and commitment to keep those early self-help meetings going. Anishinabe people need to heal within the structure of the family and community. When we start our healing journey, we need not only to consider the family and community in healing but also to involve them in the process. Sometimes our families may still be “stuck” within their own issues. How, then, can we go to our father and ask for support for our abuse of alcohol when he himself is caught up in the cycle of addiction? As a young person growing up in a family where some of the members had not yet begun their healing journey, I had to rely solely on my parents as my primary means of support. After treatment I began attending a self-help group that my mother had been going to for years. In time, however, I began to feel there was something missing. I didn’t feel as if I truly belonged to the group. Despite everyone’s attempt to make me feel welcome, I still felt at a distance to people. I had a difficult time letting my down my defences enough for people to get to know me. I realized that I could not complete the circle without going back and discovering my own identity—discovering who I was as a complete person. This search for my identity meant I had to stop denying my Anishinabe ancestry and believing that the mainstream ways of healing had all the answers. Although I am grateful to my many teachers and counsellors who have helped me along the way, I ultimately had to take responsibility and complete the final journey myself. I began to attend ceremonies and pow wows. I spoke to and learned from our elders about our Anishinabe ways. When comfortable enough, I brought tobacco to an elder and asked to receive my spirit name. Eventually, I began to feel comfortable with my own identity. As I listened at healing and talking circles, my fear of being Anishinabe began to evap-

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orate. In the end, I was no longer ashamed of my past. I was proud of my Anishinabe ancestry. I have always heard people talking about wholistic healing but have come to realize that until we make healing all-inclusive by including men, families, and communities, our attempts at healing will always fall short of their mark. To feel complete as a person, I also had to begin dealing with my sexual abuse as a child. One of the problems I had encountered was that there were no support groups for men who were victims of child sexual abuse. I realized that the system was designed to see men as offenders, with very little programming directed to the victimization of men. And for that reason, I had to go through that healing process by myself. For wholistic healing to be a reality, healing must be all-inclusive; everyone, including men, need to be part of the healing process. As Anishinabe people, we can all relate on some level to the victimization of those who have been oppressed. We still are, to some degree, victims of the dominant culture. This concept of all-inclusiveness goes beyond the present definition of mind, body, and spirit as it takes into account everyone within the family, community, and society. The Besante model of family healing looks at family as an important element in healing and moves beyond to include the community in the healing process. Without community responsibility, we will continue to fall short in our efforts to reach out to our neighbours still suffering from the effects of alcohol and other traumas. If we are to speak about wholism, we must move beyond talk and incorporate accountability and community into our programs and services. Using this simple definition, we are now able to view the entire picture. A wholistic family healing model based on responsibility would, then, look like figure 1. Notice from this model that the circles are interconnected, indicating the importance of maintaining the connection between the individual, family, and community. In the middle circle, we see the areas of responsibility for the individual in relation to the family and the community. The individual is responsible for his/her feelings, body, sexuality, and breath. When we fail to assume responsibility for ourselves, we drift into indifference by blaming everyone else for the way we feel, we transfer those same messages to our children, and the cycle of blame continues from one generation to the next.

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Figure 1: A Wholistic Family Healing Model

Denial becomes a way of life for children of alcoholic parents. I hadn’t realized just how often I unconsciously distorted the truth. I grew up believing that drinking parties lasting from Friday night to Sunday afternoon were normal. I believed this because everyone I knew and was friends with in my community did the same thing. Growing up in a community where everyone I knew drank led me to believe that all people drank, and drank to excess. I thought it was normal to have parties start out with lots of laughter and later turn into bloody fights, desperate cries, and sounds of breaking glass. Never did I suspect that anyone grew up without such sights. Not until later in adolescence did I realize there were some families who played, listened, and spoke kindly to each other. I was astonished to find families whose time spent together was filled with joy and laughter. THE FAMILY’S ROAD TO ASSUMING RESPONSIBILITY FOR ITS MEMBERS

As I was going through the final stages of alcoholism, my family had also entered into a new era of healing; it began with my mother, who had always been the true leader in our family. When she first sobered up in 1975, my mother’s wish was to die sober. On 22 October 1995, my mother passed away, having achieved sobriety for over twenty years. The greatest gift she gave me was life, and she did so twice, the

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day of my birth, and the day in 1977 when she drove me to a treatment centre in Thunder Bay. It is not surprising that within the Aboriginal community women play such an important role in the healing of the family. When our women are still stuck in their own pain, the effects can be felt by individual members of the family and community. Women need to recognize the importance of their role and the importance they play in the lives of the community. As well, men need to recognize the importance of our women. No longer can we teach our young men to disrespect our women. From a very early age, we must teach our men that our culture will only be as strong as our women. I was travelling back from a northern First Nation with a prominent elder one day in 1993. It was my pleasure to ride with him for over six hours. As we travelled, we spoke of many things, including the role of women and medicine. As he spoke of the strength of our women and how the role of women was changing within the culture, I asked him what kinds of medicine (sacred herbs used for healing and purifying) were for women. In his kindest and gentlest voice, he leaned over to me, and touching my shoulder said, “Young man, women are the medicine.” As I thought about his words, I couldn’t help but think of the importance of the women in my life. For the first time, I saw the role of our women through different eyes. No longer would I view women as second-class citizens. I was able to see that whenever I put a woman down I was putting myself down, for I am a product of my mother, and for me to be a healthy human being I must respect that part of myself which is my mother. I endeavour to be more sensitive to the inequality that prevails in our society. My healing encourages me to speak out against wife assault and other forms of violence against woman. In Aboriginal society, men and women are healing in the same circle. Although it is the Aboriginal way, men and women should not be in the same circle until each has worked through their own sexuality issues. Both must feel comfortable with each other in order to heal together. When a man is hurt by a woman, sometimes only a woman can help the man complete the cycle of healing; however, it is the helper’s responsibility to ensure the healing takes place on a spiritual as opposed to a physical level. Unfortunately, we have listened to the mainstream view of male and female roles. We believe them when they tell us that women are subservient to men. All too often, we see women as our possessions,

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when in reality women are the real leaders. Without their ability to bring forth life, our whole society would cease to exist. I have witnessed over the past twenty years women leading their husbands and their children into healing. This was definitely the case in my family. After entering treatment, when I looked at my family I began to see my parents in a different light. I began to see what they were doing with their recovery. For the first time, I felt a deep sense of admiration and respect for them. Slowly it began to filter into my mind that recovery was possible. Over the course of that summer, I began to think if they could do it then maybe I could. I began to think maybe they were right. Recovery for my family was a process. By witnessing the recovery of my mother, I was able to demonstrate sobriety to my siblings by being a positive role model. I do not believe our young people will listen to us when we talk about the ravages of alcoholism and other social ills. Instead they will be watching to see how we demonstrate healing in our day-today lives. I demonstrated sobriety by staying sober. It wasn’t surprising, then, to see other siblings in my family look towards recovering from family issues and substance abuse. This created a whole new way of looking at things and a whole new way of relating to one another. No longer did we feel the need to pretend that we had the perfect family. As a family, we were very lucky because our mother chose to show and teach us about sobriety through her actions and not her words. In this way, our mother was the medicine our family so desperately needed. As a result of her courage and determination, her children were able to enjoy what every child of alcoholic parents dream of—sober parents. She took her role as mother seriously and stood beside her children through their own weaknesses and near-death experiences with alcoholism and codependency. Of course, tempers still flared. But the difference now was that all of my family members knew a great love for each other. In recovery, we began to respect our parents for the work they did in providing us with two lives, one at birth and the other in sobriety. We began to share a common bond with each other. Those in recovery became the keepers of those painful memories of each family member and the valuable contributions each made during those early days of childhood survival. It felt as if we had lived two lives. We had lost much in childhood because of alcoholism, yet we had gained far more in recovery. The endless bouts with depression, anger, confusion, rage, shame, self-doubt, and apathy have become our great-

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est teachers. The greatest gift we can give our families and our children is ourselves. Our greatest challenge will be to continue to be our real selves in the face of uncertainty and discord. The test of our recovery will be how we feel each morning as we stare at the person reflected back in the mirror. If we can look at ourselves with confidence and love, this will be passed to our children. When we view life in this light, we see the ability to change and end family violence within our power. THE COMMUNITY’S ROAD TO ASSUMING RESPONSIBILITY FOR ITS MEMBERS

Aboriginal people appreciate that our communities need to be involved in the healing process. Yet there are many who do not understand the traditional ways, nor do they understand what it means to be Aboriginal. Much of our self-worth and identity comes to us through our identification with our communities. As our communities heal and change, so will their value systems. Strong leadership is the key factor in healing our communities. Without strong leadership, those who are willing to face the realities of our situation will continue to be lost. We are in the midst of overcoming six generations of oppression which have left our families in shambles, our young men without vision, our old men without wisdom, our women without power, and our children without a future. Facing this is paramount in bringing those still lost into healing. Our families need to relearn many of the things they have been taught about ourselves and our parenting. We need to recognize that within our communities lie the answers to all of our hardships and that recognizing those hardships is the first step towards community healing. When a hurricane comes and tears down our buildings, uproots our trees, destroys our water supply, and cripples our children, it is not enough to say “Finally the sun is out. I can’t see anything wrong now.” Instead of taking a short-sighted view of the damage, we must survey it, acknowledge what the hurricane has done, empathize with and help those who are crippled, bury our dead, ensure the safety of the survivors, and begin to repair the harm caused by the hurricane. Our leadership must begin to address issues through an honest sharing of concern. Community members must begin to take part in that process, and our leaders need to hear what the members of their communities are saying.

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Within First Nations communities, there is a tremendous expectation for our leadership to be able to deal with many different types of situations. We expect our caregivers to be advanced crisis interventionists who can deal with a wide variety of crises. Recently one of our chiefs was quoted as saying that his community did not have a suicide problem because his people had taken a suicide training course. This alone is not the answer. The answer lies within the community’s ability to provide each member with a sense of purpose and a reason for living. As leaders, it is our responsibility to ensure that each of our community members has the opportunity to acquire the skills necessary for long-term employment. By providing long-term solutions for employment opportunities, our community members can reach towards self-sufficiency. I began work with a Native organization given a mandate to provide information on health and family violence to twenty-four First Nations within the Province of Ontario. We started our work as a project conducting community development workshops in those twenty-four communities. As we progressed, we were able to form a corporation and apply for funding to provide more services to First Nations. The project flourished. In 1995 the residents of Ontario elected a government whose sole intent was to reduce and/or eliminate the provincial budget deficit. In order to fulfill this mandate, social programs were cut across the province. The organization I worked for had one of those programs. We lost employees who provided community development and training in family violence. We have gone on, however. As I continued to plan a strategy towards self-sufficiency, I noted that many of the First Nations were not equipped to access our service through the World Wide Web or Internet. I proposed to the board of directors that we offer that service to people at cost. The service would provide and maintain home pages on the Internet, software development, computer installation, and provide any training people needed on computer programs. The second part of the strategy was to develop curriculum on healing principles which could be used towards credit for university and colleges courses. The curriculum would also be used for hands-on training of caregivers in the communities. The third component of the self-sufficiency plan was to create a newspaper promoting articles, people, agencies, and programs, which would shed positive light on Native people. Many Aboriginal people

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are concerned that the only news written about them is negative. This paper would do two things: generate income for programs and create a positive atmosphere for Aboriginal people. Further, by contracting research projects through this newspaper, we would produce more accurate information about our people. The money raised through these initiatives has the potential to make the organization self-sufficient if it is supported by the communities. What started as a project in the basement of a band hall has been developed into a corporation that will see some degree of self-sufficiency within four years. This is a great example of economic and social development working cooperatively within the same framework and a kind of community initiative that needs to be created and supported by our people. COMBATING COMMUNITY DENIAL

Historically, community denial has served its purpose. In the 1970s, if we told anyone that sexual or physical abuse was taking place within our communities, the Children’s Aid Society would come in and take our children away. Community denial was clearly a survival tactic. We have only begun to demonstrate our courage by rejecting disavowal and facing the truth. When we create programs and services helping our families, we are creating an atmosphere in which our community members can feel safe and good about themselves. Instead of looking at our social safety network as a symbol of our need to heal, we must look at it as our healing. The creation of a social network helps us to view our communities in a more positive light. It lets members who are still suffering from the effects of oppression and assimilation know there is a way out whenever it is wanted. Social programs create a change in the value system. We begin to tell the world that we as a community value the healing of our members. It does no one any good if we stand up and pretend nothing is wrong. The only ones we hurt are those who really need the services. While working on a project, I came across an article about a community that had constructed a sign placed at a road entering into the community. That sign clearly stated the community’s policy on family violence, that this community would not tolerate family violence of any form. It told community members that the community valued healing and created a need to address outstanding needs of support victims and offenders of family violence.

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For the formation of community policy to be effective, the community had to look at a way to address violators and victims. To do this, they addressed five key areas. 1. Finding ways to reach out to those still suffering from violence, addictions, eating disorders, loss of identity, purposelessness, hopelessness, anger, disdain, and suicide. 2. Developing plans to ensure people are able to feel safe in discussing issues of family violence and healing—such things as safe homes, removing offenders from the community for the safety of the victims, and legal issues concerning the police. 3. Looking at ways to help individuals heal from trauma and abuse. 4. Looking at ways families can heal from abusive situations and relationships which were/are abusive. 5. Ending the cycle of violence and abuse in our families and communities by looking at ways to prevent family violence and other issues.

By addressing all five areas of concern, this community can develop individual and community plans to address those issues and, in turn, help enhance the quality of life for its members. MOVING BEYOND GRIEF

To move beyond grief, we must begin to deal with the losses that have happened in our communities. Beginning in 1830 and finally ending in the 1960s, many of our children were taken away and placed in residential schools. Others were fostered out to non-Native homes, and lost touch with their families. My father was sent to a residential school in Fort Frances. He was taken away from his family for ten months of the year. At residential schools, our parents and grandparents learned to either obey the rules while under the strict care of the church or defy them. I am a second-generation survivor of the residential school. I have felt the effects of the residential school in the losses we experienced from alcoholism and family violence. I have felt it in the loss of my parents’ ability to connect with my brothers and sisters on a deep emotional level. My father and mother found it difficult to say those three magic words “I love you.” Through the acceptance of our responsibility as individuals, families, and communities, we will come to realize the real meaning of wholism. It will become for us the only way we can heal. This message will be

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accepted by others who, like ourselves, could not complete the circle of healing without walking a natural road leading to a deeper self-understanding. Instead of seeing ourselves as people who needed to be saved and rescued, we need to recognize the importance of the role we will play in the Hopi prophecy mentioned earlier in this chapter. This new way of viewing ourselves and our willingness to share our wisdom, strength, and faith will be the ground on which new foundations for living will be built—foundations created out of a free gift given to us by the Creator. Those gifts are our ability to love and care for each other. The interdependency created through the acceptance of our individual responsibility will enable us to eradicate the ravages created by dependencies and codependencies; both of which have for too long paralyzed our families and communities. How do we make the transformations required to bring about this shift in the way we view healing and life? There is no easy way to bring ourselves to the forefront of healing, but through dedication and commitment, we can build healing for all people. I believe that by relearning some simple concepts and applying them to life, you can accept a responsibility for yourself that can create a chain reaction of recovery within your family and community. But there is a proviso: don’t do it for anyone else but yourself. The only person you can change is you. Recovery is often a slow process to which there are no quick solutions. It took us over six generations to get to the point where we are today—so we need to be patient and settle for small steps on the road to recovery. What is important is the way we measure our progress by our ability to live life to the fullest and our willingness to share our recovery with those who want to hear about it. We must keep in mind that we have the resource people needed for healing within our individual communities. Our people are survivors, champions, and warriors who have survived an oppression striking at the very core of our spirits. Today our challenge is to accept a new prophecy, one bringing self-fulfillment and self-worth. That prophecy is to accept responsibility for ourselves, and to end the cycle of blame, creating an atmosphere and attitude that promotes and generates healing. We must look for progress in our recovery and not compare ourselves to others. There are no perfect people, so be gentle with your criticism. We will make mistakes, and maybe fall, but we must be willing to get up, shake off the dust, and move on. By expressing our feelings appropriately and not hurting others, we can move on without holding onto the past.

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ACKNOWLEDGEMENT From Calvin Morrisseau (1998). The healing journey. In Into the daylight: A wholistic approach to healing (pp. 61–84). Toronto: University of Toronto Press. With permission from the University of Toronto Press.


Part 3 Frontiers and Research


12 Old Religion, New Spirituality, and Health Care Carlton F. Brown

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new spiritual wine is being fermented in the health care field by new winemakers. Pastoral counsellors and chaplains find themselves relegated to the older stock—and in health care, older is not better. In Mark’s gospel (2:22, Jerusalem) there is a caution against the pouring of new wine into old wineskins. This chapter provides material for reflection on the new type of wineskin that this new spiritual wine will require. THE SEPARATION OF RELIGION AND MEDICINE

Religion and medicine find their common roots in ancient understandings of disease and healing. Shamanism attributed illness to a loss of “soul-power” (Inglis, 1979, p. 12). Both the ancient Greeks and the biblical Jews frequently attributed disease to a disfavoured God. Christianity brought treatment to the fore, with Jesus’ express mission of healing the sick. For hundreds of years, healing was part of the Church’s business. The Church, however, began to divest itself of its healing mission in the Middle Ages: Although the Church approved of hospitals for the poor, at the Council of Tours in the twelfth century, Pope Alexander III warned that the devil was seducing clergy to treat the sick with the excuse that they were serving suffering humanity. The study of medicine, the Pope feared, submitted them to many mundane temptations; in future treatment was to be left to the physicians. (Inglis, 1979, p. 20) 191

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As soon as the church divested itself of medicine, the secular authorities regulated it: by 1224, no one was allowed to be called a doctor without passing an examination and obtaining a licence (Inglis, 1979, p. 21). Medicine began charting its own course, influenced, at various times, by alchemy, vitalism, mechanism, and, eventually, the modern sciences. Priests attended patients “only for spiritual consolation,” with prayers “designed to supplement treatment, not to supersede it” (Inglis, 1979, pp. 23–24). While the Church and the medical profession individuated from one another, the shaman’s role began to be parcelled out to separate professionals, as well. “The shaman’s function…to heal the mind, body, and spirit” was split among the separate professional roles of the physician, attorney, teacher, cleric, and psychotherapist (Peterson, 1992, pp. 12–18). Religion was now completely separated from medicine. THE CLINICAL PASTORAL EDUCATION (CPE) MOVEMENT

But by the 1900s, physicians like Richard Cabot were inviting clerics back into the hospital to do more than pray: they were being trained in the “case method” of clinical learning. Without the benefit of Pope Alexander III’s vigilance, clerics like Anton Boisen eagerly heeded the call (Powell, 1975). Clinical pastoral education (CPE) became the offspring of this reunion of religion and medicine, with the development of two new health care professionals: chaplains and pastoral counsellors. A hundred years later, the ground is shifting again. Western postmodern society demands that doctors listen to patients’ stories of their experience of illness (Frank, 1995). This same society asks for the continuance of spiritual care while having become distrustful of the Church (Bibby, 1987). In health care, this is causing another change in the relationship between religion and medicine. VandeCreek’s analysis of the health care literature shows an increasing interest in “spirituality” in health care (VandeCreek, 1999). “Religion” appears to be falling into disfavour because of its rigid boundaries, while “spirituality” is seen as more creative and transcendent of boundaries (VandeCreek, 1999). Unfortunately, chaplains, and perhaps pastoral counsellors, too, are more frequently seen as “religious” rather than spiritual. Health care is enjoying a spiritual revival, not a religious one, and its growth is being championed by a multi-disciplinary team of health care professionals, which excludes chaplains and pastoral counsellors.

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REDEFINING SPIRITUALITY THROUGH ONTOLOGY

Health and belief are powerful aspects of being. People seek to name their experiences of these aspects of being in order to render them manageable. As everyone experiences them, they are named and described in myriad ways. In a climate that is distrustful of professionals, the naming proliferates, resulting in problems of definition and confusion of meaning. Ontology offers a way through this. Ontology, the study of being, serves to define aspects of being. Even aspects of being as pervasive and powerful as love, power, and justice, can be subject to ontological analysis (Tillich, 1954). Health and spirituality can be looked at through the lens of ontology, with the hope of gaining clarity.

The Structure of Being The basic structure of all being is dialectical: there is a self in dialogue with its environment or world (Tillich, 1951). A self in dialogue with its environment may tend towards its centre, away from its environment— favouring self-identity—or it may tend away from its centre, towards its environment—favouring self-alteration. Three processes describe the balance between these two tendencies of the self: (1) self-integration, in which the self is concerned primarily with self-identity. At the biological level, self-integration is seen in the maintenance of cellular homeostasis; (2) self-creation, in which the self is concerned primarily with selfalteration, or the formation of a new centre of self. In biology, self-creation is observed in cellular reproduction; (3) self-transcendence, a “vertical” case of self-alteration in which the self is “driving beyond itself as finite life” or “going beyond limits” (Tillich, 1963, pp. 30–31). Biologically, this is difficult to describe, until being is viewed in several dimensions. The dimensions of being Being, including all matter, non-living and living, exists in various dimensions. The metaphor of dimension allows for the description of different “realms of being in such a way that there cannot be mutual interference” (Tillich, 1963, p. 15). A “realm” describes a portion of being predominated by a particular dimension. The realm of inorganic matter is predominated by the inorganic dimension of being. The organic realm is predominated by organic molecules. The biological realm is predominated by biological life. The psychological realm is predominated by self-aware organisms. The spiritual realm is predominated by organ-

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isms that transcend their self-awareness to acknowledge the demands and limitations of their environment. Although each dimension does not interfere with the other dimensions, each succeeding dimension builds on the preceding dimensions. Organic molecules require inorganic atoms. Biological life requires organic molecules. Psychological self-awareness requires a biologically functioning brain. A “spiritual being” is a biologically functioning, psychologically self-aware organism that has transcended its self-awareness to include an awareness and acknowledgement of its environment’s limitations and demands. By definition, this is a human being (Tillich, 1963). Spiritual function, under this model, requires self-awareness, which requires biology, which requires organic chemistry, which requires basic atoms. Theologically, this requires an intense amount of integration, and Tillich points out the general failure of theologians to include a theology of the inorganic. But we are, after all, made out of dust (Tillich, 1963). Nor does this necessarily contradict New Testament theology (2 Cor. 5:1–5, Jerusalem).

Transcendence Transcendence is the process by which a dimension of being “climbs beyond” its normal limits of existence. Inorganic matter transcends itself by becoming organic matter. Organic matter transcends itself by becoming biological life. Biological life transcends itself by becoming psychological life. Psychological life transcends itself by becoming spiritual life. Spiritual life transcends itself by entering the historical dimension (Tillich, 1963). RELIGION AND MEDICINE IN THE CONTEXT OF ONTOLOGY

The Spiritual Dimension While the health care literature seeks to operationalize spirituality in a myriad of definitions, ontology simply defines the spiritual dimension as the dimension of being characterized by an awareness of the other. A spiritual self is a self that is aware that it exists in a dialectical relationship with its environment, and that its environment sets limits and places demands upon it. The hallmark of spirituality is self-definition in the context of environment. Self-integration, self-creation, and self-transcendence may be operationalized in this dimension as questions:

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1. Who am I in the context of my environment? What power can I legitimately claim? What limitations does my environment place upon me? (self-integration) 2. What meaning do I make out of my existence in this environment? What do I contribute to my environment? What is the content of my story? What are my feelings? (self-creation) 3. In what larger context do I place myself, and how does this enable me to climb beyond my limitations? What is my part in history? (self-transcendence)

Religion is the way in which many people deal with the self-transcendent function of the spirit. Therefore, religion is part of spirituality; any scheme which attempts to separate religion from spirituality is not ontological—and perhaps, not helpful.

Spirituality and Medicine Medicine is a spiritual pursuit (Sulmasy, 1999). The practice of medicine is the practice of a self—the physician, nurse, or other health care practitioner—in dialogue with a limit-setting environment, including the limits of the profession, and the demands of the person seeking care. Medicine is not always aware of these limits and, at worst, risks “falling” into a non-spiritual dimension of being. It may cease to be aware of the person seeking care as a person, and instead treat it as a sick body (reverting to the biological dimension) or a sick mind (reverting to the psychological). At its best, however, medicine is an art in which the relationship itself can be healing (Yalom, 1989). In the relationship between any health care practitioner and the person seeking care, there is the potential for “spiritual” healing that transcends the biological and psychological dimensions of care. The cure of souls and the care of the body may function synergistically. It is no wonder that clergy are continually drawn to the care of the sick, and that physicians are drawn to the cure of souls. It is as if some primitive force drives each of these modern and separated professions towards a “reunion of the estranged” (Tillich, 1954, p. 25). THE INVESTIGATION

The dynamics of the relationship between spirituality and medicine need to be described in more detail. It is not enough to say that chaplains are no longer welcome at the table (VandeCreek, 1999): it is necessary to look at who is at the table, and at what is happening to the people at the table, over time. This chapter describes temporal

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changes in religious, spiritual, and occupationally related variables in the health care literature.

Methodology An electronic search for keywords related to religion and spirituality was carried out using an IBM laptop computer, Internet access, and the website PubMed. “PubMed, a service of the (U.S.) National Library of Medicine, provides access to over 11 million citations from MEDLINE and additional life science journals” (PubMed, 2001). With a primary focus on MEDLINE, PubMed provides a publicly accessible and powerful online searching tool for the health care literature. All PubMed citations were searched for the occurrence of the words “old” and “new” to test for a language bias favouring “old” or “new” sources of knowledge in health care. PubMed was also searched for the occurrence of the words “better” and “spirituality” in the same citation as “old” and “new.” Both Medical Subject Headings (MeSH) and non-MeSH keyword searches were carried out. The MeSH keywords constitute “controlled vocabulary,” set by the National Library of Medicine; they allow for consistent retrieval of information (PubMed, 2003). Words that have not yet been defined as MeSH keywords (e.g., “spirituality”) are simply searched for their literal presence anywhere in the electronically coded health care citation. All of the words searched are shown in table 1. Complex searches were carried out using the logical operators AND and OR combining professions with “Pastoral Care.” “Spiritual care,” a non-MeSH keyword, was tested as an alternative keyword. MeSH keywords for the health care professions of physician, nurse, social worker, occupational therapist, and chaplain—“Medicine” OR “Physicians,” “Nursing” OR “Nurses,” “Social Work” OR “Social Work Department, Hospital,” “Occupational Therapy” OR “Occupational Therapy Department, Hospital,” and “Chaplaincy Service, Hospital,” respectively—were combined with the MeSH keyword “Pastoral Care” to delimit the attachment of each health care profession to publications concerning pastoral care. The “date of publication” limiter, “[dp],” was used to return the total number of citations in PubMed for any given year of publication (e.g., “[dp] 1999”). This allowed for calculations of frequency of occurrence of keywords in PubMed citations. The total number of citations of a keyword in a given year of publication was divided by the total number of

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Table 1: Medical Subject Headings (MeSH) and Non-MeSH Keywords Searched Word Searched New Old Better Spirituality* Religion Pastoral Care Chaplaincy Service, Hospital Medicine Physicians Nursing Nurses Social Work Social Work Department, Hospital Occupational Therapy Occupational Therapy Department, Hospital Note. Medical subject heading keywords (MeSH) are underlined. *Spirituality became a MeSH keyword in 2002, after most of this study was completed.

citations in PubMed in that same year, and then multiplied by 100, to yield a percentage occurrence of that keyword in that year of publication. RESULTS

The word “new” appears in 800,868 citations in PubMed. The word “old” appears in 299,803 citations. The ratio of “new” to “old” is 2.7 to 1. “New AND better” appear in 24,645 citations. “Old AND better” appear in only 5,115 citations. The ratio of “new AND better ” to “old AND better” is 4.8 to 1. Currently in PubMed there are 80 citations containing “new AND spirituality,” and 7 citations containing “old AND spirituality.” The ratio is 11.4 to 1. The number of citations containing at least one occurrence of the word “spirituality” were counted and plotted according to the year of publication. The result is an exponential curve, as shown in figure 1. The total number of citations in PubMed, arranged by date of publication, is shown in figure 2. The frequency of citation of “spirituality” in PubMed, calculated by dividing the total number of citations of “spirituality” (figure 1) by the total number of citations in PubMed (figure 2), and multiplied by 100

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Figure 1: Citations of “spirituality” in PubMed

Total number of citations containing at least one occurrence of the word “spirituality” in the electronically coded part of the citation (usually the title and the abstract), found in the database for each year of publication from 1960 to present.

Figure 2: Total citations in PubMed database

The total number of all papers coded in PubMed, plotted against the year of publication of those papers.

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Figure 3: The frequency of PubMed citations with “spirituality” (f[spirituality]) appearing at least once in the citation

This is the total number of citations with “spirituality” in a given year, divided by the total number of papers coded in PubMed in that same year, multiplied by 100 per cent.

to give the percentage of the database that contains references to “spirituality” in any given year, is defined as f(spirituality), and is shown in figure 3. The frequency of spirituality citations is increasing exponentially. Using SPSS (1999), the data fit the exponential equation f(spirituality) = exp(.1791(year)-362.02). Currently, “spirituality” occurs in about 0.02 percent of the PubMed database. The frequency of “religion” citations in PubMed, f(religion), is shown in figure 4. If the f(religion) data are approximated to a straight line, using SPSS and linear regression, a modest increase in the citation of religion is seen over time. The data fit the equation f(religion) = .0023(year)-4.4980. Currently, “religion” is found in between 0.102 (calculated) and 0.19 (actual for 1999) per cent of the database, or anywhere from five to ten times the current frequency of spirituality. That is to say, “religion” as an interest in health care citations surpasses “spirituality” by a factor of from 5 to 10. Figure 4 also lends itself to an alternative interpretation—that is, that health care’s interest in religion has followed a biphasic course over time, peaking around 1973 and again in the year 2000.

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Figure 4: Frequency of occurrence of “religion” in citations in PubMed

Calculated in the same manner as for spirituality, shows the percentage of papers in the PubMed database containing the keyword “religion” at least once in the paper, plotted against year of publication.

Figure 5: Frequency of occurrence of “spiritual care” in PubMed citations 0.007

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The percentage of papers with at least one occurrence of “spiritual care” plotted against year of publication.

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Figure 6: Percentage of PubMed citations containing “Pastoral Care”

“Spiritual care,” while not a MeSH keyword, was tested for its usefulness in showing trends in spiritual care in health care. The frequency of occurrence of “spiritual care” is shown in figure 5. There is an increasing trend, but the data are quite scattered and the frequency is quite small. “Spiritual care” occurs in less than 0.006 percent of the database. The frequency of occurrence of “Pastoral Care” in PubMed is shown in figure 6. Pastoral care seems clearly to be following a biphasic pattern, rising exponentially from PubMed’s inception to a maximum, in 1978, of just over 0.03 per cent of the database. It falls from there until 1990, and since 1990 appears to be rising exponentially again. PROFESSIONS ASSOCIATED WITH SPIRITUAL CARE

The frequency of occurrence of the MeSH keyword, “Chaplaincy Service, Hospital,” is shown in figure 7. This keyword, which tracks citations of chaplains in health care, peaks at just over 0.012 percent of the database in 1979, and has been falling since. When pastoral care (figure 6) and chaplains (figure 7) are plotted on the same graph (figure 8), it is apparent that there have always been more references to pastoral care than to chaplaincy services in PubMed. These two both peaked in 1978, but while chaplaincy citations continue to fall, pastoral care citations are on the rise again, without reference to

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Figure 7: Percentage of PubMed citations containing the keyword “Chaplaincy Service, Hospital,” indicating a paper that makes reference to chaplains in health care

Figure 8: Temporal association between Pastoral Care and Chaplaincy Services in PubMed citations, showing an increasing disparity over time

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chaplains. For the last ten years, in health care, there are increasing citations in pastoral care and decreasing references to chaplaincy services. When each profession was combined with the MeSH keyword “Pastoral Care” and the logical operator AND, the following data were obtained, showing the relationship of citation of pastoral care with each health care profession in PubMed (table 2). Table 2: Total PubMed Citations Associated with Each Health Care Profession and Pastoral Care Profession

Citations of Profession and Pastoral Care

Nurses Doctors Chaplains Social Workers Occupational Therapists

606 376 329 29 1

Figure 9: Frequency of PubMed citations associating a particular profession (nursing, medicine, chaplaincy) with Pastoral Care over time

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Chaplains, doctors, and nurses appear to be the three most important health care professions associated with pastoral care, and these three professions were tracked for changes in association with pastoral care over time (figure 9). Doctors and chaplains peaked in the early 1970s, coincident with the first peak in pastoral care. Over the last ten years, pastoral care is on the rise in association with the nursing profession. The physicians are second in line, and chaplains are third. DISCUSSION

Tom O’Connor (personal communication) has previously stated that the rate at which interest in spirituality in health care is increasing is exponential. This finding is confirmed here and related to the changes of other spiritual variables in health care.

New Is Better Spirituality is a “new” finding in health care. It enjoys the privileged status of all new things, and is nearly three times more likely to appear in a health care publication than “old.” When combined with the word “better,” “new” is nearly five times more likely to appear than “old.” When combined with “spirituality,” “new” is more than eleven times more likely to appear than “old.” Spirituality is exciting in health care because it is new. Health care is a culture that values the new. The literature of health care is biased towards “new” treatments and “new” discoveries. “New” is better than “old.” This is odd, given the long history of health care, which is “old.” It is older than Christianity. Yet the literature of health care eschews its history, embracing the “new” as “better.” “New” things tend to grow at an exponential rate. Biologically, and mathematically, when self-alteration is favoured, “doubling” occurs: one cell makes two, two make four, four make eight new cells, and so on. This is exponential growth. Self-alteration is favoured as long as the environment allows it and the being attempts it. Given a relatively receptive audience for “spirituality” and enthusiastic researchers who wish to study and write about it, “spirituality” will continue to grow exponentially. When researchers become tired or the health care audience becomes less receptive—for example, when spirituality becomes an “old” topic in health care—this growth will slow down. It may reach a plateau, as religion has. If “old” spirituality fails to have enough substance to be useful to health care, it may eventually decrease or die.

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Religion is no longer increasing exponentially because it is not a new thing. However, neither is it in danger of dying in health care: at ten times the concentration of spirituality, religion has considerable substance and staying power. Even though it is “old,” it is tolerated because it may yet be useful.

Total PubMed Citations and Trends PubMed contains health care articles with dates of publication that go back only to 1964. No meaningful data is available much before 1970. From 1970 onwards, PubMed provides a fairly stable pool of health care citations, although each year there are more citations per year. So far, for the year 2000 alone, nearly 500,000 citations exist in PubMed. “Spirituality” shows a decrease in the number of citations in the year 2000, which may be because all the citations of health care articles with dates of publication in the year 2000 have not yet been added into the PubMed database. The data for this study were originally collected from PubMed early in 2001, but were updated on 30 April and 1 May of 2004. Between early 2001 and four months into the year, PubMed citations for 1999 had increased by 1.25 per cent; for 1998 by 0.675 per cent; and for 1997 by 0.361 per cent. For the year 2000, pastoral care citations had more than doubled (from 41 citations to 92). Therefore, the data may not yet be accurate for the last two or three years. “Spirituality” was introduced as a Medical Subject Heading (MeSH) in PubMed after this study was completed (PubMed, 2002). Prior to this, the closest MeSH words were “Spiritualism—Religious philosophy expressing the fundamental belief that departed spirits may be contacted by the living through a medium,” and “Mental Healing—The use of suggestion or faith to cure disease, particularly physical illness” (PubMed, 2001). Neither seemed to be appropriate for a chapter that seeks for a more general usage of the word “spirituality.” In the absence of a matchable MeSH word, PubMed simply finds the number of citations that contain the word “spirituality” anywhere in the stored version of the citation—this typically contains the title of the article and limited bibliographical information, including abstract and keywords. The recent addition of “spirituality” as a MeSH word may make the ongoing work of defining spirituality in health care easier, because “MeSH terminology provides a consistent way to retrieve information” (PubMed, 2003).

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Religion “Religion” is a MeSH word, and is defined by PubMed as “A set of beliefs concerning the nature, cause, and purpose of the universe, especially when considered as the creation of a superhuman agency. It usually involves devotional and ritual observances and often a moral code for the conduct of human affairs” (PubMed, 2003a, s.v. “religion”). At the current rates of increasing citation of both spirituality (exponential) and religion (linear), and if spirituality does not suffer as an interest in health care as it becomes older, spirituality will surpass religion as a topic of interest in the field by the year 2010. What is the difference between religion and spirituality? PubMed defines “spirituality” as “sensitivity or attachment to religious values, or to things of the spirit as opposed to material or worldly interests” (PubMed, 2003a, s.v. “spirituality”). While there may be some overlap, PubMed citations containing “spirituality” may be expected to include papers that are “opposed to material or worldly interests” (PubMed, 2003a). In another place, “spirituality” is defined as “incorporeal” (“Spirituality,” 2002). It may be that health care professionals are beginning to appreciate the ways in which the “incorporeal” can provide power or health to the “corporeal.” Zohar and Marshall borrow from Webster’s Dictionary to postulate this energizing connection between spirit and body; they write that “Webster’s defines spirit as ‘the animating or vital principle; that which gives life to the physical organism in contrast to its material elements; the breath of life’” (Zohar and Marshall, 2000, p. 4). Health care may be searching for this vitalizing principle. A qualitative analysis of the “spirituality” citations in health care is required to explore this further and is beyond the scope of this chapter. Pastoral Care Pastoral care, denoting the practice of spiritual and religious care in health care, has had a biphasic existence, peaking in 1977, falling off somewhat in the mid-1980s, and is now on the rise again. “Pastoral care” is the MeSH term for “counselling or comfort given by ministers, priests, rabbis, etc., to those in need of help with emotional problems or stressful situations” (PubMed MeSH Browser, s.v. “pastoral care”). “Spiritual care” was not a significant search term in PubMed. Despite PubMed’s definition of pastoral care, this form of care in health care has never been the exclusive purview of the clergy. If this were so, then cross-referencing pastoral care with “Chaplaincy Service, Hospital” would have captured all or most of the references to pastoral

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care. It didn’t. Even when pastoral care peaked in 1978, chaplaincy references accounted for only half the articles. Since that time, the gap has widened. In the last five years, less than 17 percent of the articles written about pastoral care have included references to chaplains. Others are providing the “new” writing on pastoral care. The creation of the new is consistent with an ontological understanding of life: it is a process that favours self-alteration, the formation of a new centre. But self-alteration requires risk: it requires that the selfcreating being step out of its centre and place itself in a foreign environment. On the other hand, ontology understands that self-creation is a dynamic process of self-identity and self-alteration: even as the self is putting itself out into a new centre, it returns to the original centre and then steps out, time and time again. This is analogous to the health care metaphor of equilibrium, which is always a dynamic process, or of cell reproduction itself: the “new” cells contain much of the “old.” Self-alteration never occurs without self-identity. The new creation incorporates and transforms the old. Yet a cursory view of the nursing literature on spirituality suggests that nurses are trying to create spirituality without reference to its selfidentity. Most of the nursing literature on spirituality seems to refer back to itself (Goddard, 1995; Hermann, 2001; Hicks, 1999; Baldacchino & Draper, 2001; Tuck, McCain, & Elswick; 2001). In the “new” creation of spirituality in health care, there is not enough “old” to give it the vitality that it seeks. Ontologically, it is unbalanced. Spirituality in health care requires more history, and without it, it will die. Our results of the prevalence of “new” over “old” in the literature suggest that health care is predisposed to ignore history. Chaplains and pastoral counsellors, as part of the shamanistic profession that honours history, have what health care needs to produce a more vital spirituality. “History” is the dimension into which spirituality transcends itself (Tillich, 1963). As the bearers of the “history” of spiritual care, chaplains and pastoral counsellors are responsible for it. We may transcend their understanding of practice and spiritual care so as to remain in the “history” of health care, or we may become the irrelevant “history” of the past. It may be that we are already considered irrelevant and un-“pastoral.” Meanwhile, the nurses are assuming pastoral care. This is consistent with a theological understanding of the raising up of new shepherds: if we fail to do our job, God will replace us (Jer. 23:1–4, Jerusalem).

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To remain relevant to health care, we must don new skins. Operationally, we can adopt or create a new language to express the “old” ideas that we know to be valuable to health care. We might think of this as “new skins” for “old wine.” Kurt Parkum (1985) borrowed from the language of sociology to describe the function of chaplaincy and pastoral counselling as the meeting of “expressive” needs. He distinguished these needs from “instrumental” needs, and said that chaplains and pastoral counsellors were the only health care providers dedicated to dealing with the first set of needs. “Instrumental” and “expressive” were “new” terms borrowed from sociology and were better received than “old” words like “medical” and “religious” needs. Chaplains and pastoral counsellors may wish to consider something new to recapture the imaginations of their health care colleagues and to show that they still have something useful (i.e., new) to offer to health care; such is its culture. Our working within it, while requiring energy and creativity, may be viewed, quite literally, as the “creative” function of the spirit, transcending into history. If Tillich is right, we do a disservice to the process of spirituality by overemphasizing self-identity. The human being, as a spiritual being, may ultimately be destined for selfalteration: “new wine into new skins” (Mark 2:22, Jerusalem). REFERENCES Baldacchino, D., & Draper, P. (2001). Spiritual coping strategies: A review of the nursing research literature. Journal of Advanced Nursing, 34 (6), 833–41. Bibby, R.W. (1987). Fragmented gods. Toronto, ON: Irwin. Frank, A.W. (1995). The wounded storyteller. Chicago, IL: University of Chicago Press. Goddard, N.C. (1995). “Spirituality as integrative energy”: A philosophical analysis as requisite precursor to holistic nursing practice. Journal of Advanced Nursing, 22, 808–15. Hermann, C.P. (2001). Spiritual needs of dying patients: A qualitative study. Oncology Nursing Forum, 28 (1), 67–72. Hicks, T.J. (1999). Spirituality and the elderly: Nursing implications with nursing home residents. Geriatric Nursing, 20 (3), 144–46. Inglis, B. (1979). Natural medicine. Glasgow: William Collins Sons. Parkum, K.H. (1985). The impact of chaplaincy services in selected hospitals in the eastern United States. The Journal of Pastoral Care, 39 (3), 262–69. Peterson, M.R. (1992). At personal risk. New York: W.W. Norton. Powell, R.C. (1975). CPE: Fifty years of learning through supervised encounter with living human documents. New York: Association for Clinical Pastoral Education. PubMed. (2001). U.S. National Library of Medicine. Retrieved March 15, 2001, from http://www4.ncbi.nlm.nih.gov/PubMed/

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PubMed. (2002). U.S. National Library of Medicine. Retrieved March 15, 2002, from http://www.ncbi.nlm.nih.gov/entrez PubMed. (2003). U.S. National Library of Medicine. Retrieved May 15, 2003, from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=mesh PubMed. (2003a). U.S. National Library of Medicine. Retrieved from http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Search&DB=mesh “Spirituality.” (2002). Infoplease.com Dictionary. Family Education Network. Retrieved March 15, 2002, from http://www.infoplease.com/ipd/A0665786 .html Sulmasy, D.P. (1999). Is medicine a spiritual practice? Academic Medicine, 74 (9), 1002–5. Statistical Package for the Social Sciences (SPSS). (1999). Release 10.0.1. Retrieved from http://www.spss.com Tillich, P. (1951). Systematic theology: Vol. 1. Reason and revelation, being and God. Chicago, IL: University of Chicago Press. Tillich, P. (1954). Love, power, and justice. London: Oxford University Press. Tillich, P. (1963). Systematic theology: Vol. 3. Life and the spirit, history and the kingdom of God. Chicago, IL: University of Chicago Press. Tuck, I., McCain, N.L., & Elswick, R.K., Jr. (2001). Spirituality and psychosocial factors in persons living with HIV. Journal of Advanced Nursing, 33 (6), 776–83. VandeCreek, L. (1999). Professional chaplaincy: An absent profession? The Journal of Pastoral Care, 53 (4), 417–32. Yalom, I.D. (1989). Love’s executioner and other tales of psychotherapy. New York: Basic. Zohar, D., & Marshall, I. (2000). SQ: Spiritual intelligence, the ultimate intelligence. London: Bloomsbury.


13 God-Talk in the Spiritual Care of Palliative Patients Colleen Lashmar

T

here is one question, often referred to as THE question, which is frequently and specifically asked of hospital chaplains as well as of spiritual caregivers in general. The question is simply, Why is God doing this to me/to him/her? The corollary to the first question is a second question, which forms and informs the heart of this research project: How does one speak about God in the context of innocent suffering? In order to explore the language of suffering, it is helpful to probe the source and origin of suffering as a part of the evil that is present in the world. Theodicy is defined in the New Dictionary of Theology as “the problem with evil.” David Hume raises essential questions around this topic. He writes “Is God willing to prevent evil, but not able? Then God is impotent. Is God able to prevent evil, but not willing? Then God is malevolent. Is God both willing and able to prevent evil? Then why is there any evil in the world?” (Komonchak, Collins, & Lane, 1991, p. 360). For Teilhard de Chardin (1960), a twentieth-century theologian, evil is “no accident.” He viewed evil as “an enemy,” the “shadow which God raises by His very decision to create” (see also Faricy, 1967). Dorothee Sölle, in her book Suffering (1975, p. 139), speaks of the passion narratives as a locus for speaking of God and suffering. She also identifies three phases or stances of suffering. The first phase is muteness, powerlessness, and the totally turned-inward stance of isolation. The second phase is protest, or “the language of lament” such as that used by the psalmists. Sölle asserts that some form of the first two phases

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must be experienced before one can arrive at the third, which is faithful acceptance (p. 73). A twentieth-century Jesuit theologian, Karl Rahner, gives the following definition of grace: “Grace is God’s communication, in which the divine self-gift to us is the divinizing loving kindness which is God. Here God’s work is really God’s self, as the one communicated. From the very first this grace cannot be conceived as separate from God’s personal love and human beings’ answer to it” (cited in Kelly, 1992, p. 102). This approach to grace, as God’s presence to us in all of the circumstances of our lives, shapes the context of speaking about grace in this chapter. Many writers on grace state that God is the initiator of grace. Some believe that after the moment of initiation, grace becomes a twoway street, a place where there is a partnering of responsibility. In the introduction to On Job: God-Talk and the Suffering of the Innocent, Gustavo Gutierrez (1987) asserts that the question “My God, where are you?” springs from the suffering of the innocent. It also has its source in faith. “It is precisely because they believe that their perplexity has arisen” (p. xv). Gutierrez goes on to ask the question whether it is possible to believe in God without expectation of reward, or “for nothing?…Is there a correct way of talking about God within the most strained and knotty of all human situations: the suffering of the innocent?” (p. 93). He uses the crucifixion of Jesus as an example. He notes Jesus’ protest and acceptance: “Even in his lament Jesus spoke correctly about God…His cry on the cross renders more audible and more penetrating the cries of all the Jobs, individual and collective, of human history” (p. 101). This chapter is based on a research project I conducted in 2000, which followed the methodology of a qualitative study. Bruce L. Berg (1995) notes that “qualitative research (thus) refers to the meanings, concepts, definitions, characteristics, metaphors, symbols and descriptions of things” (p. 3). My research explored the core issue of the experience of God for palliative patients in an “open-ended, descriptive” way, looking for some pictures or images of God in the context of the innocent suffering of a palliative patient. Another aspect of qualitative research that was valuable to this study is that it emphasizes the processes and meanings rather than various measurements. RESEARCH PARTICIPANTS

There were twenty-two research participants, ranging in age from thirty-seven to ninety-five years of age. Seventeen were female

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and five were male. Eighteen participants had a diagnosis of cancer as the primary disease. Of the other four participants, two patients were listed as being chronic palliative, one of these with renal failure; one had a diagnosis of post-polio syndrome and illness not yet diagnosed; and one had a primary diagnosis of heart disease. The research population included any male or female eighteen years of age or older, who was on the palliative care list at the participating institutions. They participated either as an in-patient or as an outpatient, for a total of twenty-two subjects who were currently in palliative care at two acute-care hospitals and one long-term care facility, which are owned and operated by a denominational health care system in southwestern Ontario. Table 1 Age

Gender

Relational Status

Church Affilia- Diagnosis tion or Heritage

Patient 1

95

F

Anglican

Patient 2 Patient 3 Patient 4 Patient 5

83 73 77 72

F F M F

Never Married Married Widowed Married Separated

Orthodox Christian R.C. United

Patient 6 Patient 7

91 69

F F

Widowed Married

R.C. United

Patient 8 Patient 9

55 73

F M

Married Married

Patient 10 Patient 11 Patient 12 Patient 13 Patient 14 Patient 15 Patient 16 Patient 17 Patient 18

78 37 68 77 83 73 75 72 59

M F F F M F M F F

Married Married Married Widowed Widowed Widowed Married Married Married

Patient 19

68

F

Divorced

Patient 20 Patient 21 Patient 22

63 73 84

F F F

Married Married Widowed

United Christian Missionary R.C. Protestant R.C. Pentecostal R.C. United United/R.C. United/Anglican Born Again Christian Mennonite/ Presbyterian Presbyterian United United

Illness not diagnosed (Chronic Palliative) CA Bone CA Bladder CA Throat/Lung/Brain Post-Polio Syndrome & Illness not diagnosed Heart Aneurysm, Renal Failure (Chronic Palliative) CA Breast/Lung CA and Heart CA Prostate CA Uterus CA Ovary CA Lung CA and Heart CA Breast CA and Heart CA Breast/Bone CA Brain CA CA Brain CA Bowel/Breast/Bone CA Uterus/Pelvis

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RESEARCH QUESTIONS

The core question of the research study was: How do you experience, or how do you speak about God at this time of possible physical, emotional, or spiritual suffering due to your illness? Additional questions were: • How would you describe your family and your life story so far? • How do you experience physical suffering due to your illness? • How do you experience emotional suffering due to your illness? • How do you experience spiritual suffering due to your illness? • What has been your worst experience of suffering? • What or who helps to lessen your suffering?

In the interview process, these questions evolved to include three other questions that took into account participant content. During interviews, it was discovered from the responses that the story of patient illness needed to be addressed. There was also the need to raise questions concerning faith group and specific images of God. These three questions were added to the interviews: • How did your illness begin, and how did it develop? • What is the level of support from your faith group? • How do you image God in the context of your suffering?

The addition of questions to the research interviews is consistent with qualitative methodology. When analyzed, the data from the first interviews demonstrated that it would be valuable to add the questions which the interviewees deemed to be relevant to the topic of God-talk and innocent suffering. The adding of questions expanded the database so that the emerging theory could be refined. Within the process of data analysis, the responses to the interview questions were first examined for similarities and differences. Then each response was re-engaged to seek out themes that appeared to be emerging out of the data, and the possibility of thematic interrelationships was explored (Rafuls & Moon, 1996, p. 70). The process of standard content analysis was used and took into consideration both manifest and latent concepts. In the manifest content analysis, “those elements that are physically present and countable” (Berg, 1995, p. 176), that is, the statements of the participants that fitted closely into the categories which evolved from the interviews, were explored. This form of content analysis constituted the major categories for the research findings. In “latent content analysis,…the analysis is

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extended to an interpretive reading of the symbolism underlying the physically presented data” (p. 176). The actual process of the research played an important part. The questions, which the first interviewees were asked, were not as sharply focused as those in subsequent interviews. There was also the desire to facilitate telling the story, so questions became more focused and asked specifically about an image of God. The participants noted how they talked about God in the context of their disease. Some participants were asked about their life stories, and the importance of their life stories as it related to their coping with their illness was highlighted. A significant piece of theory in interpreting the data comes from narrative therapy (Freedman & Combs, 1996; VanKatwyk, 1998; White & Epston, 1989; White, 1988). Its emphasis on storytelling and the possibility of “re-storying” or of “finding an alternative story,” which might instill hope into a dominant story of pain and hopelessness, became quite relevant. Narrative therapy as a theory piece was not in my original research plan, but the data received through the interviews underscored its importance to the research in progress. Continually, the interview responses stressed the importance of storytelling and the value of placing these stories in a narrative therapy context. RESULTS

In deciding on how to collect and sort the data, it seemed best to use the interview questions and their answers as categories, according to which the raw data could be coded. This initial process seemed to be the most logical system. Similarities and differences within the interview responses were then explored, with themes and interconnecting themes drawn from among the common threads in the research.

Life Story of the Patient The responses to the questions indicated an overall theme of commitment. For example, the participants worked hard for their family; many of the men had gone to war out of a commitment to their country; and family members were strong resources for the participants. Prayer and faith were also often mentioned as resources for the participants throughout their lives. One woman spoke about “a spiritual retreat” where she seemed to regain and sustain her strength. Although the responses generally reflected commitment and the accessing of inner and outer

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resources, three responses reflected a lack of support or a broken relationship. One patient was not able to rise out of a difficult early life. She noted, “My mother died when I was three. My father was a drinker. It was my elder sister and myself.…Then in about 1935 I got polio.…I did not get the proper care. No one knew what to do.…It was always hard. I had faith.…[I married] about 1944…we hadn’t been together for years.…It is an unhappy story.” Her words told how she was still caught in the emotional pain that followed her in her youth, and she expressed a view of life that was quite different from the majority of the patients who were interviewed. The life story of patients facing life-threatening illnesses often revealed how the participants faced this challenge. They told stories of how they were able to face the pain, often through their ability to access and use their inner and outer resources.

Stories of the Patients’ Illnesses The stories of the patients’ illnesses reflected both a long-term and a short-term context. Some participants had struggled with the progression of their disease over a number of years, while others had found out about their disease only weeks or months before the research interview, often being given a short-term prognosis. For those who had had cancer over an extended period of time, the cancer often appeared to be cured, but there was the trauma of it recurring or spreading. These form the predominant similarities in the research findings. For one person there was an experience of futility of treatment. She stated, In June of 1997, I became really tired. Sunday I was getting ready to go out to church in a neighbouring town to lead the service. I became very ill, terrible headache…We went down to an American university for a trial of a new chemotherapy treatment. We had the first treatment done there at the end of August, and then came back here for the rest of the treatments. But we were delayed, because we had a hard time finding a doctor who would do it…the doctors down at the university recommended that we come off the treatment because the tumour was growing.

Having to face either a short-term or long-term crisis, which may have compounded by either metastases or a reoccurrence of the disease, was a source of suffering for the participants, but generally this suffering did not overcome the support systems of the patients. Once again, com-

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mitment and the development of inner and outer resources played a significant role in coping with the disease. The differences in the responses pointed to themes of extended survival and the futility of treatment.

Physical Pain The similarities found within the responses to the question regarding pain consisted of exploring the ways in which pain adversely affected the personhood of the participants. Some did not speak about their pain, but their non-verbal communications related their distress. Others talked about the “aching” or sharp components of their pain. Some noted a discomfort, and very few stated that they were pain-free. The findings of the interviews demonstrated the significant negative effect of physical pain, especially a constant, aching pain, on the suffering of the person. The similarities in the responses reflect the reality that, for most patients interviewed, pain was a very real component of their suffering. Seventeen patients stated that they experienced some form of physical pain, predominantly a pain that ached and that was constantly present unless it was dulled temporarily by medication. Few emphasized the stress or the explicit suffering this pain caused them, but the battle with pain was evident during the interviews. One patient could hardly speak, and three or four patients had great difficulty breathing. The one woman who had the most difficulty in breathing spoke the longest, and she did most of the talking. It seemed that she needed to tell her story, and this need took precedence over the physical needs of her body. Her story of pain did not dominate her spirit. Another woman, who consented to an interview in her home shortly before Christmas, could not sit still for more than a few moments because of the pain, which was evident in all parts of her body. She was in constant motion, because it was too painful for her to sit for any length of time. She wanted to help with the study and so told her story; sadly, she died a few days after Christmas. When the chaplain first phoned her to ask if she was willing to be interviewed, she said no. She then phoned the chaplain back and told her that she had changed her mind. It is a mystery why a person who was going through very explicit physical suffering herself would strive to help the research. Gutierrez provided an answer. In his discussion about innocent suffering, he notes that for Job, “to go out of himself and help other sufferers (without waiting until

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his own problems are first resolved) is to find a way to God” (Gutierrez, 1987, p. 48). This altruistic benefactor assisted greatly in the research. Her response can be situated in the understanding that she found a way to God in the midst of her suffering, and that she discovered that it is “life, not death, that has the final say” (Gutierrez, 1987, p. 100).

Emotional Pain Many patients stressed how the anxiety, uncertainty, or feeling of powerlessness affected their process. Emotional pain seemed to be more significant than physical pain for the majority of the participants. In exploring the similarities of the responses, many expressed how significant emotional distress was to their overall sense of suffering. In reflecting on the differences within the responses, there were a few patients who indicated that the emotional suffering had been quite difficult at one point, but they had more of a sense of peace in their current situation. One participant stated that the physical pain was not “as bad as the mental pain. Thinking that you’re going to leave everything behind, your wife and your children—it hurts.…Would you put everything into the hands of God?…That’s what I do. I cry. I have to cry, that’s hard.” Seventeen out of the twenty-two patients interviewed claimed some form of emotional suffering at a point in their disease process. For those who did so, the source was quite diverse, but seemed to have loss as its locus of meaning. Three patients spoke of emotional pain in general terms, and one patient labelled it “anxiety and uncertainty.” One woman spoke explicitly of the death of her husband six years previously. Four patients spoke about loss stemming from the disease process and two specified a fear of dying. In other statements they also mentioned that there was a fear of an increase of physical pain in the active dying process. Two patients related that a lack of sleep caused them stress. Generally, the participants saw that their emotional pain flowed out of the loss of physical functioning and their uncertainty about the future. The theme of the positive effect of faith and relationships was present for most of the participants. When emotional pain was significant for the person facing a life-threatening illness, the support of family and friends was a sustaining force that enabled them to endure pain. Those participants who experienced little emotional pain stated that this was because of the presence of their faith, the knowledge that God was present in the crisis, and the support of family members, friends, and caregivers, all of which helped reduce their emotional pain.

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Spiritual Pain The experience of spiritual pain was significant for many of the patients; the majority of those interviewed claimed some form of this distress. There were some different responses in these findings, which contain statements implying little or no distress. This was due either to support structures that enabled the participants to cope or to a faith that sustained them in the crisis. One patient, who was burdened by a painful life story, related: “Well, God has lost faith in me. God doesn’t want me, I’m too miserable. I can’t pray. God can’t listen to me.…God is angry at me.” Another participant, who was diagnosed with her cancer shortly before her call to the church ministry, asked: “What does God want of me?…I thought I was called to the ministry, and how long is a call?” This question elicited a range of answers from “You do get angry at God” to “I never question the Lord.” The majority of the responses indicated some form of spiritual suffering. Some of the responses reflected little or no spiritual suffering. Two responses indicated both “yes” and “no” to this question. Patients’ responses were influenced by a combination of factors. These included their life stories and their ability to cope positively with earlier crises; the story of their illness and whether or not the disease progression was sudden or long term, painful, or gentle; individual faith journeys; and where/how God had been present for them in earlier crises and if He was present in this current challenge. Spiritual suffering, then, was significant for the patients who responded. Some of the participants mentioned that they had not risked questioning God or voicing some form of protest to God before being asked this question. For the research purposes, it helped to formulate a response to the question of how palliative patients speak of God in the context of innocent suffering. All of those interviewed spoke about belief in God, anger at God, and love of God. Since anger and conflict, when handled appropriately, are part of any close relationship, these people expressed a belief that they were close to God, and that God was close to them. Even the woman who feared that God was angry with her admitted that she once “had faith.” The fact that she allowed the interview to occur and was vulnerable in her responses appears to demonstrate some spark of hope concerning her belief in the goodness of God. Worst Experience The majority of the patients stated that their worst experience of suffering was emotionally based or had an emotional component and took place before the onset of their illness. This was true for nine of the

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twenty-one patients who responded to this question. Three participants claimed that their worst experience of suffering did stem from the disease process and contained a physical component. One participant noted: “It’s not physical, but emotional, if you would call it that. I like to be independent. I’ve been independent all my life. And now I can’t be because of the illness. I had to sell my horse this year. That was probably pretty hard. Riding is a freedom you can’t get anywhere else.” Another participant related, “I think it’s the pain. ’Cause I am so long in pain—almost two years. I once said to my son and his girlfriend I would give a thousand dollars if I could spend one day without pain. I have forgotten how it is to be without pain.” Of those patients who claimed an emotional source for their worst experience of suffering, loss was the most common theme. Four patients explicitly named the death of a family member, usually a spouse, as the worst suffering in their lives. As these participants described the events of the death of their partners, there was the sense that the images were indelible and were often recalled. For a young mother, the worst suffering was in the here and now. She described how difficult it was for her young daughter to experience physical closeness to her because of her illness and the medical machines that interfered. She related that even though it was difficult for her daughter, she felt this physical distancing was important, because “there will be a time when she can’t lie in bed beside me.” This mother’s protection of her daughter from some of the pain of her anticipated death must have been most difficult for both of them. The suffering caused by the loss of a loved one or the anticipated loss seems to capture the mystery at the heart of innocent suffering. Generally, the experience of a loss in some form was the most profound experience of suffering—loss of loved ones, loss of independence, loss of the freedom that accompanies good health—were all a part of the suffering voiced by the participants. There was also anticipated loss as they looked at their approaching death and worried about how their family and close friends would cope.

What or Who Helps? Throughout the research interviews, there was one constant theme the majority of participants expressed in a similar way. To each question which was asked about suffering, replies were given that covered various aspects of physical, emotional, and spiritual distress. The participants stated that they were sustained in these times of suffering by the inner resource of faith and the outer resource of the support of family,

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friends, and caregivers. In response to the direct and specific question “What or who helps you to get through the suffering?” the patients reiterated that they were supported by faith, prayer, family, friends, and others, including church people and physicians. One participant related, “My pastor, the church workers…Jesus Christ himself—I don’t mean to put him as number three!…and my wife. I know that I am going to heaven, this doesn’t cancel the fear but makes it bearable. All of this helps.” Predominant supports for the majority of palliative patients were family and faith. Of the twenty-two patients who were interviewed, one provided no data on this subject. One participant did not provide explicit data but there was enough implicit data to name her supports. Her husband was by her side as she spoke, and it was obvious that she drew strength and comfort from him during this crisis. This participant also mentioned that a friend from England phoned every evening at 6:30 P.M. and that this person was a support to her through her illness and perceived short-term prognosis. Another participant told of her going to her cottage by herself, a spiritual place of nurturing. Another mentioned the doctors, and another referred to her cancer support group as a source of real support during a reoccurrence of her cancer. It was evident from these stories that the various individuals and groups had sustained and continued to sustain these patients in their time of crisis and suffering. The majority of patients who were interviewed spoke about God positively and intimately. God was present to them in the midst of their suffering. Three patients expressed a negative experience when speaking about God. One told me, “It’s hard when it’s God’s choice. Why don’t criminals get sick and go through this? I don’t understand.” In exploring the core theme of God-Talk and Innocent Suffering, nineteen of the twenty-two patients spoke about God as a positive force in their life at this point. These participants discussed the theme of the power of God and/or the presence of God in a positive manner. Four patients spoke about the power of God, one patient praying that God would “take her,” because she finds her suffering so difficult. Two patients related that God’s power would be evident in the Second Coming or on Judgement Day. They saw themselves as righteous, so they had no fear, and anticipated a chance to “shine…like the stars, forever and ever.” This again hints in some way at the theory of temporal retribution, but none of the patients saw her/his suffering as a result of wrongdoing.

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Eleven of the patients not only spoke about God in a positive way but also in an intimate way. One participant simply stated, “I trust in God. He will take care of me.” Two patients remarked that “God was there,” and another that “I talk a lot with Him through the day.” My final participant said, “He’s right there,” as she extended her hand. In discussions with these patients, there was the feeling that this intimacy with God had assisted them in coping with the crisis of their disease progression. It did not take away their pain, or their fear, or their questions, but it did make it bearable and enabled them to live life as fully as possible in their final days and weeks. Of the twenty-two patients, fifteen imaged God in a positive manner. Four of these offered a “neutral” image of God; three described images that spoke to the theme of protest, that is, a negative image of God; and one said, “My image of God is up there, directing traffic, and we have no control.” Another relayed that, “I feel that he is holding my hand when I talk to him.” These images helped them in coping with their suffering. Many similar themes emerged in the interviews as the participants related narratives about “life hurts,” which they generally overcame (except for one participant, for whom hurt was the nucleus of her life story). In general, they narrated stories about supportive faith groups whose members volunteered to help with their care, and talked about God being “close,” describing Him as the “the great physician,” “up there,” sometimes “confusing” and sometimes “faithful.” No one blamed God directly for their illness. Many questioned God or protested to God in faith, wondering why they had to suffer when they were innocent of any wrongdoing. SUMMARY AND CONCLUSIONS

What stands out in this study is the discovery that more than 50 percent of the patients who were interviewed claimed that they not only had faith but that it was faith that sustained them in their time of physical, emotional, and spiritual suffering. Many of the patients stated that they felt supported by their faith group, while a few noted that they did not feel supported. One participant, for example, felt let down by his church: “We’re United.…We got our children through Sunday school and got them married there, and then, we felt that we weren’t welcomed by the new minister.” The research also shows that it is important for hospital chaplains to facilitate communication between patients, family members, and their

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faith group leader. Chaplains need to ask patients or their significant others if he/she could contact their home parish if their pastor has not been in to visit. Many clergy have stated that they are unaware that one of their parishioners is in hospital until that parishioner or a family member notifies them. Therefore, the hospital chaplain’s role can be beneficial. Most important, this study supports the belief that the crisis of a life-threatening illness deepens the spirituality of the patient. It would seem that many of the patients travelled through the stages or places of suffering which Sölle (1975) has named. For many, the initial muteness evolved into the courage to question their experience and to demonstrate faithful protest. There was a sense of faithful acceptance of their suffering in the positive way they spoke about God. This was the essential response to the core research question on how palliative patients talked about God in the context of their physical, emotional, or spiritual suffering. The prevailing positive image of God is a significant revelation for spiritual caregivers caring for those facing a life-threatening illness. If the chaplain can assist these people in naming, more fully recognizing, and developing this inner resource which the patients already possess, their ability to cope with their crisis will be strengthened. Whether or not their image of God was explicit, as it was for the majority of the participants, or spiritually based, this image can sustain these patients by helping them understand the place of God in their illness, that God can be “a friend” and can be “closer” to them at this time. It speaks to the importance of God-talk for those patients who find this helpful. These participants were spiritually enriched by their belief in a God who was present with them in their time of greatest need. All the categories explored in this chapter—the experience of life and relationships, the illness, the suffering, the faith in community support, and the descriptions and images of God—were revealed in the context of stories. The principal themes connected the points between these stories. It was not anticipated that the key to this research would be based in stories, and identifying it was a revelatory moment. The interviews provided ample evidence of the power of stories to sustain, comfort, strengthen, and offer hope in the midst of crisis. The principal interconnecting theme is the “life story and its effect on the story of the illness.” The majority of the patients used inner and outer resources that they had acquired during earlier life crises to assist them in coping positively with their illnesses. In their life stories, there were accounts of earlier traumas, usually of an emotional nature. Fam-

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ily, friends, and faith sustained them through these difficult times. Therefore, when the crisis of a life-threatening illness presented itself, the participants knew how to face the moment. Also, they had a sense that they would not be alone in this crisis but would have the support of others. Some of the patients did not realize this immediately, and came to see this truth as they reflected on their experience in the telling of previous suffering and how they coped with that traumatic experience. They made this connection in their narrative, as one man did when he said that “if God was present with me at D-Day, God is present with me in this crisis of cancer.” One woman’s perception of her life as sad caused her to hold onto that sadness, thereby leaving her unprepared to cope with her illness. The lesson here is the importance of attending to spiritual distress such as feeling distant from God or being abandoned by others. The pastoral presence of a chaplain or another member of the interdisciplinary team can assist the patient who is suffering from the spiritual distress of feeling distant from God. The chaplain can help the patient achieve a sense of hope despite the sadness of a past life. A second interconnecting theme is that of “stories of God and GodTalk and innocent suffering.” One patient experienced a grave crisis in confronting the reality of constant physical pain and a short-term life expectancy. Her life story and faith journey empowered her to claim a radical faith in God as she faced her approaching death. She spoke about God positively and she prayed as long as she was physically able to do so. Her suffering exhibited the spiritual constructs proposed by Sölle (1975) and Gutierrez (1987). Many patients told stories of faith that sustained them in their suffering and helped them to believe that their suffering would not have the final say. For most of the patients, talk about God was intimate and gentle. They knew God’s presence in their suffering and they believed that God would always be present with them. This helped them address such issues as loss, physical pain, and even the need to protest to God about their situation. Thus, they protested in faith. A few of the patients could not talk about God so positively; some felt that God could, but would not, help them in their current suffering, and they resented this. However, most felt that God walked with them, shared their suffering, and would greet them when death came and they journeyed into eternal life. As the patients responded to the questions, the majority of them wanted to talk about God. They held God as a central positive force as they coped with their suffering. Many patients imaged God as close and loving, a true inner resource in this time of

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crisis. The participants also noted that they had experienced other times of suffering in their lives and were aware of God’s presence and care at those times. It appears curious that one person can respond positively to a crisis and is able to access support and resources while another, in a somewhat similar situation, is unable to do so. The opinion of the writer is that God is equally present to all of these people and that the vast majority of the participants believed in the presence of God. Their “God-talk,” then, was in the context of faith. It embraced the spectrum of the journey of suffering as described by Sölle (1975): one was mute, and many were either in protest or had arrived at the place of faithful acceptance. It is this acceptance to which Rahner (1983, 1978) refers in his theory of suffering and grace. It was this acceptance that these palliative patients described as they voiced their lived experience of grace. REFERENCES Berg, B.L. (1995). Qualitative research methods for the social sciences (2nd ed.). Boston, MA: Allyn and Bacon. Faricy, R. (1967). Teilhard de Chardin’s theology of the Christian in the world. New York: Sheed and Ward. Freedman, J., & Combs, G. (1996). Narrative therapy. New York: W.W. Norton. Gutierrez, G. (1987). On Job. (M.J. O’Connell, Trans.). Maryknoll, NY: Orbis. Kelly, G.B. (Ed.). (1992). Karl Rahner. Minneapolis, MN: Fortress. Komonchak, J.A., Collins, M., & Lane, D.A. (Eds.). (1991). The New Dictionary of Theology. Collegeville, MN: Liturgical. Rafuls, S.E., & Moon, S.M. (1996). Grounded theory methodology in family therapy research. In D.H. Sprenkle and S.M. Moon (Eds.), Research methods in family therapy (pp. 64–80). New York: Guilford. Rahner, K. (1983). Why does God allow us to suffer? Theological Investigations 19 (pp. 194–208). New York: Crossroad. Rahner, K. (1978). Foundations of Christian faith. (W. Dych, Trans.). New York: Crossroad. Sölle, D. (1975). Suffering (E.R. Kalin, Trans.). Philadelphia, PA: Fortress. Teilhard de Chardin, P. (1960). The divine milieu. New York: Harper and Brothers. VanKatwyk, P.L. (1998). Parental loss and marital grief: A pastoral and narrative perspective. The Journal of Pastoral Care, 52 (4), 369–76. White, M., & Epston. D. (1989). Narrative means to therapeutic ends. Adelaide, AU: Dulwich Centre Publications. White, M. (1988). Saying hullo again: The incorporation of the lost relationship in the resolution of grief. Dulwich Centre Newsletter, 1–3.


14 Measuring and Assessing Suffering in Arthritic Patients Beverley Clarke A.R.M. Upton Claudia Castellanos Mary Lou Schmuck

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raditionally, “spirituality” is thought to relate primarily to matters that “belong to the church” and are “sacred” and “ecclesiastical rather than temporal” (Concise Oxford Dictionary, 1982). Some definitions regard spirituality and religion as being synonymous. In medical practice, interpretations of spirituality as separate from religion are often broader than in religious practice and not confined to the ecclesiastical. “Sacred matters” include all life experiences “worthy of respect and honour.” Suffering is one such matter. Common theoretical perspectives of pain and suffering in medicine are that (a) pain and suffering are one phenomenon, (b) suffering is often considered to be a secondary component of pain, and (c) if pain is controlled or eliminated suffering will cease (McCaffery, 1983; Garcia & Altman, 1997; Loeser & Melzack, 1999). Clinical practice, however, shows that some individuals with high pain levels do not suffer and others with low pain levels may report severe suffering. Prevailing attitudes that combine suffering and pain are often based on the belief that it is not possible to objectively assess suffering. Pain, measured in terms of tissue damage and behavioural dysfunction, is considered to be amenable to treatment. Suffering, thought to be highly idiosyncratic, culturally bound, and not quantifiable, is considered not to be amenable to treatment interventions. Value judgments are given to those who suffer and psychological “treatments” are applied when determinations of “abnormal” (pathology) suffering are made. Suffering is also thought to be the province of the clergy or of psychologists. However, medicine has long addressed “sacred matters.” The

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health problems of patients are indeed “worthy of respect and honour.” In spite of many important technological and therapeutic advances, the extremely complex problem of pain and chronic disability persists. These problems account for considerable health care fiscal expenditures as well as severe losses in human potential. In 1995, in Canada, the cost of musculoskeletal disorders alone was reported to be at 2 per cent of the gross national product with chronic disabilities estimated at 31.9 per cent of all costs (Badley, 1995). Costs continue to escalate, and a re-examination of the phenomenon of suffering and its relationship to pain is warranted (Chapman & Gavrin, 1993). CONTEMPORARY PERSPECTIVES OF SUFFERING

Current complexities surrounding the understanding of suffering are influenced by cultural, religious, and political influences from the past. Suffering is now understood in human terms as opposed to only regarding it in the context of the religious (the passion of Christ). The notion of “self ” in society as opposed to religious cosmic “selflessness” is a twentieth-century conceptualization directly connected to “personhood” (Wachtel, 1996). “Personhood,” in turn, refers to how one sees oneself in the world in the present, past, and future, and it encompasses one’s vocation, avocation, and relationships with friends and family. Cassell (1992) states that suffering is separate from pain and occurs when there is a perceived threat to “personhood.” Suffering may be defined as a process that occurs when some vital part of a person’s “idea of self ” is threatened or perceived to be threatened. “Idea of self ” relates to those qualities of human beings that are individual and identify a person. Those qualities are perceived by individuals as being critical to their ability to continue their existence (Cassell, 1991, 1992). Not all people who experience a threat to the “self ” and “personhood” suffer. If the changed “self ” is acceptable to the individual, or if the person is able to see a way of developing a new idea of “self,” then suffering does not occur. Suffering has definable characteristics, and it is only the expression of these features that is highly idiosyncratic. To assess suffering as a separate phenomenon in modern society requires slight shifts in both secular and religious thought (Cassell, 1982; O’Brien, 1996; Clarke, 1998). First, it is important to understand the theoretical basis of suffering as a phenomenon separate from pain. Second, it is important to recognize that it is the expression of suffering, not the

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experience of suffering, that is idiosyncratic and culturally bound. Third, relevant measurements of suffering are measures of time (how long the phenomenon lasts rather than measures of the intensity of the experience). Fourth, measures of suffering assess the perception of “threat” to the individual’s idea of self, not the moral value of experiencing suffering nor the dynamics of loss. Fifth, measures of suffering assess the degree of concern or worry about the impact (threat) of an illness on an individual’s perceptions of self and personhood. These measures are different from quality of life assessments that evaluate abilities and opportunities. SUFFERING AND ARTHRITIS: THE CHALLENGE

Arthritis affects every aspect of the patient’s “personhood.” The body is afflicted with pain, systemic complaints, joint deformity, and limited functional abilities. People with arthritis also experience impaired interpersonal relationships, work restrictions, and community estrangement. The number of losses and types of support systems are key issues. Arthritic patients may undergo considerable changes in physical appearance, and the persistence of chronic, often severe pain wreaks havoc with the person’s “idea of self.” The effects of aging and the uncertainty of disease outcomes are strong influences on the restoration or formulation of an idea of self in persons with arthritis. Some people with arthritis experience suffering (Dildy, 1996; Affleck, Urrows, Tennen, & Higgins, 1992). The challenge to the integration of suffering measures into clinical practice is to acknowledge that, while physical pain is a powerful indicator of pathology, suffering has a powerful impact on rehabilitation methodologies and is a significant determinant affecting the efficacy of rehabilitation programs (Chapman & Gavrin, 1999; Clarke, 2000). The first step in reassessing the concept of suffering is to show that suffering is separate from pain, and that suffering indices are important clinical outcome measures in a sample of subjects where pain is a major factor. In our study, a group of persons with arthritis were assessed.

Methodology A questionnaire to measure and assess suffering (MASQ) was designed, validated, and given to 122 arthritic subjects on admission (T1) and on discharge (T2) (approximately three weeks’ duration) from a day hospital rehabilitation program. This interval was chosen because expert opin-

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ion regarding the appropriate interval for test–retest reliability varies from an hour to a year, depending on the task, but intervals of two to fourteen days are usual (Jaeschke, Singer, & Guyatt, 1989). This time frame is appropriate because a large change in the patient’s total suffering score during the relatively short hospital stay is not expected. The patient’s history and “treatment” were consistent. This was not a randomized control trial with interventions and control groups. Thirteen people who were tested at Time 1 later withdrew from the program because of health problems unrelated to their arthritis. There were complete Time 1, Time 2 paired data sets for 97 subjects. Of the total data set, there were 22/28 males and 75/94 females with a mean age of 60.27 ± 13.35 S.D. years in the subset (N = 97). The mean length of illness for the entire sample (N = 122) was 10.86 ± 11.14 S.D. years. Twenty-nine percent of the people were taking antidepressant medications or medications producing an antidepressant side effect. Subjects were classified into three diagnostic categories (table 1). All subjects received a combination of physiotherapy, occupational therapy, and educational instruction about managing arthritis; as well, psychological counselling was available upon request. No specific interventions were given to address suffering. Table 1: Classification of Arthritic Subjects (N = 122) Category Osteoarthritis Inflammatory Arthritis Other*

No. of Subjects 56 52 14

Gender Females Males 43 38 12

13 14 2

*Other: disorders included in this category were mechanical low back pain, myofascial pain, avascular necrosis, pseudogout, and chronic soft tissue pain.

Measurements The MASQ (figure 1) consisted of five pain questions that related to pain intensity and beliefs about pain, and three of the questions addressed the patient’s perceived ability to cope with pain. There were nineteen suffering items that asked how much worry or concern the patient experienced because of the effects of having arthritis. The questions focused on interpersonal relationships, emotions (anger, sadness), community involvement, body image, self, insight and perception, hopefulness, support systems, and number of losses. Because there is not a gold standard upon which the MASQ could be based, the items selected were

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Figure 1: Questionnaire (MASQ)* 1. Characteristics of Suffering “Idea of Self” • Current Perspective • Future Views • Hopefulness • Loneliness • Aging • Body Image “Personhood” (impact of disorder) • Relationships • Job • Avocational Activities • Support Systems • Community Participation

Total Items: 19

2. Pain Measures • Intensity • Recurrence • More Pain • Less Pain (persistent) • No Pain

Total Items: 5

*Likert-type Scale: 1–5 (5 = the worst response)

those items in which there was reported agreement between theorists in the field (Hill, 1992; Cassell, 1999; Van Hooft, 1998; Edwards, 2003). Items were scored on a five-point Likert-type scale with 1 indicating the most positive response and 5 the most negative; an example of the questions is found in table 2. The pain questions were based on a modified McGill Pain Scale and were included in the questionnaire to test the hypothesis that suffering and pain are two separate entities. Two examples of the five pain questions are: 1. Do you have pain? Yes___ No ___ (if the answer is NO please go to Part B). 2. How much pain do you have? None A Little Some A Lot (1) (2) (3) (4)

Sometimes Unbearable (5)

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Two examples of the nineteen suffering questions are: 1. How much worry/concern do you feel that your illness will have a bad effect on your personal life with friends? None A Little Some A Lot A Great Deal (1) (2) (3) (4) (5) 2. How much worry/concern do you feel that your illness will have a bad effect on you as you age? None A Little Some A Lot A Great Deal (1) (2) (3) (4) (5)

The outcome measures of suffering and pain (both individual items and total scores) were examined in the context of analysis of variance and covariance designs to look for mean differences between the two domains. The test–retest (intra-class) and item (Cronbach’s alpha) reliability coefficients were calculated, respectively, to look for stability of effect over time and the degree of internal consistency of the pain and suffering item sets. RESULTS

The Relationship between Suffering and Pain All items were scored across the five-point scale. Endorsement frequencies at baseline and again at discharge showed that the full range of the five-point scale was used for each of the nineteen suffering items. In almost every instance, each of the response options (Likert scale values 1 through 5) represented between 5 and 95 per cent of the patients. Endorsement frequencies within this range for each of the five response alternatives provided evidence that the suffering items can discriminate between patients who suffer in varying degrees. A measure of internal consistency (Cronbach’s alpha) of the nineteen-item suffering set was examined to determine if a domain of suffering could be defined. The five-item pain set was examined in a similar way. The item reliability was good, R = 0.893, for suffering items, while the results for pain were low, R = 0.066. Item reliability is the weakest form of reliability testing, but it does have important implications. Item reliability was used to further define the distinction between suffering and pain. Subsets of suffering items hypothesized to belong to specific domains (traits) were analyzed to determine the extent to which they tap into some concept of suffering (i.e., idea of self). Therefore, in addition to examining the internal consistency of each of the pain and suffering

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scales, test–retest reliability was assessed to see whether the traits of pain and suffering were stable over time (from baseline to discharge). Test–retest reliability for pain was R = 0.500, and for suffering R = 0.546. The overall scale reliability encompassing both the time and item factors is another way to show that suffering is a less volatile trait than pain. For pain R = -0.318 (because the score is a negative value it was set to zero), and suffering R = 0.879. Total scores for each of pain and suffering at Time 1 and Time 2 indicated that suffering is a more stable trait than pain. Pearson correlation coefficients support this notion. In the absence of a true “gold standard” to assess criterion validity, we chose to use the question (q. 3), How much worry/concern do you feel about your illness/injury? and compare it with a sum score from the other eighteen suffering items. The moderate Pearson correlations indicate that the above question can be used as a criterion measure particularly at (T2) discharge. A perfect correlation between the criterion measure (q. 3) and the sum score from the other eighteen suffering items is not sought because a perfect correlation would indicate that the new suffering scale could be condensed to only question 3. The Pearson correlation coefficient for the relationship between the sum of eighteen suffering items and question 3 at baseline (T1) is r = 0.590, and is even better at discharge (T2), r = 0.735. The correlation between the sum of the eighteen items and pain intensity at (T1) is weak, r = 0.311 and r = 0.421 at Time2 (T2), indicating that pain is distinct from suffering. Measures of construct validity showed a moderate correlation between pain and suffering (r = 0.487, p = 0.01) at Time 1 and a weak correlation at Time 2 (r = 0.131, p = 0.01), indicating that suffering and pain are discrete but sometimes related entities. The relationship is clearly demonstrated on a scatterplot (figure 2), where one would expect a clustering of data points about the line of fit if the relationship between the two concepts was strong. Clearly, pain is independent of suffering. Pain intensity correlations with total suffering were also weak at Time 1 (r = 0.319, p = 0.01) and moderate at Time 2 (r = 0.428, p = 0.01), indicating that pain intensity is not strongly associated with suffering. However, regression analyses showed that total suffering scores were the best predictor of pain intensity (p = 0.01). These results provide evidence that suffering and pain are separate entities.

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Figure 2: The Relationship between Total Pain and Total Suffering for Arthritic Patients

Suffering as a Clinical Outcome Measure On admission, 77.1 per cent of subjects rated pain intensity as severe, compared with 43.3 per cent on discharge (figure 3). Mean pain intensity scores expressed as a percentage of the sum of the total pain scores were 0 57.75 ± 9.75% S.D. at Time 1, and 0 54.90 ± 12.33% S.D., p = 0.04 at Time 2. On admission, the percentage of people responding at the most negative end of the scale for key suffering items ranged from 63.9 per cent to 87.9 per cent, and on discharge the range was from 45.4 per cent to 68.9 per cent, indicating that suffering is an important symptom in arthritis and that in spite of current treatments, the number of people still experiencing suffering on discharge was high (figure 4). Mean total scores for suffering were 0 65.44 ± 12.85% S.D. at Time 1 vs. 0 56.73 ± 15.68% S.D., p = 0.0001 at Time 2. Mean values for total pain scores were 0 56.46 ±10.22% S.D. at Time 1 and 0 53.19 ± 12.07% S.D., p = 0.02 at Time 2. Although these items showed significant improvement over time, levels of suffering and pain were still high at discharge (figure 5). There was no significant change over time for the other pain items for the most severely involved subjects. There were no significant gen-

Measuring and Assessing Suffering in Arthritic Patients

Figure 3: Percentage of Arthritic Subjects Responding to Pain Questions at Levels 4 and 5

Figure 4: Percentage of Arthritic Subjects Responding to Suffering Questions at Levels 4 and 5

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Figure 5: The Relationship between Suffering and Pain for Arthritic Patients

Figure 6: Changes in Suffering Items* over Time Item

Significance

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) = F(1,96) =

Concern about Job Concern about Children Concern about Partner Concern about Friends Concern about Life in the Future Concern as you Age General Worry Body works the Same Feelings are the Same Feeling “normal” Problems Never got Better Anger Sadness Managing Illness Alone Being part of the Community Other people Caring

12.41, 16.29, 8.63, 32.23, 45.93, 28.43, 29.99, 12.63, 21.59, 8.40, 9.09, 6.25, 19.92, 10.45, 3.91, 6.47,

*Mean differences were less than 1 point apart on a 5-point scale.

p = 0.0007 p = 0.0001 p = 0.004 p = 0.00001 p = 0.00001 p = 0.00001 p = 0.00001 p = 0.0006 p = 0.00001 p = 0.004 p = 0.003 p = 0.01 p = 0.00001 p = 0.001 p = 0.05 p = 0.01

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der or age differences for total pain or total suffering scores. Sixteen of nineteen (16/19) suffering item scores improved significantly at Time 2, but mean differences were less than one point apart (figure 6). Clinical interpretations of suffering based on such slight differences are questionable (Jaeschke et al., 1989). CONCLUSION

Data analyses provided evidence of a domain of suffering, and showed that suffering items were stable over time. Further, pain intensity was found to have a weak correlation with individual items within the suffering domain. Correlation results provide strong evidence that suffering and pain are separate but sometimes related phenomena in arthritis. To determine whether these findings are generalizable to subjects with other diseases, we are continuing our investigations with subjects who have epilepsy, spinal cord injuries, and migraine headaches. The clinical importance of recognizing suffering as separate from pain is evident from our results. While there were statistically significant improvements in total suffering scores and specific items over time, for those subjects who experienced severe suffering on admission, scores were still very high on discharge, providing evidence that suffering requires specific interventions. Fifty-five per cent of subjects still rated pain as severe on discharge. For key suffering items, more than 45 per cent of subjects (range 45 per cent to 69 per cent) responded at the most negative end of the scale. While current treatment interventions may be having some indirect impact on suffering, people are still in considerable distress on discharge. We argue that the failure to resolve the problems of suffering results in increased health care costs and loss of human potential. Suffering-specific interventions are required, and need to be applied by all health care providers who are treating the patient. Our future studies are examining whether subjects would report less severe pain on discharge and less chronic disability overall if suffering-specific interventions were applied throughout. More studies are needed to determine if those people who are discharged with high suffering scores continue to be readmitted for treatment more often than those who scored more positively. Based on our current results, it is reasonable to expect that the management of suffering in clinical practice would also have a positive effect on the outcomes of pain management. We conclude that suffering is an important clinical outcome measure. The specific management of suffer-

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ing in clinical practice is beyond the scope of this chapter. Physicians and other health care practitioners must ask about suffering so that it can be specifically addressed. The MASQ will provide health care practitioners with a valid and reliable assessment tool to determine those patients who experience suffering with or without the presence of pain. Those persons experiencing suffering can then be appropriately referred to chaplaincy, social work, and/or psychology services. The education of medical students, nurses, therapists and chaplains should include knowledge about cultural, spiritual, religious, and societal attitudes towards suffering. Sensitivity training in history taking and physical assessment would assist clinicians in obtaining information about patient’s suffering as separate from pain. The end result would be more comprehensive problem identification, and more effective treatment interventions which would be reflected in a decrease in fiscal costs and enhanced human potential. REFERENCES Affleck, G., Urrows, S., Tennen, H., & Higgins, P. (1992). Daily coping with pain from rheumatoid arthritis: Patterns and correlates. Pain, 51, 221–29. Badley, E.M. (1995). The economic burden of musculoskeletal disorders in Canada is similar to that for cancer, and may be higher. Editorial. Journal of Rheumatology, 22 (2), 204–206. Cassell, E.J. (1982). The nature of suffering and the goals of medicine. New England Journal of Medicine, 36 (11), 639–45. Cassell, E.J. (1991). The nature of suffering. New York: Oxford University Press. Cassell, E.J. (1992). The nature of suffering: physical, psychological, social and spiritual aspects. In P.L. Starck & J.P. McGovern (Eds.), The hidden dimension of illness: Human suffering (pp. 1–10). New York: National League for Nursing Press. Cassell, E.J. (1999). Diagnosing suffering: A perspective. Annals of Internal Medicine, 131, 531–34. Chapman, C.R., & Gavrin, J. (1993). Suffering and its relationship to pain. Journal of Palliative Care, 9 (2), 5–13. Chapman, C.R., & Gavrin, J. (1999). Suffering: The contributions of persistent pain. The Lancet, 353, 2233–37. Clarke, B.M. (1998). Pain, suffering and physiotherapy. Physiotherapy Canada, 50 (2), 112–22. Clarke, B.M. (2000). The impact of suffering in physiotherapy practice: Cost containment issues. Physiotherapy Canada, 52 (1), 25–32. Dildy, S.P. (1996). Suffering in people with rheumatoid arthritis. Applied Nursing Research, 9 (4), 177–83.

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Edwards, S.D. (2003). Three concepts of suffering. Medicine, Health Care and Philosophy, 6, 59–66. Garcia, J., & Altman, R.D. (1997). Chronic pain states: Pathophysiology and medical therapy. Seminar in Arthritis and Rheumatism, 27 (1), 1–16. Hill, C. Stratton, Jr. (1992). Suffering as contrasted to pain, loss, grief, despair, and loneliness. In P.L. Starck & J.P. McGovern (Eds.), The hidden dimensions of illness (pp. 69–80). New York: National League for Nursing Press. Jaeschke, R.J, Singer, J., & Guyatt, G.H. (1989). Measurement of health status: Ascertaining the minimal clinically important difference. Controlled Clinical Trials, 10 (4), 409–15. Loeser, J.D., & Melzack, R. (1999). Pain: An overview. The Lancet, 353, 1607–9. McCaffery, M. (1983). Nursing the patient in pain. Cambridge, MA: Lippincott and Harper and Row. O’Brien, M. (1996). Relief of suffering: Where the art and science of medicine meet. Post Graduate Medicine, 99, 189–208. Van Hooft, S. (1998). Suffering and the goals of medicine. Medicine, Health Care and Philosophy 1, 125–31. Wachtel, P.L. (1996). The contextual self. In C.B. Stozier & M. Flynn (Eds.), Trauma and self (pp. 45–56). Lanham, MD: Rowman and Littlefield.


15 Psychosomatics and the Spiritual Entities of the Human Psyche Marie-Line Morin

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lthough much research on psychosomatic disorders has been carried out in the medical field (Arnold & Keck, 2000; McCain, 1999; Dwight, Arnold, O’Brien, Metzger et al., 1998; Bonaccorso, Lin, Verkerk et al., 1998), this chapter discusses the topic from a psychospiritual perspective. Following a brief literature review on the treatment of fibromyalgia from an interdisciplinary perspective, a presentation of the psychoanalytic explanation of the psychosomatic organization is given. This is followed by an introduction to psychosynthesis concepts that offer grounds for a psychospiritual interpretation of fibromyalgia recovery, and a discussion of the results of a qualitative analysis of a woman’s psychospiritual journey in her recovery from fibromyalgia. The results support the conclusion that the psychosynthesis concepts of “I” and transpersonal self elucidate the presence of a psychospiritual dimension in a therapeutic process that works to achieve integral harmony. LITERATURE REVIEW

Fibromyalgia is a complex syndrome characterized by pain amplification, musculoskeletal discomfort, and systemic symptoms associated with stiffness, “fatigue, nonrestorative sleep and tenderness at 11 or more of 18 designated ‘trigger points’ where ligaments, tendons, and muscle attach to bones” (Demitrack, 1998; Stahl, 2001). No structural pathology in muscles, ligaments, and joints in found, although abnormalities in the hypothalamic-pituitary axis or in neurotransmission in

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pain pathways are hypothesized (Stahl, 2001). Fibromyalgia is accepted by many rheumatologists as a distinct diagnostic entity. Contemporary medical and psychiatric nosologies accept a unitary classification that sees fibromyalgia as either physical or psychological in nature (Demitrack, 1998). Based on its co-morbidity with depressive disorder, anxiety, and somatoform disorder, Stahl (2001) considers it a psychosomatic disorder. Effectiveness of interdisciplinary approaches in reducing fibromyalgia symptoms (tender points, pain threshold, fatigue) are statistically significant. This is the case with treatments using (a) cognitive-behavioural intervention, connecting mind and body, relaxation, meditation training, and Chinese movement therapy (Creamer, Singh, Hochberg, & Berman, 2000; Keel, Bodoky, Gerhard, & Muller, 1998); (b) interdisciplinary treatment, including medical, physical, occupational, and psychological therapies (Turk, Okifuji, Sinclair, & Starz, 1998a, 1998b); (c) brainwavebased intervention—EEG, electroencephalograph-driven stimulation, EDS (Mueller, Donaldson, Nelson, & Layman, 2001); (d) counselling, cardiovascular exercises, and relaxation training (Mengshoel, 2001); and (e) rehabilitation programs, including education and counselling on “topics such as taking charge, improving sleep, management of fatigue, coping skills, managing stress, memory, nutrition, and medical management” (Bailey, Starr, Alderson, & Moreland, 1999). According to Holroyd (1996), various studies show the effectiveness of hypnosis to reduce pain associated with fibromyalgia. Ebell (2001) found that alternative medicine (CAM) therapies such as acupuncture, biofeedback, S-adenosil methionin, spa treatments, massage, hypnotherapy, and meditation are effective. Finally, nonpharmacological treatments (cognitive-behavioural, acupuncture, education, psychotherapy) are found to be more effective than pharmacological treatments (Rossy, Buckelew, Dorr et al., 1999). Most studies show that treatment reduces but does not eliminate the symptoms. Complete relief of the fibromyalgia syndrome seems far from reach since the causes are not yet understood. I discuss how to alleviate symptoms from a psychospiritual interdisciplinary perspective that is based on psychoanalysis and psychosynthesis. PSYCHOANALYSIS

To understand the intrapsychic organization in fibromyalgia, I use the explanation of psychosomatics drawn from psychoanalytic the-

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ory. I refer to this theory because, among the prominent schools of thought in psychology, it is the most helpful frame of reference.

The Fundamental Psychic Conflict In Freud’s view, the personality is organized around a fundamental psychic conflict in which two basic types of instincts (life and death) are in opposition. After identifying three levels of psychological activities— unconscious, preconscious, and conscious—Freud (1960) distinguished three agencies in the psychic apparatus: the id, the ego, and the superego. The id characterized the sexual drives or life instincts (eros) that find satisfaction in pleasure. Mother ’s love is experienced as the first source of pleasure for the infant. Thus, the pleasure of being loved is the id’s principle aim. However, as this first experience is confronted by mother’s limits in caregiving (including accidents and sickness, as well as negligence and abuse), the id’s aim for pleasure faces the limitations of reality. Other drives emerge, then, as the psyche attempts to adapt to reality: the ego drives or self-preservation instincts (also called instincts of death, destruction, and aggression, thanatos). The ego drives are, by nature, in conflict with the id drives. They respond to the principle of reality to assure the conservation of the personality when facing external limitations and demands. Endowed with a capacity of perception and consciousness, the ego evaluates, coordinates, and organizes the personality to adjust according to external demands, while at the same time taking into consideration the pressure of id instincts and desires. Though defensive and inhibitive, the ego gives structure to the personality. It is a mediator between the requirements of reality and id drives. The third agent of the mental system, the superego, comes from parental identification. It is the inner judge that replaces parental authority when a child breaks away from its “first-love” attachment to his parent of the opposite sex (around five and a half or six years old). The superego is said to be the “heir of the Oedipus complex; the internalization of parental authority and interdictions.” The first role of the superego is to reinforce the ego’s attempt to repress id instincts through criticism and punishment. According to the French psychoanalyst Lacan (1977), the superego is the secondary agent of repression. It is the ego that initiates the repressive movement from which the superego develops. In this respect and for the purpose of my analysis on psychosomatic disorders, I take into account the ego’s repressive and defensive role rather than the superego’s.

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The fundamental psychic conflict can be summarized as follows: the child’s first sexual drives or life instincts are organized by the ego, according to the evaluation it makes of the demands coming from the environment and reality. Internalized parental authority reinforces that organization as the superego develops. Thus, the psyche’s structure is formed through the ego’s repression and suppression of id instincts. However, in spite of the ego’s firm hold on libidinal energy, id instincts continue to search for satisfaction in adulthood and influence adult behaviour. The result of the conflict in adult personalities is that of a defensive structure formed to allow the personality to survive the pain associated with losing absoluteness of the first lost love. In fact, the id instincts’ satisfaction is usually experienced as being complete and absolute. The child seems to have no limit to experiencing the happiness of feeling and the pleasure of being nourished and loved by the primary caregiver. When this first experience, called paradisiacal love, is replaced by the pain associated with the encounter of limits in the presence and love of the object, the defensive organization develops to protect oneself against that pain. This defensive structure, in turn, determines a large number of adult behaviours. Adults continue to yearn for the lost paradise and instinctive satisfactions physically experienced as a child. They react to pleasant and non-pleasant experiences in their relationships according to the sensitivities inscribed in their psyche at that time. Thus, the nature of the defensive structure reveals the origins of adult psychological disorders, including that of psychosomatic illnesses.

Psychosomatics and Symbolic Language Psychosomatic disorders are explained, from a psychoanalytic perspective, by the fact that somatic manifestations seem to be the only way in which the repressed instincts manage to express themselves. Normally, defensive unconscious instincts find their expression through images and symbols. They attempt to make their way into consciousness through the language of symbolic representations. This type of language expresses the emotional and sensory experiences felt by the body and stored in repressed memory before the development of concrete intelligence. In that perspective, in psychosomatic disorders, the process by which unconscious drives try to express themselves through symbolic representations does seem to function adequately. Thus, the unconscious instincts are forced to communicate through the only path open to them: the body or, more specifically, the symptoms in the body.

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Psychosomatics and the Fundamental Conflict According to Marty, de M’Uzan, and David (1963), the expression of unconscious contents in psychosomatic disorders does not follow the usual process in which instincts would normally find their way to symbolic representations. The memories from childhood sensory and affective experiences are kept distant: they are absent or cut off from the rest of the psyche in such a way that drives do not succeed in their passage towards symbolic representation. In the first years of development, the absence or lack of satisfactory love object blocks the process of symbolic representation of id instincts. The ego’s death instincts then develop compensatory somatic processes, which are still at work in adults. In that process, id drives remain fixated into more or less distorted forms and are unable to attach to the ego as a narcissistic object (Marty et al., 1963). According to Smadja (1998), this process leads to “a division within the drives, the major consequence being an accumulation of free destructiveness within the ego [and] an occupancy of the [symbolic representation] area by the death drives and its destructive effects” (my translation). In that sense, death instincts lose their drive (se dépulsionnalisent, a French expression conveying a sort of “drive lost”: Rosenberg, 1998) and create a distortion within the ego. They are then forced to express themselves through the only available way: the body or, more precisely, the physical symptoms. Anxiety resulting from this distortion is temporarily alleviated through biological destruction (Rosenberg, 1998). Such a complex defensive structure gives rise to the disturbed identity or a “false-self ” (Jaeger, 1998) characterized by mental hyperactivity and a weakly developed sense of the imaginary. McDougall (1989) adds that psychosomatic malfunctioning can be conceived as a symptom in which…the psyche searches, with primitive and infraverbal means, to send messages that will be somatically interpreted. Thus, in some psychosomatic states, an organ or a corporeal function, not in the least disturbed organically, can act as if it were called to answer, psychologically, to an antagonistic conflictive situation felt as biologically threatening. An individual’s body may, for example, act as if it wanted to get rid of a toxic substance without, however, having been exposed to any poison, whatsoever (e.g., hemorrhagic rectal colitis, bronchial asthma)…. Somatic phenomena of this sort are messages sent by the psyche when it is in danger of re-enactment of painful, guilt-provoking or threatening events, but whose representation is immediately ejected…such phenomena, although having psychological

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meaning, belong to a pre-symbolic sequence and are somatopsychic responses given by the psyche as an effort to protect itself against anxieties…the anxiety producing experiences, mobilized for a moment, could not give rise to mental verbal representation…of a thinkable nature. (pp. 83–84, my translation)

Considering the Spiritual Dimension in the Recovery Process Reorganization of the intrapsychic structure in psychosomatic disorder, as in other disorders, is not an easy task. It implies restructuring the unconscious organization by facing and working through the anxiety associated with initial pain, and raises strong tendencies to keep the defence mechanisms in place. In this chapter, based on results of a phenomenological-existential study, I consider how a person’s spiritual resources can help in such a process. To prepare for this, I present the psychosynthesis concepts of “I” and transpersonal self that will introduce the spiritual dimension of the psychic organization. Assagioli (1965), founder of the theory of psychosynthesis, stipulates that in addition to the unconscious life and death drives, the human psyche also comprises unconscious spiritual forces, which are as important as the id and ego instincts in the development of the personality. These are spiritual energies located in what he calls the higher unconscious (supraconscious), a psychospiritual region from which emerge intuitions and inspirations of the highest rank, such as “artistic, philosophical, or scientific,…ethical drives prompting us to humanitarian and heroic action…altruistic love, states of contemplation, illumination or ecstasy, etc.” (Firman & Russell, 1992, p. 5). The existence of such spiritual forces is confirmed by the phenomenological understanding of many testimonies on mystic, ecstatic experiences of illumination, joy and intense love, or of philosophical or scientific sudden inspirations. Maslow adds that such experiences are moments “when we feel a deeper sense of life, a universality in the details of existence, and maybe a unity between oneself and the universe…experiences of ecstasy, of rapture (or enchantment), of bliss and of great joy” (Maslow, as cited in Firman & Russell, 1992, pp. 5–6). The energies, intuitions, and inspirations from the supraconscious exist through the entities that Assagioli calls the “I” and the transpersonal self, constituting the unifying centre of personality. On the one hand, the “I” is pure self-awareness and will. It is the first level of one’s essence of identity, the consciousness of being unique and the will to make choices according to one’s deepest values. The Self (with a capital S refers to the

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transpersonal self), on the other hand, is unconscious. It is one’s permanent centre, conceived as the source of identity from which the “I” derives. It is the substance of one’s essence. A transpersonal will, yearning for the highest of goods or values, characterizes the Self. The “I” and the Self are united yet distinct. The “I” is the reflection of its deepest source, the Self. Its will makes judicial choices when choosing goods that are yearned for by the Self. Assagioli (1973) also asserts, from a phenomenological perspective, that “I” and Self are both present to and distinct from the psychosoma (drives, thoughts, feelings). They are always present, even if not conscious of it. When “I” is inactive, as in experiences of sleep, dreams or ecstasy, the Self acts upon it at the symbolic level by inspiring it and drawing it towards ultimate realities or spiritual enlightenment (as with images appearing in dreams whose interpretation reveals deep aspirations having spiritual as well as psychological meanings). Firman (1992) states that the presence of “I” and Self is characterized by their distinction from the psychological and physiological manifestations of the personality without, however, being dissociated from them. The “I” is conscious of experiencing thoughts, feelings, and corporeal energies. While being conscious of its own experiences and being immersed in them, the “I” transcends the flow of experiences. Thus “I,” although distinct, is present to all that is experienced at the psychosomatic level. The same goes for the Self; while being present (unconsciously) to the flow of the personality’s psycho-physiological experiences, it transcends it by remaining oriented towards ultimate reality and surpassing it. In psychosynthesis, disorders are explained as follows: the “I” is fixated on subpersonalities rather than being centred on its source, the Self. While the “I” is not centred on the Self, it is not choosing to live according to the Self ’s highest values. From this stance it could be said that recovery from psychosomatic symptoms would depend on the unification of the personality around the Self ’s highest values. In other words, for the id’s drives to reach symbolic representations and to eliminate the instinct’s distortions in the ego, the “I” needs to be centred around the Self and to orient the personality according to the values of the Self. (I discuss this recovery process in greater detail in the Discussion below.) METHODOLOGY

The basic principle of the phenomenological-existential approach is to go “back to the things themselves” as they appear to the

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person’s consciousness. The aim is to identify the meaning structure or the essence of a given phenomenon as experienced by the subjects (Edmund Husserl, in Giorgi 1985). Researchers elucidate, understand, and faithfully describe the experience and its meaning structure before making theoretical sense out of it. In the present study, I adopt Croteau’s (1994) elaboration of Giorgi’s method to emphasize existential concepts implied in the approach. The phenomenological-existential approach assumes that human beings are closely linked to the world in which they live, experiencing themselves as beings-in-the-world (Croteau, 1994, p. 5), having a consciousness of their own and being free to make choices and decisions on their own account. The world is experienced by a consciousness-incarnated-in-the-world (conscience-incarnée-au-monde) (Croteau, 1994, p. 6) and refers to three modalities of connection (1) to the surrounding world (physical and material things—umwelt); (2) in the world with others (people with whom one relates—mitwelt); and (3) the world within (thoughts, feelings, desires, values, revealing how one experiences self— eigenwelt). In elaborating on Giorgi’s method, Croteau also considers two more categories to account for the subjects’ way of being-in-theworld relative to their aspiration for meaning: the will to seek out meaning and the sense of responsibility. These five categories can help the researcher organize the variety of elements that emerge in an interview with a subject and identify the meaning structure or the essence of the phenomenon. Also expressed as an intentionality, that to which the conscience aims, the essence can be understood as the expression of the person’s will or values. The validity of this method is based on two principles: phenomenological reduction and eidetic reduction, which imply that researchers adopt a neutral position from any preconceived ideas, values, or theoretical explanations of the interview content and reduce the content of a person’s view on a phenomenon to its essence. The reduction is done using the free imaginary variation allowing “a concrete experience to float in one’s mind so as to let oneself imagine that experience in every possible modified aspect; what remains invariable thereafter is the essence of the phenomenon” (Maurice Merleau-Ponty, in Croteau, 1994). Researchers eliminate peripheral aspects of a subject’s discourse to identify with as much accuracy as possible the “invariable contingents” relevant to the subjective structure of meaning (Morin, 2000; 1999; Merleau-Ponty, 1949). Unlike traditional empirical research methods, the focus of the phenomenological-existential approach is not to arrive at inferences that

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can be generalized to larger populations but to identify stable laws, fundamental structures, and idiosyncratic profiles of invariable structures of meaning in particular phenomena. The meaningfulness of the type of information resulting for this approach is based on the stability of phenomenological meaning structures. The validity is found in the redundancy of meaning structure in repeated interview-based research with people having experienced similar phenomena. Repetition of the essence of a given phenomenon generates meaningful understanding of that phenomenon, which can be used in clinical settings as well as in theoretical elucidations. Dukes (1984) gives the example of such stable meaning structures or essences in the experience of loss or death of a loved one that comprises five stages: the initial refusal, the futile attempt to construct a set of circumstances in which it need not have been, self-blame, the shutting down of being, and the remembering of long-forgotten moments. According to Dukes (1984), such an experience is a “universally and distinctly human experience that has an inherent logic, a rhyme and rhythm of its own, and that logic or structure is the same for any human being who has ever suffered loss…regardless of the facts [surrounding the loss]” (p. 199). In phenomenological-existential research, instead of starting with a hypothesis, a question of interest is formulated, orienting the analysis. In the present study, the question is: What are the fundamental psychospiritual aspects of the recovery process from fibromyalgia symptoms? The discussion of the case study introduces the analysis I use in an attempt to answer this question. CASE STUDY

The subject is a forty-four-year-old woman, whose pseudonym is Mary. She has been married for twenty-three years, is a mother of three children (22, 21, and 15 years old), and lives in a rural area. Mary had been working as a nurse for fifteen years at the time her fibromyalgia symptoms appeared. A three-hour interview was held with her in which she was asked to describe in detail her full experience of the fibromyalgia disorder and her psychospiritual journey towards recovery. Symptoms of fibromyalgia appeared after Mary lifted a patient who weighed ninety kilograms. This was in the fall of 1991. She waited two months before receiving physiotherapy treatment, during which time she became numb all over her body. Six months later, in the spring

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of 1992, her physician diagnosed fibromyalgia syndrome. When informing her of the diagnosis, the doctor explained that nothing could be done through medical assistance. He recommended anti-inflammatories, anti-spasmodics, and anti-depressants, and said: “All you can do is to learn to live with it.” Mary did not accept this recommendation, calling it a “hopeless” route. She undertook a long journey of psychospiritual research which lasted four years and included three years of intense research, prayer, exploration of her inner life, a six-month process of forgiveness involving a family member, and six months of applied daily imagery and prayer. Her fibromyalgic symptoms disappeared in the spring of 1996—she woke up one morning free of all her symptoms. RESULTS FROM THE INTERVIEW ANALYSIS

A first level of analysis identified essential elements and classified them under Croteau’s five categories (eigenwelt, mitwelt, umwelt, will to meaning, and responsibility). The name of the categories is presented after the content summary corresponding to the interview segment. For each step of the process, after presenting the essential elements obtained under these categories, we present the essence or meaning structure identified from these elements, and its corresponding intentionality is listed. The essence and the intentionalities are two ways of expressing the meaning structure found in each of the eight steps of the analytic process (see appendix). 1. 2. 3. 4. 5. 6. 7. 8.

Before recovery. During the suffering from the symptoms (began in the fall 1991). Time of diagnosis and after (six months after the accident). Process leading to recovery (two to three years). Prayers for grandfather and forgiveness of sister (spring 1995). Imagery and prayer after forgiveness (began November 1995). Recovery itself (spring 1996, between March and May). After recovery: (a) living differently, (b) interpreting conditions of health.

For a clearer understanding of these results, let us move to the last step of the phenomenological-existential analysis, the structural synthesis, in which the invariant structure that can be deducted from the intentionalities listed above is identified.

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STRUCTURAL SYNTHESIS

For the synthesis, we refer to the series of intentionalities derived from the essence identified in each step of the process, since it expresses the subject’s intentions or values. They give useful information about fundamental aspects of the psychospiritual process that led Mary to psychosomatic recovery. Not only are they understood as the things that were meaningful to Mary in her search for recovery, but they also give indications that allow us to make theoretical and hypothetical conclusions about the implication of the spiritual elements of her personality. The list of intentionalities is: 1. Greater satisfaction with herself, the world, and her relationship with God. 2. Looking for meaning of life and relief of pain. 3. Living without pain, finding the solution, recovery through faith. 4. Recovery by resolution of psychological problems and changes in relationship. 5. Following the invitation to forgive and reconcile. 6. Finding the way to recovery, surrender, living at the level of the soul. 7. Hoping symptoms will not return and for people’s acceptance. 8. Congruence with self (values, etc.) and others, and recovery from symptoms through love and unity of her three levels of being. Taking this list of intentionalities into consideration reveals three main stages in Mary’s journey. First, she hopes for something better in her life: more satisfaction with herself, the world and God, more meaning in her life, no pain, and a full recovery from her symptoms, including recovery through faith (numbers 1 to 4 and 8). Second, she decides to resolve psychological problems and make changes in her relationships, to follow the invitation to forgive and reconcile, and to surrender with the help of imagery and prayer (numbers 4 to 6). Third, while hoping for permanent recovery and people’s acceptance, she interprets her recovery as a result of congruence at the three levels of her personality and in her relationship with herself, with others and with God (numbers 7 to 8). These three stages reflect a fundamental invariant structure that corresponds to Mary’s journey towards fibromyalgia recovery and can be summarized as follows: aspiring for greater well-being, spiritually (or religiously) and psycho-physiologically; choosing to make changes using all available means, including intuitions coming from her faith; and revising her view of self and the world in light of the results of her choices.

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This structure corresponds to three stages often identified in a psychotherapy process that considers spiritual or religious issues: (1) people are invited to recognize their aspirations for a more fulfilling way of life (in regard to self, others, and their spiritual or religious references); (2) they choose to make the necessary changes using all resources available, psychological and spiritual or religious (e.g., inner exploration, welcoming spiritual intuitions like forgiving and surrender, applying imagery and saying prayer); and (3) after having made the right choices and noticed the positive results within themselves and in their environment, they revise their conception of self and their world. These three stages also correspond to what Assagioli (1973) identified as the six stages of realization of the will when decisions are made to pursue an intention. In the first two stages we find the following correspondence: number 1 includes the motivation, intention, or goal that is pursued (stage 1), and the deliberation, consideration, or reflection about the best decision to take to achieve that goal (stage 2); number 2 includes the choice or decision to act (stage 3), the assertion or command to go on with that decision and make it happen (stage 4), the planning of the actions to take (stage 5), and the execution or carrying out of the actions planned (stage 6). Number 3 follows the result of the execution (stage 6); that is, the positive (or negative) results generate a new way of looking at reality and the process starts over with new motivation, intention (back to stage 1), new deliberation, reflection (stage 2), and so forth. The identification of this structure alone does not explain everything about the recovery. The scientific value of this structure is found, not in an explanation of what caused Mary’s recovery, but in the consolidation of the recovery process she experienced. It is also found in the correspondence between the structure of Mary’s recovery process, including the spiritual or religious dimension and the steps included in the realization of her will. On the basis of these findings, let us now go a step further. If we make a parallel between this structure and the psychoanalytic explanation of psychosomatic disorder, we arrive at the conclusion that the concepts used in this last school of thought are not sufficient to explain all that is present in a person’s deepest being and resources he/she draws on for psycho-physiological recovery. To go “back to the things themselves” implies that we do not integrate this deepest reality. We must, instead, try to find an explanation; that is, to find some theoretical considerations that can account for the spiritual dimension of Mary’s psy-

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cho-physiological organization. We can do so by using the psychosynthesis concepts presented earlier. DISCUSSION

The psychoanalytic explanation of the psychosomatic organization allows us to understand what is at stake in Mary’s inner conflict. We can suppose that her disagreement with her sister is the expression of her unconscious defensive organization that resulted from the lack of affection with her mother during childhood. Mary explained in the interview that her conflict with her sister was a catalyst for repressed anger towards her mother. The lack of symbolic representation, resulting from the absence of her mother’s loving care, contributed to the distortion of Mary’s ego instincts and their use of destructive mechanisms to face external limits. They turned against her body in order to appease the anxiety and survive the pain encountered in repeated lack of satisfaction relived in the conflicting relationship with her sister. Being able to forgive her sister meant forgiving her internalized mother, the root of her unconscious organization. Mary’s fibromyalgia symptoms can be understood as the expression of her ego’s distorted instincts and their attempt to release her anxiety through sickness. However, some aspects of Mary’s personality that played an important role in her recovery process are not accounted for through psychoanalytic concepts. The three stages identified in the analysis imply that the will is at stake in Mary’s hope for something better, in her decision to make the necessary changes, including having faith in God, and in her acceptance to allow the changes to occur in her psychological organization, in her relationships, and in her values, beliefs, and so on. The expressions of the will, inferred from the intentionalities, seem to correspond to the psychosynthesis concepts or entities of “I” and Self described earlier. By associating the “I” and the Self to the three stages in Mary’s recovery process, we can easily identify the manifestation of these entities. If the “I” is characterized by its consciousness and will, we can recognize its presence in the first stage when Mary is conscious of her unsatisfying world and her hope—or will—for something better. Mary’s refusal to accept the doctor’s “fatal” diagnosis and her aspiration or hope for a stronger well-being (implied in being unsatisfied) can be understood as the expression of the “I” being conscious of and willing—or choosing— to adjust to the aspirations coming from the Self. In the second stage, Mary’s decision to make the necessary changes using all means possi-

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ble (including faith in God) is also a clear indication of the “I’s” decision to adjust the personality to the aspirations coming from the Self (following the invitation to forgive, surrender, and so on). Indeed, the Self, being the “I’s” deepest source as well as being a catalyst for spiritual experiences, can be seen as the entity that helped Mary’s “I” recognize her lack of adjustment to her “true-self ” (which can refer to the Self, one’s real source of identity, opposite of the false-self). It is also through the Self that the invitation from God is heard. Mary’s surrendering and her trust in her inner conviction allowed changes to occur in her values, beliefs, and soul. This can be understood as the “I” trusting the spiritual intuitions and inspirations coming from the Self and allowing them to take over Mary’s personality. In the third stage, Mary’s hope for the permanence of her recovery and need to understand what happened can find explanation through the influence of the Self. Since the manifestations of the Self are known to emerge from the supraconscious, one needs to reflect on their nature; one needs to evaluate whether they are reliable, stable, and trustworthy. In fact, human beings experience spiritual realities in a different way than regular physical or psychological experiences. For example, great joy, sudden intuition or illumination can be very surprising and leave the person wondering about their meaning. There is a need, then, to verify the origin and the trustworthiness of such spiritual experiences. From a Christian perspective, for example, after being told that God is trustworthy, individuals have to (a) decide, based on testimony of people having experienced His trustworthiness, whether they will trust this God; (b) be open to allowing God to intervene and let that intervention penetrate their personality and their lives; and (c) give an interpretation to their spiritual experience of God’s intervention: is this experience coming from God or is it an illusion? Such interpretation will either make the person continue to trust in God’s assistance or distrust Him. After her recovery, Mary’s reaction clearly shows that her “I” was not fully convinced that she could trust the lasting effects of recovery. It is only through the durability of positive effects in her personality and in her way of feeling and relating to others that she could assert her conviction that unity of soul, body, and mind and an openness to God’s love and to others were reliable foundations for psycho-physiological well-being, harmony, and unification. Again, the “I” was present in such a conclusion. Associating the “I” and the Self with each stage of Mary’s recovery process allows us to formulate the following hypothesis: “Inner peace,

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resulting from the role of ‘I’ and Self, has a positive impact on the recovery from fibromyalgia symptoms by the appeasing of psycho-physiological conflicts in Mary.” Recognizing the possibility that the “I” and Self were active in the process of Mary’s recovery invites us, however, to say more about their unifying spiritual energies in human beings and to revisit psychosomatic disorders from a different angle, reading anew the psychic fundamental conflict in psychosomatic disorder. Conceiving that “I” and Self potentially exist in a newborn child, we can infer that their aspirations are present in the first moments of their lives. Thus the Self, yearning for ultimate and absolute goods, may recognize the paradisiacal experience of mother–child symbiosis as an experience adapted to its aspirations for absolute and infinite love. St. Arnaud asserts, in fact, that one’s first religious experience is that of fusion with the first love object, the mother who is experienced as a “person-everything-to-me” or, in other words, as God, who is THE Everything. The [first] structure [of the personality] is made up of the unique absolutely vital relationship experience with at least one adult person that the child felt as being really everything for him [/her], and that, for at least a few months, happens to be effectively EVERYTHING for him [/her]. This adult is, of course, the MOTHER who, for the embryo, the foetus and even the newborn, until the end of the breast-feeding period, literally plays the role of the “PERSONEVERYTHING-TO-ME.” (St. Arnaud, unpublished manuscript)

In this primary state of absolute love, the person experiences an ultimate well-being that is fully gratifying to the Self. This experience remains engraved in the sensorial memory in such a way as to influence the Self in its aspirations, in the adult personality, to reach out to God, the real EVERYTHING. In this regard, the defensive mechanisms resulting from the first experience of frustration and pain influence not only the adult behaviours and human relationships but also his/her way of relating to ultimate realities and to God Himself. Just as the first experience of absolute happiness entrenched in the unconscious and experienced by the Self serves to model one’s spiritual or religious aspirations, defences built during the first experiences of the limits of reality also indicate the kind of obstacles that will be met in later relationship with the Absolute (God). In the same way as one’s experience of his/her first love object gives way to a deep desire to relive the same experience of absolute loving satisfaction, the limits and frustrations encountered in reality condition one’s propensity to feelings of anxiety and fear of being deceived, abandoned, or betrayed by the ultimate (God). One’s way of

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relating to the ultimate source of all goods, of being touched, spoken to and loved by God, to entrust and abandon oneself to Him, has its roots in this first experience of limited love. It was said, in the previous explanation of psychosomatic disorders, that symptoms, based on a lack of symbolic representation, result from distortions in ego instincts and their destructive effects through body symptoms. By admitting the presence of “I” and Self, two new perspectives can be opened. First, the psychological wound expressed through psychosomatic body language can now be understood with respect to spiritual suffering. That is to say, the defence of the ego prevents the “I” from adhering to ultimate goods corresponding to aspirations of the Self. While expressing ego’s destructive instincts, somatic manifestations can also express the unsuccessful attempts of “I” to find body and spirit unification through the experience of absolute love yearned for by the Self. Second, in the recovery process, the presence of “I” and Self opens up their power based on the freedom and autonomy in the psychosomatic organization. In spite of the intrapsychic destructive ego drives, the Self continues to have aspirations and hopes for ultimate goods and the “I” remains capable of recognizing these aspirations and making choices accordingly. Being distinct from the psychosoma while being present to it, the “I” and the Self have the particularity of not being dependent on psychosomatic manifestations. As spiritual entities constituting the person’s centre, they are free and autonomous with regard to psychosomatic contents. Transcending the ego’s wound, while being present to it, they can overcome the defensive structure and adhere to ultimate goods to bring the personality to unification. Thus, in a psycho-spiritual perspective, we can say that the aspirations of Self, though constrained by the psychosomatic symptoms, remain present in the personality. They can continue to indicate the ways of unifying the personality through access to ultimate goods having the potential of penetrating the wound and alleviating the division. The role of the conscious “I” in this perspective is to make the necessary choices and to take the appropriate decisions to allow ultimate goods to emerge from the superior unconscious. Such goods, brought into consciousness, can help unify or harmonize the personality around the centre of the being and its values. From a Christian point of view, ultimate goods refer to God’s love, whose promise is to quench our thirst for infinite love. Accepting to trust in this promise and to open our being and personality allows His loving presence to generate a deep sense of unity in body, mind, and

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spirit by responding to our fundamental aspiration and thirst for His absolute love. When experienced as a transpersonal source of pleasure, ultimate goods can contribute to changing intrapsychic organization in a way that achieves harmony and unification.

Appendix: A Content Analysis of the Case Study Step 1: Before recovery Content summary

Category

- has low-self-esteem, is stressed, full of anger and hatred

eigenwelt

- tries to prove herself to others through appearance and performance

eigenwelt

- exists for others (perfectionist, hyperactive, rational and sociable )

eigenwelt

- is in conflict with sister (and brother-in-law— cause: inheritance from grandfather)

mitwelt

- finds life is unsatisfying and sees God as one who is watching and threatening

umwelt

Essence: Unsatisfying world view, self-concept and God image Intentionality: Hoping for satisfying Self, world, and God image (intentionalities sometimes appear as the opposite of an essence: lack of satisfaction indicating an aspiration for something better)

Step 2: During the suffering from the symptoms (began in the fall 1991) Content summary

Category

- feels pain as infernal: state of critical crisis 24 hours a day

eigenwelt

- thinks she is going crazy, occasionally goes into depression or becomes hyperactive

eigenwelt

- is not understood by close ones because symptoms are not apparent

mitwelt

- has a close friend to “dump everything on”

mitwelt

- thinks she is in another world, is mixed up about everything

umwelt

- views life as senseless, as having no meaning

will to meaning

Essence: Life is meaningless when living with constant pain and lack of understanding Intentionality: Looking for meaning of life and relief of pain

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Step 3: Time of diagnosis and after (six months after the accident) Content summary

Category

- is relieved from the thought of being crazy or having cancer

eigenwelt

- is hopeless, revolted at the doctor because of the diagnosis of no cure

eigenwelt

- asks many “whys” but believes in Christ; miracles made sense to her

will to meaning

- refuses to live with pain for the rest of her life

responsibility

- decides to come out of the symptoms and to find a solution

responsibility

- is open to everything, including God—but tries bargaining

responsibility

Essence: Relief, refusal to live with pain and decision to find a solution, including through faith Intentionality: Living without pain, finding the solution, including through faith

Step 4: Process leading to recovery (two to three years) Content summary

Category

- asks questions of herself and of God

will to meaning

- admits that the origin of fibromyalgia can be psychological

will to meaning

- discovers conflict with sister (3 years before symptoms appeared)

will to meaning

- feels the pain associated to anger, hatred, and resentment which triggered symptoms

will to meaning

- doubts herself, is mixed up, loses reference points in values, beliefs, God

eigenwelt

- finds book on power of unconscious, positive thinking, prayer, and exploration of inner life

mitwelt

- is open to all that leads to solutions

responsibility

- decides to make changes in the relationship

responsibility

Essence: Research through reading, questioning, and praying; conviction that the conflict, feelings of anger, and hatred triggered symptoms Intentionality: recovery by resolution of psychological problems and changes in relationship

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Step 5: Prays to grandfather and forgives sister (spring 1995) Content summary

Category

- prays to grandfather for a sign to make her understand, grow, and heal

responsibility

- interprets a sermon on forgiveness as an invitation to forgive sister

will to meaning

- thinks forgiving means forgetting, which makes no sense to her

will to meaning

- asks God how to forgive (what forgiveness means)

responsibility

- follows the invitation to forgive through blessing of sister (and brother-in-law)

responsibility

Forgiveness occurs around Good Friday or Easter—beginning of third year - understands the other side of life and people

will to meaning

- writes a letter of reconciliation to sister

responsibility

Essence: accepts the invitation to forgive and attempts forgiving and reconciling Intentionality: following the invitation to forgive and reconcile

Step 6: Imagery and prayer after forgiveness (began November 1995) Content summary

Category

- realizes the need to surrender

will to meaning

- brings changes in her praying

responsibility

- admits her own responsibility in emergence of symptoms responsibility - decides to recover

responsibility

- starts imagery, including prayer, every night

responsibility

One night she felt complete surrender, incredible peace, connecting to God; she was certain she would recover while saying in her soul: “May all be done according to Your will” - sees healing as making sense because she is feeling it

will to meaning

- has no doubts healing will occur

will to meaning

- her values and beliefs are turned upside down

eigenwelt

- lives at level of the soul: seeing good in self, in life, and in people

eigenwelt & mitwelt

Essence: Taking responsibility, deciding to recover, imagery, prayer, and surrender, beliefs in recovery, changes in values and beliefs, living at the level of the soul Intentionality: Finding the way to recovery, surrender, living at the level of the soul

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Step 7: Recovery itself (spring 1996, between March and May) Content summary

Category

Mary wakes up one morning without pain, no apparent reason or event having happened the day or week before except inner changes described above. Other psychosomatic symptoms also disappeared—arthritis, uterine haemorrhage, and anaemia during menstruation, asthma, allergies, and anxiety attacks. - is astonished, lacks understanding, has a hard time believing in recovery

will to meaning

- is afraid symptoms will come back

will to meaning

- slowly adjusts to the absence of pain, physically and psychologically

eigenwelt

- keeps recovery a secret at first: out of fear of what people might think (fear of rejection)

mitwelt

Essence: Astonishment, disbelief out of fear of symptoms return, slow adaptation to painlessness and people’s opinion Intentionality: Hoping symptoms will not return and for people’s acceptance

Step 8: After recovery: (a) living differently Content summary

Category

- celebrates recovery and personal achievement

responsibility

- adapts to recovery: relearning house chores, work in general, and facing risks of being seen as “illuminated”

responsibility

- lives according to “true-self ” (connected with real self)

eigenwelt

- reaches out for her own values and beliefs

eigenwelt

- feels calm, tenderness, and no need for screaming

eigenwelt

- listens to others: accepts what they offer without denying herself

mitwelt

- is open to others’ way of seeing things

mitwelt

- has less need of a social self and appearances and less fear of what people say

mitwelt

- sees life differently: as an experience, not a problem

umwelt

- discovers that full life means following her intuitions and feelings because they carry meaning and can be verified in life as making sense

eigenwelt

Essence: Adapting to absence of symptoms, living according to her true-self, her own values, intuitions, and feelings, and being open to others Intentionality: Congruence with self (values, etc.) and others

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Step 8 (cont.): After recovery: (b) interpreting conditions of health Content summary

Category

- absolutely certain that health will remain and results will to meaning from reconciliation with sister (including inner conflicts with maternal figure), inner changes at 3 levels (physical, psychological, and spiritual) and from love that opened her heart at “360 degrees,” openness to others, self, and soul, to forgiveness, to surrender, and to God’s love, which has an impact on the psychological (peace, serenity, self-esteem, and trusts feeling), which in turn, has an impact on the physical (less stress and pain) - love of self is necessary to start the psychospiritual recovery process

will to meaning

- love is unity and harmony of the physical, psychological, and spiritual

will to meaning

Essence: Recovery from symptoms and unity between the physical, psychological, and spiritual is found through love Intentionality: Recovery from symptoms through love and unity of three levels of being

ACKNOWLEDGEMENTS

This is a revision of the article “Rémission des symptômes de fibromyalgie : Une étude phénoménologique-existentielle,” published in Canadian Journal of Counselling, 37 (2) (2003), 84–100. REFERENCES Arnold, L.M., & Keck, P.E., Jr. (2000). Antidepressant treatment of fibromyalgia: A meta-analysis and review. Psychosomatics, 41 (2), 104–13. Assagioli, R. (1965). Psychosynthesis. New York: Viking. Assagioli, R. (1973). The act of will. Baltimore, MD: Penguin. Bailey, A., Starr, L., Alderson, M., & Moreland, J. (1999). A comparative evaluation of a fibromyalgia rehabilitation program. Arthritis Care and Research, 12 (5), 336–40. Bonaccorso, S., Lin, A., Verkerk, R., Van Hunsel, F., Libbrecht, I., Scharpe, S., et al. (1998). Immune markers in fibromyalgia: Comparison with major depressed patients and normal volunteers. Journal of Affective Disorders, 48 (1), 75–82. Creamer, P., Singh, B.B., Hochberg, M.C., & Berman, B.M. (2000). Sustained improvement produced by nonpharmacologic intervention in fibromyalgia. Arthritis Care and Research, 13 (4), 198–204.

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Morin, M.L. (2000). Pour une écoute en profondeur: La valeur fondamentale (Fundamental values, toward in-depth listening). Montréal: Médiaspaul. Morin, M.L. (1999). Counselling pastoral et Valeur fondamentale individuelle (Pastoral counselling and individual fundamental values). Sciences Pastorales, 18, 25–47. Mueller, H.H., Donaldson, C.C.S., Nelson, D.V., & Layman, M. (2001). Treatment of fibromyalgia incorporating EEG-driven stimulation: A clinical outcomes study. Journal of Clinical Psychology, 57 (7), 933–52. Rosenberg, B. (1998). Pulsions et somatisation ou le moi, le masochisme et le narcissisme en psychomatique (Drives and somatization or the ego, masochism and narcissism in psychosomatics). Revue française psychanalytique, 5, 1677–98. Rossy, L.A., Buckelew, S.P., Dorr, N., Hagglund, K.J., Thayer, J.F., McIntosh, M.J., et al. (1999). A meta-analysis of fibromyalgia treatment interventions. Annals of Behavioral Medicine, Special Issue, 21 (2), 180–91. Smadja, C. (1998). Le fonctionnement opératoire dans la pratique psychosomatique. (Operative functioning in the practice of psychosomatics). Revue française psychanalytique, 5, 1365–1440. Stahl, S.M. (2001). Fibromyalgia: The enigma and the stigma. Journal of Clinical Psychiatry, 62 (7), 501–502. St. Arnaud, Y. (1985). Le counseling pastoral (Pastoral counselling). Unpublished document. Ottawa: St. Paul University. Turk, D., Okifuji, A., Sinclair, J.D., & Starz, T.W. (1998a). Interdisciplinary treatment for fibromyalgia syndrome: Clinical and statistical significance. Arthritis Care and Research, 11 (3), 186–95. Turk, D., Okifuji, A., Sinclair, J.D., & Starz, T.W. (1998b). Differential responses by psychosocial subgroups of fibromyalgia syndrome patients to an interdisciplinary treatment. Arthritis Care and Research, 11 (5), 397–404.


16 Life-Threatening Illness: A Dangerous Opportunity Beverly Musgrave

T

his article describes a qualitative examination of the relationship between life-threatening illnesses and subjective experiences— specifically, experiences of long-term adjustment/coping, spiritual response, and meaning-making in a carefully selected sample of adults diagnosed with either heart disease or cancer. Life-threatening illness, coupled with the long-term adjustment of living with a sudden, unexpected diagnosis, creates a crisis that demands a response. Qualitative research methods are particularly well suited to investigations that are exploratory in nature and that focus on highly personal experiences, such as confrontation with life-threatening illness and spiritual exploration, and are used in this study. It is interesting to note that the Chinese word for “crisis” is made up of two characters—one represents danger, and the other represents opportunity. According to Frank (1991), the mystery of responding to a life-threatening illness is that each new breath is experienced as a paradoxical gift, the gift of life mixed with the ever-constant possibility of death. No aspect of life is left untouched. It is a dangerous experience of being taken to the threshold of life from which the end can be observed. For these reasons, this paradoxical gift offers “a dangerous opportunity” for coping styles to emerge as possible responses to living with illness that threatens one’s life. The onset and the ongoing process of living with a life-threatening illness is a distinct type of personal and social crisis. Crisis intervention theory conceptualizes crises as life events that are so profound as to

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shake people’s fundamental assumptions about their worlds and to exceed the capacity of their coping repertoires; thus, their egos and identities are threatened. According to this conceptualization, there are three possible resolutions that can be achieved, with or without professional intervention: some individuals become hopeless and compromised and are less able to cope with difficulties in the future; some regain their former level of personal equilibrium; and some seem to develop enhanced levels of self-understanding and personal resilience. Unfortunately, we know very little about the ways that members of this last group achieve their fortunate outcomes. According to the frequently cited framework of Lazarus and Folkman (1984), adjusting to a stressful event is an ongoing or transactional process. It begins with a primary appraisal, which attributes meaning to the event itself. If the event is appraised as threatening, as is undoubtedly the case with a life-threatening illness, the primary appraisal is followed by a secondary appraisal, at which time various coping strategies are considered and interpersonal social support, spiritual guidance, and comfort may be sought out. The short-term outcomes of a secondary appraisal set the occasion for a reappraisal of the crisis. How threatening is it now? What does it mean for me? These reappraisals, in turn, influence a second “wave” of secondary appraisals, and so on over time. A number of theories and empirical models have been suggested to account for relationships among appraisals, coping, social support, spirituality, and identity in the context of life events. Meaning and meaning-making play a major role in working through and coping with a crisis (Aarts & Op den Veld, 1996; Janoff-Bulman, 1999). Existential thinkers, such as Frankl (1985), view suffering as a potential springboard both for having a need for meaning and for finding it. Being diagnosed with a potentially terminal illness, for example, may be seen as a crisis in the fullest sense of the word, an experience of major distress or even despair that may itself offer an opportunity for growth and meaning, especially as one learns to cope with this lifethreatening intruder (Greenstein & Breitbart, 2000). Patients who report a high degree of meaning in their lives experience more enjoyment in life than those with a lesser sense of meaning, even in the case of severe pain or fatigue (Brady, Peterman, Fitchett et al., 1999). The ability to find meaning specifically within such a traumatic event as a life-threatening illness has been associated with an increased ability to adapt (Davis, Nolen-Hoeksema, & Larson, 1998; McIntosh, Silver, & Wortman, 1993). Social-cognitive models of coping and adjustment (Epstein, 1973, 1994;

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Janoff-Bulman, 1992; Parkes, 1988; Taylor, 1983) propose that meaningmaking plays a central role in the process of adjusting to loss and trauma because meaning-making seems to maintain two aspects of our sense of self that are most threatened by a crisis: our sense of self-worth and our fundamental belief or assumptions about how the world works (Davis et al., 1998). Frankl (1985) frequently refers to Nietzsche’s aphorism “He who has a why to live for can bear with almost any how” (p. 84). Trying to uncover both the why and the how of patients who cope with life-threatening illnesses is at the heart of this chapter. Little information, however, is available regarding the relationships among appraisal, coping, meaning-making, social support, and how these might connect specifically in a process that culminates in spiritual growth in the context of dealing with a life-threatening illness. THE NATURE OF CRISIS

According to crisis intervention theory, a crisis is an experience or event that introduces an abrupt and profound discontinuity into a person’s life. Crises can be associated with developmentally predictable transitions, such as entering college or becoming a widow, or with unexpected or even shocking events such as personal assault or the onset of a life-threatening illness. In any case, a crisis is said to occur because the individual’s coping repertoire, heretofore adequate, is unprepared and overwhelmed by the event. Not infrequently, the collective coping repertoire of the individual’s social network is similarly overwhelmed. Ego-psychology and psychoanalytic perspectives on crisis both emphasize the ego-fragmentation and the threat to identity associated with an experience of being-in-crisis and the regression that results, that is, there is a greater reliance on less mature defences and coping strategies that characterize the early stages of responding to a crisis (Procidano, 1982). Personal and clinical narratives about life crises are consistent with this conceptualization, and they document the fact that change is a fundamental element of crisis. The experience of crisis is typically sudden, intense, and unexpected, and can threaten and overwhelm the person or persons involved. Customary habits of handling stress and problem solving often do not work. A crisis usually involves the loss of something significant, a sudden shift in one’s life experience or the appearance of new and threatening aspects that create new challenges. This is particularly true for people confronting serious illnesses.

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Another fundamental element of a crisis is uncertainty about the future. People in crisis have reasons to doubt their abilities to cope with their immediate demands, to achieve their long-term goals, and, in the case of a life-threatening illness, to cope with the uncertainty of whether or not they will survive. For all of these reasons, a crisis always means a change, a shift, or a turning point in the way an individual reacts to the experience of living. APPRAISAL AND COPING

Lazarus and Folkman (1984) propose a parsimonious framework to guide psychological inquiries into the complex dynamics of the personal responses to stressful life experiences. They suggest that responding to a stressful event is an ongoing or transactional process, in which a threatening event prompts the person to engage in a primary appraisal, that is, to attribute meaning to the event itself or decide what is at stake. If the event is appraised as threatening and if something important is at stake, the primary appraisal is followed by a secondary appraisal, in which people consider their options and engage in various coping efforts, including seeking interpersonal social support and spiritual guidance and comfort. The framework of Lazarus and Folkman (1984) implies a clear relationship between appraisal and coping: that people respond to stressful experiences in a way that is consistent with or that seems to match the meaning they attribute to it. After twenty years, this contention remains influential, and has received fairly consistent empirical support in a variety of life contexts (e.g., Folkman, Lazarus, Dunkel-Shetter et al., 2000; Gowan, Riordan, & Gatewood, 1999; Zakowski, Hall, Cousino Klein, & Baum, 2001), including coping with pain (Boothby, Thorn, Stroud, & Jensen, 1999) and cancer (Sweet, Savoie, & Lemyre, 1999). There are many studies that describe and document the contributions of the coping process to psychological adjustment in the context of illness. In general, more active, confrontational approaches are found to be more adaptive than passive or avoidant coping ones (e.g., Meijer, Sinnema, Bijstra et al., 2002). The availability and the subjective perception of social support have been demonstrated to have similarly beneficial effects in populations with a variety of serious illnesses (e.g., Ben-Shlomo, Camfield, & Warner, 2002; Lichtenstein, Laska, & Clair, 2002).

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RELIGION AND SPIRITUALITY

For people coping with chronic illness, concepts of religion, spirituality, and their relationship to God and others are important in exploring meaning and in developing a secondary appraisal. There are many individuals who regard religion as important but who seldom attend church, and there are individuals for whom religion is not highly important but who attend church nonetheless (McIntosh et al., 1993). Generally, the concept of spirituality is regarded as broader than religion and as encompassing the need to find meaning in life, in death, and in suffering, and to find transcendence and a sense of connectedness with one’s self, other people, and a higher power (Flannelly, Flannelly, & Weaver, 2002). Flannelly et al. (2002) state that, even though religious beliefs and practices are considered to be expressions of spirituality, spirituality can be expressed apart from traditional beliefs and activities, as found in the work of Emblen (1992), Peri (1995), and Sumner (1998). For some people, religion may be the only way in which they express their spirituality (Roberts & Messenger, 1993). Religiosity is an expression of faith through the practice of a particular religion or denomination (Wald, 1988), while the predominant understanding of spirituality is meaningmaking (Thomson, 1994). Investigators are increasingly reporting that religious beliefs and practices and spirituality are important for many patients suffering with illnesses (Gordon, Feldman, Crose et al., 2002), and that religious beliefs and spirituality are found to be related to more adaptive coping and recovery strategies (Koenig, George, & Peterson, 1998; Krause & Van Tran, 1989). Researchers have found a strong relationship between the patients’ reliance on religious/spiritual beliefs and practices and their effectively coping with cancer (Holland, Passik, Kash et al., 1999; Massie, Holland, & Straker, 1990). Patients who attend religious services, at least once per week, have been shown to have stronger immune system functions (Koening et al., 1997), compared with less frequent attendees. Forty per cent of hospitalized patients say their religious faith is the important factor that enables them to cope (Koenig et al., 1998). This has also been documented for patients with gynecological cancer (Roberts et al., 1993), who were undergoing open-heart surgery (Oxman, Freeman, & Manheimer, 1995), or cardiac transplantation (Harris, Dew, Lee et al., 1995), and those experiencing health-related problems associated with aging (Conway, 1985). Patients are three times more likely to survive openheart surgery if they depend on their religious faith (Oxman et al., 1995).

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Religious values and practices (defined in different ways) have been shown to result in faster recoveries from depression (Koenig et al., 1997) and anxiety (Azhar, Varma, & Dharap, 1994). Heart surgery patients who are religious have 20 per cent shorter post-operative hospital stays than non-religious patients (McSherry, Ciulla, Salisbury, & Tsuang, 1987). In general, religious coping behaviours are related to better mental health (Koenig et al., 1998). REAPPRAISAL: THE ACT OF MEANING-MAKING

Lazarus and Folkman (1984) also propose that people continue the evaluation process—that is, evaluate the short-term outcomes of their coping efforts and then engage in primary appraisal again. In doing so, they reappraise the event (e.g., how threatening is it now? what does it mean for me?), which then leads to revised coping efforts, and so on. It is an ongoing process of looking for meaning. An important part of this ongoing process of looking for meaning is coping with shattered assumptions regarding the meaningfulness of the world, the strength of one’s body and self-worth. The ability to restore shattered assumptions when living with life-threatening illness is critical to adaptation (Davis et al., 1998; McIntosh et al., 1993; JanoffBulman, 1992, 1999; Janoff-Bulman & Berg, 1998; Janoff-Bulman & Berger, 2000). Openness to finding meaning in trauma plays a major transformative role in all major modes of treatment. Trauma therapists recognize the central role of the existential and the spiritual dimensions of healing (Rothbaum, Meadows, Reick, & Foy, 2000; Herman, 1992; van der Kolk, McFarlane, & Weisaeth, 1996). Wong (1998) defines personal meaning as an individually constructed cognitive system that endows life with personal significance. This is particularly relevant when critical illness becomes a way of life and when it becomes necessary cognitively to reframe and reassess the meaning of life in order to cope with a new self-image and, for some people, a new lifestyle. Discovering this personal meaning-system is important in terms of overall functioning, particularly when coping with a lifethreatening illness. Kegan (1982) says that human beings are “constitutive meaningmakers” who are continually working to make sense of their world by actively constructing their reality. Similarly, Perry (1970) says that the human organisms organize meaning. Thus, it is not so much that a person makes meaning as that the activities of being a person are activities

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of meaning-making. When life seems capricious and out of control because of an unexpected illness and when a sense of hopelessness and helplessness prevails, faith and meaning can play a crucial role. Suffering is at the core of the human condition and living with this reality requires one to discover and uncover meaning throughout his/her lifespan. The task of rebuilding a meaning system, or, for some, finding a meaning system for the first time, is a significant challenge when confronted with an ever-changing self in the face of dwindling life opportunities, particularly when illness occurs early and unexpectedly in the lifespan (Thurnher, 1975; Erikson, 1963; Baumeister, 1991). ADVANTAGES OF QUALITATIVE METHODS

Qualitative research methods, such as interview techniques and content analysis, are gaining recognition and prevalence in psychological research (Ratner, 2002). Increasingly, investigators see qualitative methods as a way of facilitating and even hastening the convergence of new and important knowledge with information accumulated through more conventional, quantitative research designs (BrydonMiller & Tolman, 2001; Marecek, Fine, & Kidder, 2001). In particular, the use of qualitative approaches has enhanced investigations of personal life histories (Cole & Knowles, 2001), important emotional aspects of interpersonal relationships (Billig, 2001), and adaptive coping (Richards & Folkman, 2000), all of which were important considerations in this study. This qualitative research explored the nature of the process of longterm adjustment and how some people give meaning to serious illness, the role of social support within the process, and the experiences of spiritual growth. The stress that necessarily accompanies illness need not be a negative and debilitating experience, but it may in fact be a “dangerous opportunity” for constructive life change. For some, traumatic stress can be a challenge to discover and accept whatever meaning the experience introduces into their personal life. Responses to this intrusion of stress will be unique for each individual and may vary according to the time in the life cycle when the crisis occurs and how it is assimilated over time. The purpose of the study described in this chapter is to provide a preliminary understanding of what enables some people who have a specific serious illness (cancer or heart disease) to cope with the crisis.

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METHODOLOGY

Participants Twelve adult participants were recruited through physicians and self-help group facilitators. The only inclusion criteria were a previous diagnosis of a life-threatening illness (either a form of cancer or heart disease) and an impression on the part of the referral source that the participant was coping well. By satisfying these two criteria, the participants were considered “expert witnesses” of optimal coping with life-threatening illness. Potential participants were invited by phone to be part of this pilot study. Each participant was interviewed for approximately one and a half hours using a semi-structured interview schedule. The interviews were recorded and transcribed, then the data was reviewed using content analysis. The interview questions asked were: 1. Describe your illness. How long have you had it? How old were you when it began? 2. When you first got sick, did your life change? In what ways? How has that changed over time? 3. Has your illness changed how you feel about yourself ? How? 4. What people helped/not helped you to live with your illness? What are the most helpful/not helpful things that each has done? 5. Has being sick changed your relationships positively/negatively with others? How? 6. When you reflect on your illness today, what does it mean to you? Has that changed over time? 7. Does your illness affect the way you find life meaningful? How? 8. Does your spirituality and/or religion play a part in your life? Has that changed since your illness? How ?

Data Analysis Taped interviews were transcribed, and subsequently content analysis was used adapting code analysis defined by Strauss (1987), reported in Neuman (2003). The task of the coding analysis was to reduce a wide variety of idiosyncratic items of information taken from the response to the eight research questions. The data was coded and systematically organ-

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ized into categories on the basis of themes, concepts, and similarities of features. “Open coding” focused on the content of questions that each participant answered; these answers were compared and the beginning structures of themes emerged, followed by repeated reviews of the transcripts, revisions, and elaborations of the initial “open coding” system. Subsequently, conceptual or thematic codes were derived in the “axial and selective” coding process. Finally, analytic notes were compiled from the various selective coding procedures that helped to inform the discussion section of the research.

Figure 1: Method of Data Analysis Adapted from Strauss (1987)

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Initial reading: The initial reading of all the transcribed interviews was for the purpose of gaining a general overview of content and an initial sense of the responses to the questions asked. Open coding: In open coding, this “first pass” through the collected data on each question was an initial attempt to condense the data into general categories. The themes evolved from the questions asked. This was the first search for the critical concepts and themes from inside the data. Axial coding: This “second pass” through the data consisted of organizing the initial set of open coding data for each question. In this section, specific categories and possible consequences were identified. This coding pass stimulated thinking that regarded the possible links between the concepts and/or themes. These links were then included in the analytic notes that informed the discussion section of the research. Selective coding: With the major themes identified, this “third pass” through the data involved scanning all prior codes and connections, then selectively choosing the data that illustrated the themes, thus enabling comparisons and/or contrasts to be made. It is important to note that, once the themes were identified, another full reading of the transcripts was required in order to gather direct quotes from the initial transcripts that would be used to illustrate the themes. Analytic theme writing: Throughout the coding processes, notes were taken on the data, recording the thoughts, ideas, and connections about the content and the process. These notes, along with the literature review, informed the discussion section. RESULTS

The group consisted of four men, and eight women, two Italian Americans, seven Irish Americans, one African American, and two Jewish Americans. The age range was forty-six to sixty-eight. Five were married, one divorced, two widowed, and four were members of a religious congregation. The group was somewhat homogeneous, with many Roman Catholic participants. All were high school graduates and nine were college graduates. Their illnesses had spanned a significant portion of their middle adult years. It is important to note that eleven of the participants were diagnosed in their mid-fifties or younger and only one person was diagnosed later in life. Four of the twelve have had two or more diagnoses. The time range of living with the life-threatening illness was six months to fifteen years.

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The results are organized around the adapted coding analysis of Strauss (1987). In open coding, the data was organized into general categories. This was followed by a set of major themes identified in axial coding, namely, the experience of illness, meaning-making and coping, role of relationships, religion and spirituality. Lastly, in selective coding, described here, the final themes were connected and data from the interviews were used as illustrations. There are four final themes: (1) experience of illness and how it changed their lives; (2) meaning-making and coping; (3) the role of relationships in coping and living with illness; and (4) religion and spirituality in coping with illness. I will discuss each one briefly.

Experience of Illness The general consensus was that life had changed since the initial diagnosis. Eleven of the interviewees felt that their illness had truly affected their lives; only one stated that life had not changed. The change in their lives was experienced as traumatic for five of the eleven interviewed. This was experienced as a major shift in their relationship to their body, expressed in indifferent ways: “not able to trust my body,” “a change in intimate relations,” “I do not know this body.” Four others related that the experience of physical changes affected both their personal relationships and their relationships at work. For example, one person with breast cancer was afraid to be in a crowd, and two persons had to give up their jobs to attend to their health. Of these four, two members who experienced either cancer or a stroke and were suffering with physical disabilities felt the change most deeply. External manifestation of illness made the process of coping more challenging. Heart and leukemia patients mentioned that they struggled with low energy and an inability to keep up prior self-expectations. Heart patients reported that others did not notice how life had changed for them because their physical changes were more hidden in contrast to someone with an obvious physical disability. Expressions of anger, fear, and disappointment were expressed by 80 per cent of those interviewed; these feelings were experienced at different times in the process. From the outset, the responses reflected different styles of coping with the crisis of living with illness. The crisis of the illness was expressed in terms of shock, surprise, and being overwhelmed and traumatized. Specific comments reflecting the different experiences include “feeling caught off guard,” “anger,” “being

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overwhelmed,” “a deep sense of intrusion into my life,” and “my body failed me.” One person said, “I lost my sense of identity. I could no longer eat real food. I could not feed myself. I lost my job, my savings. I had to start over. Each day was a fight to survive.”

Meaning-making and Coping Meaning and meaning-making were particularly on the minds of the people who were diagnosed at an earlier age (eleven out of the twelve were diagnosed in their mid-fifties or earlier) and meaning-making was most significant when more than one life-threatening illness was diagnosed. Since the time range of living with a life-threatening illness was six months to fifteen years, the responses over time differed. For example, someone diagnosed a while ago said, “I now respect time and I have made it my life challenge to overlook the small stuff,” whereas someone recently diagnosed expressed anger at God and the world for letting this happen to her. About 75 per cent said life had taken on a new meaning, expressed in different ways. Slowing down and taking care of one’s health was a general theme, as well as regular visits to the doctor. Several people mentioned that in the past they never visited a doctor ’s office or had regular checkups. One person expressed it this way: “I now listen to my body, it has become a way of life.” Of the group interviewed, about 85 per cent were both simultaneously aware of the difficulties of living with the illness, while at the same time articulating a need to find a coping style or make some meaning out of the experience. Several people felt challenged to look at their lifemeaning and how they might make changes. This was expressed as “I want to let go of anger and learn to forgive,” or “I have now found a purpose to life,” and by expressing greater gratitude, humour, and appreciation for life. One person decided to help others as a way of finding deeper meaning in life. Several people, trying to make sense of the experience, expressed their concerns and fears. One said, “Cancer is not a death sentence.” Another said, “I don’t have to live by the family-oforigin role. I can speak about my illness and get support. I do not need to hide behind the big ‘C’ word.” Death and dying, a familiar theme, is reflected in the following comments: “Illness opened my eyes to a new perspective on life and death,” and “Being ill does not encompass the totality of me. I am more than my illness.” Concern was expressed as “I struggle with hope. Is this all there is to life?” Another person said, “I have a new awareness of my coping strengths and limitations.”

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One person expressed the desire to find meaning in this way: “My body was trashed. My ability to communicate was seriously disrupted, I was unable to work, I lost my sense of myself, I lost my place in the world, I was homeless, but I want to find out what it means for me.” This courageous woman, when she felt better, decided to minister to the homeless, because she felt she understood their world from the inside out.

Role of Relationships The importance of others, social support, and relationships in general made up the third category of themes. Work relationships were expressed in the following ways: “Work relationships have been altered,” or “I choose my battles; I no longer take on authority figures.” Intimate relations were affected, and concern about this was expressed as “My intimate relationship is now different, I fear sex,” and “I fear being hugged and touched.” Relationships and meaning were very directly related. In consolidating the themes, two questions arose: Is one’s ability to find meaning in life contingent on relationships? Or, are relationships essential to finding meaning in life? These were reflected in the following response: “Friends affirmed and encouraged me. I appreciated the dimensions of their friendship and how they reached outside of themselves more noticeably to me.” Nine respondents noted the importance of the central people in their life at this time of crisis, namely, family, friends, and medical people. Seven respondents commented on the importance and value of discovering support in the church and medical community. Several said, “I have a new belief in the goodness of others,” and six said, “I have a new sense of gratitude for people in my life.” Other responses included: “I now know the power of support. I believe others love me.” “Church people were extraordinarily supportive by calling and sending cards. I found it overwhelming. I did not know how much they cared.” Negative experiences and feelings were also expressed: “My brother was jealous of all the attention I was getting.” “I felt anger and disappointment at the people who stopped visiting.” One person became aware of personal resentment, anger, and jealousy, and decided to choose personal battles more wisely in the future. Our family of origin often teaches us how to cope and respond to illness. This was illustrated by one person in this way: “In my family you don’t ask if someone is ill, and if you are ill, you don’t tell.”

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Religion and Spirituality in Coping with Illness The ability to cope corresponded with the individuals’ ability to have a religious or spiritual dimension in their lives. Ten of the twelve interviewed were clear that spirituality (prayer, meditation) were important to them in the coping process. Religion, attending church services, and having church members respond were important to five who were interviewed. One person expressed that she was not spiritual, but she found strength through creativity and the arts, especially writing. Another said that neither religion nor spirituality were of significance in her life. The religious and spiritual dimensions of coping were present in the initial responses, even when spirituality and religion were not a part of the question: “I am aware of God’s presence.” “Life is now more spiritual.” “I am central to God even when I cannot focus on myself.” Other responses included: “I say ‘wow,’ God is on my side.” “You can never be sure when your time is going to come up and never sure about your health.” “God is my coping system, dying is always on my mind.” “I am too young to die, I have too much to live for.” “I know God is present, loving, and caring.” “God gave me a new lease on life.” “I now have a sense of gratitude before God.” One person said: “My spirituality has changed but not my religion. I am feeling a deep sense of belief in goodness. The loving God is with me.” Another expressed it this way: “Spirituality, yes; religion, no. Spirituality for me is the feeling and the belief in the goodness of what religion teaches but no one follows. It is the good part of religion, not the controlling organized part of religion that is manmade.” After experiencing three diagnoses, one person was extremely angry with God, and felt that God had truly abandoned him. Several questioned how God could have let this happen to them, especially at an early age (mid-life). “I was half way through my life. Why did this happen to me? I wish it never happened. I’m groping with the isolation. I can still be the person I was in my heart.” “God is in this rubble somewhere, I know it.” Anger at God and how He could let this happen were also expressed: “God forgot me, He abandoned me.” One woman profoundly expressed her experience of going through the pain by comparing her illness to “being homeless,” but felt that “God was always present even in the homelessness.”

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DISCUSSION

The focus of this pilot study was to interview twelve adults, considered “expert witnesses,” diagnosed with either heart disease or cancer. The focus was to learn about their experiences of long-term adjustment, subjective experiences of meaning-making, and spiritual responses. In general, the results are consistent with the empirical literature. These carefully selected participants demonstrated how the experience of living with a life-threatening illness becomes a personal and social crisis and how important coping, meaning-making, relationships, and spirituality or religion are during that journey. Crisis can threaten and overwhelm a person. Frank (1991) refers to the mystery of responding to the crisis of illness as a paradoxical gift, the gift of life and the ever-constant possibility of death. Karl Rahner says that life “is one single, great question, to be decided freely by each person: whether he[/she] will surrender himself trustfully and hopefully to the insoluble mystery we call God; whether he will entrust himself to it as to the holy, forgiving love which gives things their ultimate meaning and gives itself to us” (Kelly, 1992, p. 141). Rahner goes on to say that “sickness is one of the events in which this one final question of life, which as such is always present, presses more clearly, is more rigorously stated and demands our answer” (p. 141). The participants of this study were both conscious of the “paradoxical gift” and genuinely engaged in trying to answer the “great question” of life by using various coping styles and meaning-making possibilities in an effort to integrate this crisis into their lives. The ability to restore broken assumptions when living with a long-term illness is critical to adaptation (Davis et al., 1998; Janoff-Bulman & Berg, 1998). It is clear that the sample in this investigation was neither random nor representative of the broader population of adults dealing with serious life-threatening illnesses. This research does support the framework of Lazarus and Folkman (1984) because it implies a clear relationship between appraisal and coping. The interviewees reported having been religious or spiritual before the onset of the illness. At this point, however, the extent to which antecedent spirituality is important or essential is unknown. For instance, some individuals may experience religious “conversion” following illness, but this cannot be inferred from these results. We do know that ten out of the twelve interviewed stated that spirituality/religion was very important to them in their coping process. This finding is supported by the work of Gordon et al. (2002), and religious

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beliefs, practices, and spirituality are found to be related to more adaptive coping and recovery from illness (Koenig et al., 1998; Krause & Van Tran, 1989). As noted earlier, trauma therapists recognize the significance of spirituality in healing (Rothbaum et al., 2000; Herman, 1992). Similarly, the results raise questions about the importance of antecedent personal adjustment and prior illness in people’s ability to attribute positive meaning to a life-threatening situation. Knowing a person’s history of personal adjustments to other major difficulties in their life would be informative. Receiving a diagnosis of a life-threatening illness is consistent with the currently accepted definition of posttraumatic stress disorder (PTSD). Post-traumatic stress is the non-specific that persists after a traumatic incident (Rothschild, 1995). Thus, knowing people’s history of prior trauma, including illness, and understanding their distinct process of appraisal and coping, may be very important. When the effects of illness are visible and disabling, such as could be the case with cancer or stroke, people’s personal narratives may be more guarded. Undoubtedly, there is a spectrum of physical and psychological outcomes influenced, in part, by individuals’ unique histories (with or without prior trauma, including serious illness), as well as the course of the illness itself. These considerations will be the object of a broader, more systematic investigation of spiritual development and positive and negative psychological adjustment outcomes in a larger, more demographically varied sample of adults dealing with life-threatening illness, in which this investigator will take into account prior illness and trauma. The impact of life-threatening illness on people’s identities and, more generally, on their life-meaning structures, must be understood in the context of the age of onset and the duration of the illness. This needs more research. Many people, including practitioners, associate life-threatening illness with old age. In contrast to such an assumption, eleven of the twelve interviewed were diagnosed in their mid-fifties or earlier; only one person was diagnosed later in life. These participants acquired their illness in mid-adulthood and coped with it for significant periods of time during that stage of development. In Erikson’s (1978) well-known developmental stage theory, each stage is conceived in terms of a set of polarities (trust vs. mistrust; autonomy vs. shame; initiative vs. guilt; industry vs. inferiority; identity vs. role confusion; intimacy vs. isolation; generativity vs. stagnation; ego integrity vs. despair). In these terms, many of the participants’ life-threatening illnesses were part of their negotiation of the generativity versus stagnation continuum, even though they may not have been in that development phase.

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Erikson’s (1978) placement of the word “versus” in his formula of stage development is carefully calculated. Furthermore, he proposed that these crucial shifts or changes are reached in response to the challenges presented within the ongoing experience of the life cycle. Whenever it occurs in the life cycle, health versus illness can be viewed as a polarity of identity choice. Siebert (1983) described people who are made stronger by extreme situations or who survive a crisis as having “survivor personalities.” Carlsen (1988) noted, “If crisis is the reaching of our limits of knowing—of a way of being—then the wider the repertoire for imagining life, for fitting together, for solving dilemmas, for opening oneself to new experiences, then the greater the ability to handle crisis effectively in preparation for the next one” (p. 234). This research opens many possibilities for future investigations on several levels: the role of prior traumatization and coping measures; developmental issues facing illness and death “out of time”; prior spiritual, religious, and meaning-making coping responses. An experienced sailor knows well how to read the changes in the wind and must be alert to the exact point when a shift in the sails is needed in order to “come about” and continue to speed along, otherwise the opportunity will be missed and the ship will founder. This exploratory research examined the life-threatening illness experiences of particular individuals, discovering some of the ways they have to “come about” and find an opportunity to cope with their individual crisis. REFERENCES Aarts, P.G., & Op den Velde, W. (1996). Prior traumatization and the process of aging: Theory and clinical implications. In B.A. van der Kolk, A.C. McFarlane, & L. Weisaieth (Eds.), Traumatic stress (pp. 359–77). New York: Guilford. Azhar, M.Z., Varma, S.L., & Dharap, A.S., (1994). Religious psychotherapy in anxiety disorder patients. Acta Psychiatrica Scandinavica, 90, 1–3. Baumeister, R.F. (1991). Meanings of life. New York: Guilford. Ben-Shlomo, Y., Camfield, L., & Warner, T. (2002). What are the determinants of quality of life in people with cervical dystonia? Journal of Neurology, Neurosurgery and Psychiatry, 72, 608–14. Billig, M. (2001). Discursive approaches to studying conscious and unconscious thoughts. In D.L. Tolman & M. Brydon-Miller (Eds.), From subjects to subjectivities (pp. 290–303). New York: New York University Press. Boothby, J.L., Thorn, B.E., Stroud, M.W., & Jensen, M.P. (1999). Coping with chronic pain. In R.J. Gatchel & D.C. Turk (Eds.), Psychosocial factors in pain (pp. 343–59). New York: Guilford. Brady, M.J., Peterman, A.H., Fitchett G., et al. (1999). A case for including spirituality in quality of life measurement in oncology. Psycho-oncology, 8, 417–28.

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17 The Neurobiology of Consciousness and Spiritual Transformation in Healing Stephen M. Sagar

SPIRITUALITY AND SCIENCE

At the beginning of the third millennium, humanity is poised between its ancient roots in mystical spiritual experience and an era of objective, material scientific dogma. As human beings, is it possible to grow and evolve by simply utilizing the principles of a secular, technological society? Can human experience and growth benefit from a rapprochement of spirituality and science? Can we utilize the principles of spirituality within our health care systems? What are the various ways we can experience reality in order to transform ourselves? The famous quantum physicist Niels Bohr (1957) suggested the concept of complementarity, which posits that we can combine philosophies based on different fundamental assumptions, thereby providing a more realistic multi-dimensional view of so-called reality. A physical example of complementarity is the observation of light, which may be viewed as particles or waves, depending on the experimental conditions. Another well-known quantum physicist, Werner Heisenberg (1930), conceptualized the uncertainty principle, which he derived from experiments that showed that we couldn’t be certain about both an atomic particle’s position and momentum at the same instant of time. In other words, the way we observe and experience reality can have a major effect on how we perceive reality, and what aspects of reality can be observed (Frattaroli, 2001). Gödel’s theorem states that we cannot prove our ontological assumptions from within the discipline that derived them (Nagel & Newman,

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2002). Any assessment of reality requires a multi-dimensional approach. The modern science of consciousness is evaluating these ontological questions and is a platform for the chaotic boundary that lies between the subjectivity of spirituality and the objectivity of science. This frontier of chaos is at the root of existentialism and is a source of humanistic growth through transcendence. Current studies of consciousness involve the strengths of mysticism, anthropology, philosophy, psychology, and theology, as well as physics and the biological sciences. I argue that both spirituality and science are necessary for human growth and healing. This chapter focuses on the neurobiology of spiritual consciousness and the mind-body connection. I do not wish to imply that the explanation of experiencing God through neurobiological processes disproves a transcendent consciousness that is greater than our individual sense of awareness. Although changes in the mix of neurotransmitters and electrical activity of the brain can certainly lead to spiritual experience, we can just as correctly presuppose that connection and communion with God or a cosmic consciousness may result in the measured physiological changes. It is not my purpose in this chapter to distinguish the epistemological truth, but to describe some of the neurobiological associations that occur with religious experience and to propose that these can contribute to the evolution of human individuals and the human race. Spiritual intelligence is defined as a mental process that develops our longing and capacity for meaning, vision, and value (Zohar & Marshall, 2001). It is an intelligence of the deep self or soul that asks fundamental questions and has the ability to reframe the answers. It involves a process of holistic integration and transcendence. Wholes can be greater than the sum of their parts. Spiritual intelligence is the capacity that allows us to dream and to strive, to have passion, to set increasingly more complex goals, and to seek joy and happiness. Spiritual intelligence can be a path to integration of unresolved conflicts, reason, emotion, and yearning. Paradoxically, resolution of deep conflicts through spiritual intelligence can be associated with suffering before happiness is attained. Moreover, I propose that spiritual intelligence drives human evolution through its ability to transcend dogma and stagnant ideas. It is not to be confused with religion that, in contrast, is based on a foundation of dogma. Spiritual intelligence is a source of creativity. The unique ability of humans to utilize a spiritual intelligence through the cognitive processing of the human brain may ironically support a theory of evolution that transcends neo-Darwinism. The mech-

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anism of evolution in humans does not simply reside in genetic mutation and selection but in a neo-Lamarckian propagation and selection of memes, that is cultural concepts, which may often be derived from a holistic, transcendental synthesis rather than a reductionist analysis (Persell, 1999). The spontaneous emergence of new cultural concepts may then be selected, according to their survival advantage, and passed on to future generations through the human being’s unique ability to communicate through language. However, in addition to this materialistic explanation is the metaphysical proposal that primeval concepts may be transmitted through an all-embracing or universal consciousness. Jung proposed the concept of the collective unconscious, which contains imaginal categories or archetypes, namely, aggregates of metaphorical representations and meanings that can be accessed by the minds of individuals and cultures, without necessarily having had previous exposure (Jung, 1959). Sheldrake (1995) proposed a morphic field. The morphic field is an information system that communicates between all life forms. It attempts to explain coincident adaptation of a species at different locations, without any apparent direct contact. The theory recognizes the holistic nature of the emergence of life. Sheldrake first proposed the morphic field in the 1980s. Modern biology sees the morphic field as a universal matrix that guides the development of the nervous system and other tissues. It is a field that mediates learning and consciousness. Moreover, each species has its own morphic field that governs the consciousness, behaviour, and development of that species. The conclusion of the theory is that human learning occurs on a planetary level and not just on an individual level. When a sufficiently large number of people learn a new behaviour, the learning is imprinted on the morphic field, making it easier for other human beings to learn that same behaviour. In other words, a tipping point is reached, after a critical mass of learning, when it becomes much easier for other people to learn the new concepts. This globalization of creativity and learning is also reflected in the philosophy of the Jesuit priest and paleontologist Teilhard de Chardin (1975). He proposes a “confluent synthesis” of learning and evolution through a field that he terms the “noosphere.” Modern physics provides further support for field theory in biology, especially through quantum mechanics, which demonstrates that reality manifests itself as a “potentiality,” as “both one and the other,” in contrast to material phenomena that are subject to our logic of “either/or.” Potentiality appears as a unity that cannot be separated or divided (Dürr, 2003). Field and quantum

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theories describe a holistic structure of reality in which “everything is connected to everything else.” Events in nature are no longer to be seen as analogous to predetermined mechanical clockwork, but instead have the character of a continuing evolution, in which every moment contains the potential for change and renewal. Intentionality through conscious awareness or contemplation may congeal potentiality into matter. The intelligence associated with intentionality may influence the morphic field and socio-cultural direction. In contrast to simply learning from a “universal consciousness,” “morphic field,” or “noosphere,” adaptation may be through classical neo-Darwinian natural selection (Caporale, 2002). Instinctual complexes are inherited genetically as pre-patterned neural constructs awaiting activation. They may be kindled into activity by exposure to an existential stress. Perhaps they originally arose through random mutation and then were selected for transmission to future generations because they had a survival advantage through enhancing environmental and social adaptation (Dickens, 2000). In other words, archetypal thinking contributes by encouraging the development of de novo ideas for adaptation and contributes a survival advantage for the mystical or spiritual mind. The logic of scientific positivism limits creativity, since it makes the assumption that reality consists of only the tangible and measurable. In contrast, spiritual thinking may lead to an Archimedes-type “eureka” or “ah-ha” experience during which an innovative idea spontaneously emerges from individual components that synergistically produce a novel concept that cannot be derived from the individual parts. Of course, these spiritual ideas may be utilized inappropriately for evil as well as for good. A transcendental solution also requires moral choice and both science and spirituality require a strong sense of ethics. PSYCHODYNAMICS OF THE MIND

Freud attempted to express the powerful dynamics of the mind systematically, proposing energies such as libido, thanatos, and eros (Mitchell, 1996). In addition he proposed a continuous tension between the id, ego, and superego from which arose a subconscious conflict between motivations to fulfill needs and relieve tension. The superego represents the transcendent part of the mind that can resolve dialectics and paradox, and make moral choices. The death drive, termed thanatos, represents stasis, lack of adaptation, and therefore decay. In contrast, eros represents the dynamic construction of solutions and mindful evo-

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lution. Jung developed the concept of the spiritual mind further, viewing it as a source of personal growth and evolution, integrating and transcending the fragmented conflicts which may have arisen in earlier life (Jung, 1989). Maslow viewed the spiritual mind as the peak of mental development, which arises after the basic needs of life have been met (Maslow, Frager, & Fadiman, 1987). Clearly, the spiritual mind is a powerful aid in coping with existential crises, resolving paradox, adapting to the environment, and providing a source of creativity (Maslow, 1994). We now recognize a new form of intelligence that transcends the previously measured quotients of rational and emotional intelligence. The spiritual quotient may be developed for solving problems that cannot be resolved using other forms of thinking. It is especially relevant for making sense of catastrophes such as illness and deriving solutions that contain personal meaning and purpose, so that suffering can be reduced and mindful coping can occur. Transpersonal psychotherapy and spiritual counselling are powerful tools that can allow sick people to cope and even derive strength from their illnesses. The expression of psychological conflict and resolution in psychodynamic terms can now be correlated with neurobiological measurements. IS THE BRAIN WIRED FOR SPIRITUAL INTELLIGENCE?

The neurobiological correlation with spiritual experience was hindered by the philosophy of René Descartes, which was espoused at the start of the scientific Renaissance during the early seventeenth century (Descartes, 1999). Descartes was not entirely wrong in separating the soul from the physiological machinery of the human body, since the soul may well be a separate functional entity, as yet not defined by science. The soul and mind are functional entities that are distinct from the anatomical structures of the brain and body. However, most scientists would agree that the conscious awareness of the mind requires a functioning brain and body. Whether the so-called soul has independent awareness is a conundrum. Descartes’ error was to separate the function of the mind from the body, since our experience depends upon the integration between the brain and the body through a complex electrophysiological communication network of nerves, cells, and hormones (Damasio, 1995). The mind–body dualism was encouraged by Francis Bacon for political reasons to appease the Church in the face of the emergence of a secular world view based on science (Vickers, 2002). On the other hand, Oriental cultures have maintained a philosophical belief in

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the integration of the mind and body as a complementary and interdependent system, and they believe in a driving force, vital energy, or spirit that maintains a balanced communication system between the emotions, cognition, and physical function (Sheikh & Sheikh, 1996). Disintegration and disharmony of this body–mind network can lead to both mental and physical illnesses. Scientific mechanisms for this intimate connection are being discovered through holistic methodologies, such as psychoneuroimmunology and electrophysiological research (Sagar, 2001). It is only recently in health care that a rapprochement of spirituality and science has become established and their complementary attributes recognized. The brain is a complex processing system “designed” for adaptation and transformation. It is the interface between preconscious activities occurring throughout the body, focused attention, and the nebulous concept of the soul. Descartes eloquently stated, “Cogito ergo sum” (I think, therefore I am); however, science has not defined the source of conscious awareness, free will, and choice. Therefore, any description of neurobiological processing and analogies to computation are useful explanatory models of how we may think, but do not explain ultimately who we are. There is some evidence that decisions are made unconsciously, prior to our becoming aware that we have made a choice (Lewicki, Hill, & Czyzewska, 1992). The awareness of making a choice may only occur in order to affirm our preconscious decision making. Making choices and adaptation may depend on our state of mind at that time. For example, decisions from the heart or intuition, made during a mind-state of prayer or meditation, may contrast with the objective weighing up of the odds using the rational highly focused brain. Indeed the evidence (to be described) suggests that the brain is functioning uniquely during spiritual processing and is in an altered state of consciousness. The spiritual state of consciousness allows adaptation and growth to occur and may resolve paradoxical issues that can cause existential suffering. The spiritual state of consciousness is associated with unitive thinking, transcendence, and the emergence of novel ideas and, sometimes, a new ontological construct that can change the way we view the world. This is illustrated by Saul’s experience on the road to Damascus: The border of the town was not more than half a mile away when Saul suddenly swayed in his saddle. Everything he could see and hear and feel all around him underwent a change. There was a

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chill wind blowing at him, a blinding light shining on him from the heavens, and the roar of great waters in his ears. Saul clutched at the reins but his palsied hands could not hold them. He pushed with his heels against the stirrups, but his ankles quaked, and all power had gone out of his legs. With a great gasp he realized he had no strength to help himself. He fell to the ground and lay there helpless. Then the roaring sound ceased and he heard a voice assuring but compassionate: “Saul! Saul! Why do you persecute Me?” Groaning, not daring to lift his face from the earth, Saul replied: “Lord, who are you?” And the answer came in winning tones: “I am Jesus, whom you persecute. It is hard for you to kick against the goad.” Saul felt very much as helpless now. He sensed, dimly, that some futile rebellion had been at the root of his emotional storms in the weeks since Stephen’s death (Saul had implemented the stoning to death and martyrdom of Stephen). Trembling and astonished, Saul faltered the question that spelled his immediate, instantaneous surrender: “Lord, what will You have me to do?” The voice of the Lord replied to the man lying face down in the dust: “Arise and go into the city and there it shall be told you what you must do.” “But by the grace of God, I am what I am; and His grace in me hath not been void, but I have laboured more abundantly than all they: yet not I, but the grace of God with me.” Saul arose from this vision, and was blind. He was led by the hand to Damascus, where, instead of persecuting the early Christian Church, he joined it and his eyesight was then miraculously restored. (Acts 9:1–19, Jerusalem)

Skeptics are still cynical regarding this encounter. Nearly two thousand years later, with no testimony for their own theories, they dismiss Saul’s conversion as an epileptic seizure. Since then, there have been countless epileptics, but not one of them has been documented as affecting the world so profoundly, nor converting peoples’ attitudes, nor capturing the imagination for posterity. Saul had no previous history of having seizures, either prior to or after this epiphany. No skeptic can dispute the complete transformation of Saul’s outlook, or what suffering he endured for it. In that one blinding, falling moment Saul trans-

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formed and became another man. The hunter of Christians became in one instant full of yearning to be a Christian. He had seen God, and trembling before that glory, stripped naked of his intellectual pretenses, he had cried out in the hope and fear of all believers: “Lord, what would You have me to do?” Saul’s revelation is a description of metanoia (a change of mind or turning around to face a new direction). The turning towards the light resulted in the complete transformation of Saul’s existential perspective. How can we explain this fundamental change in belief and behaviour in terms of neurobiological adaptation? SPIRITUAL NEUROBIOLOGY

The cerebral cortex consists of two hemispheres that have independent functions. Aside from the independent representation of sensorimotor function of the contralateral side of the body, each cerebral cortex contains contrasting operators that determine the way we experience our environment (D’Aquili & Newberg, 1999). These cognitive operators are functional units that are only partly associated with specific anatomical domains in the brain. A large part of their function is to bind sensory experience in time and space by bringing together multiple pieces of information such as current sensory input, memories, evoked emotions, and orientation. A hologram of reality is created and projected back onto the environment, thereby influencing behaviour. Concurrently the brain formulates a future strategy based on past experience. There is a dynamic interaction between different loci within the cerebral cortex via so-called re-entry neurons that connect the various functional units (Edelman & Tononi, 2000). The re-entry neurons descend from the cerebral cortex and junction in the thalamus (which is a relay station for neurons ascending back into the cerebral cortex) and connect with nerve pathways from the brainstem, which is the source of a vast preconscious mind. The two cerebral hemispheres are connected via the thalamus and via a bundle of fibres termed the cerebral commissures that run through the corpus callosum. The right and left cerebral hemispheres process contrasting functions. The right cerebral hemisphere is artistic in nature, expressing functions of imagery, pattern formation, metaphors, and analogies. In contrast, the left cerebral hemisphere deals with focused awareness, analyzing the parts, logic, temporal order, internal consistency, and linguistics. It is usually the source of verbal expression and therefore requires information to be categorized and specific.

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The topographical relationship of the cerebral cortex to function has been mapped out by the famous neurosurgeon Wilder Penfield (1891–1976), using electrical stimulation of the exposed brain. More recently non-invasive measurements of blood flow or glucose metabolism have been made using functional imaging, such as radio-isotope scanners and nuclear magnetic imaging techniques (D’Aquili & Newberg, 1999; Newberg, D’Aquili, & Rause, 2001). The left frontal lobe is usually the dominant lobe and is often associated with being right-handed. It focuses attention, evaluates cause, and delivers the sense of intention or free will. The superior portion of the left parietal lobe is reductionist and analytical of parts. The inferior left parietal lobe is more abstractive and deals with general concepts and linkage of facts, tends to be quantitative, and can abstract meaning by ordering abstract elements into dyads or polemics. The left temporal cortex contains Wernicke’s speech area that is necessary for experiencing and expressing concepts in terms of language. In contrast, the non-dominant parietal lobe (usually on the right side of the brain) experiences holistic function. In other words, it views reality as a whole and in a global context. It is associated with orientation in time and space, and a perception of self, such as being aware of being a distinct entity, and being aware of the integrated position and relationship of parts of the body. This contrasts with the dominant parietal cortex that, as I have discussed, divides the whole into its parts. The right temporal lobe appears to be associated with Divine experience. The process of transformative thinking consists of complex non-linear algorithms of information which self-generate the emergence of novel paradigms. Although metaphorically we can view this autogenic process as similar to a self-modulating computer software program, it is made more sophisticated by the introduction of meaning and emotions. It is controversial to speculate whether a computer can truly emulate and surpass the human brain in creative thinking and also have conscious awareness, but some futurists believe that this will occur (Kurzweil, 2000). We have learned that sophisticated computer software programs, which deal with the complexities of prediction and adaptation, can be written using the principles of neurobiological processing, such as neural nets and genetic algorithms. We can also model transformative thinking using the mathematics of non-linear dynamics, better known as chaos theory. The relative contribution of various psychodynamic contexts is determined by the pull of attractors (centres of psychological gravity) that hold together preconceived constructs of ideas, meanings, and emotions within virtual limits termed phase spaces. The strength-

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ening of one attractor over another may literally pull and transform one construct of ideas into an alternative one, resulting in psychospiritual transformation (Palombo, 1999). Eventually, this translates into changes in the relative production of neurotransmitters, kindling of different neurological circuits, pruning and regrowth of the dendritic connections in neural networks, and a possible readjustment of meaning in the memory banks of the hippocampus. Access to memories appears to require the involvement of the limbic system (emotional brain). We now know that new neurons can be reproduced from the granular cells of the hippocampus (Jacobs, van Praag, & Gage, 2000). Current evidence suggests that the brain remains quite plastic and susceptible to remodelling throughout adult life. Spiritual intelligence, holistic thinking, and transcendental states of consciousness involve the hierarchical integration of neurological domains from the nuclei of the brain stem, through the limbic system, including the memory bank of the hippocampus, and the cognitive operators of the cerebral cortex. Widespread activation of the cerebral cortex may derive from the reticular activating centre and locus coeruleus, located in the brain stem, which innervate the upper echelons of the brain through neurons that release serotonin and norepinephrine. We can speculate that primordial memories may also arise from kindled neurological circuits that connect the brain with viscera, muscles, and other tissues. Resolution of conflicts in these circuits may have a healing effect on somatic tissues, through peripheral neurotransmitters, biological growth control molecules (such as neuropeptides), and hormones. Rebalancing of the autonomic nervous system can modulate tissue blood flow and affect cell division. In other words, integration of unconscious functions into self-conscious awareness may help in the integration of psyche and soma, thereby restoring normal function and allowing healing to occur. SPIRITUAL TRANSFORMATION AND SHAMANIC HEALING

Shamanic practices can induce healing by allowing the integration of information processing and psychocultural beliefs (Eliade, 1972; Winkelman, 2000). The shamanic ritual elicits and integrates information processing through combining altered states of consciousness that would normally be kept compartmentalized. Self-awareness is shifted to a dreamlike state described as sacred or spiritual. Through the direction

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of the shaman, psycho-integration is allowed to occur. Memories may be brought into conscious awareness, often as symbolic representations. These often take the form of animals or supernatural beings, which are powerful archetypal representations of emotions and values. Many of the shamanic processes work through linking the limbic system (emotional brain) and the brain stem (preconscious brain) with the awareness and focus of the cerebral cortex. This involves binding together the attributes of personal identity, social identity, attachments, emotions, and meanings. There is increased absorption into internal imagery and a sense of novelty. Feelings of significance, distorted time sense, and the emergence of unconscious conflicts can occur. This state of consciousness may enable the person to become an observer of his/her own mind. Clarity of consciousness increases, with a focus on internal experience, followed by integration and insight. A similar experience has also been described during Reiki energy healing sessions (Engebretson & Wardell, 2002). Entheogens (plants or chemical substances taken to induce spiritual experience) have revealed altered states of mind that allow resolution of existential crises and can potentiate creativity (Forte, 2000). South American shamans use ayahuasca to conduct vision quests and archetypal journeys that can provide insight and adaptation. Transformation often occurs within lucid dreamlike states. Spiritual experience and states of consciousness induced by entheogens potentiate the construction of meaningful stories or myths. Dimethyltryptamine (DMT) is the psychomimetic alkaloid in ayahuasca and often induces an experience similar to that described by mystics and visionaries (Metzner, 1999). A natural form of DMT is found in the brain. The experience of ingesting DMT can be similar to a spiritual unity experience. Thoughts and visions crowd in at great speed. There is a sense of leaving or transcending time, and a feeling that objects have lost all form and have dissolved into a play of vibrations. The effect can be like instant transportation to another universe for a timeless sojourn (Strassman, 2001). The rituals of shamanism induce the integration by physically stimulating systematic brainwave discharge patterns that activate the psychodynamic processes of self-understanding, socio-emotional dynamics, repressed memories, unresolved conflicts, intuitions, and metaphorical representations into self-conscious awareness. The shamanic ritual often involves entering a state of ecstasy, during which there is conscious awareness of deep preconscious memories that are not normally communicated to the language centre of the dominant temporal lobe. The

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experience is probably very similar to that of pre-language primitive human (an era prior to the mythological fall of humanity in the Garden of Eden), an era of the bicameral brain, when conscious awareness could not differentiate the environment from self, and inner thoughts were projected back into the environment (Jaynes, 2000). During this state the censoring activity of the superego is removed and the free will of critical conscious awareness may submit to the preconscious imagination. The shamanic experience, whether produced by the rituals of drumming and dancing, or by entheogens (such as ayahuasca), results in an electrophysiological fusion of the central nervous system, associated with an overspill of activity from the autonomic nervous system. A sense of unity is achieved by a loss of spatial-temporal awareness of boundaries. This subjective state of being allows metaphorical and archetypal journeying through the depth of the person’s consciousness and permits the awareness of shape-shifting into physical and living entities within the environment. The ego identity becomes an observer of his/her own soul. His/her journey takes the observer into the complexity and conflicts of his/her own inner world that, in the altered state of consciousness, cannot be differentiated from the outer world (Winkelman, 2000). This state is very reminiscent of the ancient source of creation myths and metaphorical legends of self-discovery, including archetypal journeys, which enable us to find meaning, purpose, and wisdom during catastrophe and the vicissitudes of paradox in life. The surge of neural spatial-temporal binding breaks down boundaries between the cognitive operators of the cerebral cortex via the system of cortical-thalamic re-entry. It allows an instantaneous free flow of communication between the occipital cortex (visual), parietal cortex (temporal- spatial), temporal cortex (auditory and language), amygdalalimbic cortex (emotions), and the frontal cortex (focused awareness). This instantaneous integration or fusion of the brain into a holistic operator is a quantum event, namely, a superposition of the preconscious mind and all the cognitive operators. Indeed, the process may involve quantum physical communication at the atomic level of events (Zohar & Marshall, 2001). I believe that this unity, peak, or oceanic event is a fundamental part of spiritual intelligence. It is a holistic binding of neurophysiological components that are normally kept separate. The sense of solution, when resolving an existential paradox, may be an ecstatic feeling of enlightenment. The feeling may be described as being at one with God. This state may be entered through multiple portals, which induce theta and delta electrical brain waves (three to six cycles per second), for

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example rhythmic drumming, meditation, chanting, hypnosis, fasting, sleep deprivation, and sensory deprivation. Many religious disciples entered this mind-state through an ascetic way of life. The slow wave electrophysiological response can transform into a higher frequency ecstatic state, associated with excess autonomic nervous activity. The contrasting cognitive operators found in the respective cerebral hemispheres are then combined by the process of hemispheric synchronization, during which information becomes widely distributed through distinct gamma waves resonating at forty-five cycles per second (Zohar & Marshall, 2001). Activity in the right temporal lobe is often perceived as divine experience, and the overwhelming activity in the right parietal lobe of the brain may give rise to the awareness of a unity experience, with loss of spatial and temporal orientation (D’Aquili & Newberg, 1999). The relative excesses of the parasympathetic or sympathetic nervous systems determine the contrasting experiences of either deep calmness or restless ecstasy. This process should not be confused with epilepsy, which is a pathological event, although both processes are characterized by overwhelming electrophysiological activity. Spiritual experience is not simply temporal lobe epilepsy, as described by the neuroscientist Michael Persinger (Buckman, 2000), or a pathological process, as described by the psychoanalyst Sigmund Freud (Mitchell & Black, 1996). This coherent oscillation produces a state of quantum coherence, resulting in the multiple processing components becoming a single unit. During this state of mind, distinct digital information may transform into a novel solution to a problem. This process contrasts with analogue blending of information, which will simply produce a solution that is the average of the parts. Digital transformation synthesizes a synergistic solution that is more than the sum of its parts. SPIRITUAL INTELLIGENCE

Spiritual problem solving can be viewed as the synthesis of dialectics, in other words seemingly incompatible polemics, a thesis and an antithesis. Hegel proposed a model (now termed the Hegelian Triad) in which the contradictions of the polemics are transcended (Gadamer, 1982). The dialectical method involves the notion that movement or progress is the result of the conflict of opposites or paradox. As a result of the conflict between the thesis and antithesis, a third point of view arises, the birth of a novel idea termed the synthesis that overcomes the

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conflict by reconciling at a higher level the truth contained in both the thesis and antithesis. Hegel understood reality as the Absolute, unfolding dialectically in a process of self-development. These seemingly incompatible dyads are often the subject of mythology, and an explanation of their psychoneurological resolution essentially involves the language of mythology. This process is clearly defined in the Jungian process of active imagination and is illustrated in the many analyses described by Jungian psychologists, for example, in the book Close to the Bone: Life-Threatening Illness and the Search for Meaning by Jean Shinoda Bolen, MD (1998). After the diagnosis of cancer, the contradictions of the current desperation to live versus the uncertainty of facing death in the near future may result in a process that transforms into the joy of meaningful living in the present moment. The spiritual process that generates this transformation in attitude is often accompanied by a period of suffering, as the ego struggles to maintain its previous existential framework. At the neurobiological level, reshaping of thought complexes by a new attractor, plus a remodelling of the temporal-spatial binding between cognitive operators, accompany this shift in attitude. The period of suffering may transform into ecstatic joy as the cognitive operators adjust to the new existential reality. Following “the dark night of the soul,” a sense of joy may be accompanied by a rise in the serotonin level. When depleted, this neurotransmitter is associated with depression. As its levels rise, it may stimulate regeneration of new brain cells in the hippocampus (the emotional brain concerned with memories and context), thereby remodelling the emotional experiences and the contexts of meaning (Jacobs et al., 2000). When a person is facing death, both time perspective and values can change (Kübler-Ross, 1997). A subject may experience a Divine agency that communicates with the subject and reveals supernatural knowledge. The Divine other may adopt cultural characteristics that reflect the morals and psychosocial dynamics of the time and environment. Union of self and the Divine can occur, followed by the revelations. After further contact with the Divine experience, convictions, intuitions, and beliefs about the authenticity of ultimate reality increase. An example of Divine revelation is the series of visions and callings experienced by Joan of Arc (Pernoud & Clin, 1998). These are reputed to have intensified following the witnessing of atrocities by the English invaders. She experienced Divine union through the images of St. Michael and St. Catherine, resulting in a powerful obsession to unite France and vanquish the English. A modernday example of a spiritual peak, unity, or oceanic experience is that of

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Apollo 14 astronaut, Edgar Mitchell. When Mitchell (1996) was travelling back to earth after walking on the moon in 1971, he had a profound sense that all things are interconnected and that the universe is an intelligent process in which we need to participate. He developed a vision in which technology and intuition are harmonized in pursuit of a more advanced consciousness. Mitchell tells how, while returning to earth, he carried out a private ESP experiment that seemed to yield positive results. Subsequently, he founded the Institute of Noetic Sciences, in order to test paranormal phenomena scientifically. Another example of a genius who had a mystical experience is Kary Mullis, the 1993 Nobel Prize winner in chemistry, who invented a method to amplify DNA for genetic engineering. He describes an alien abduction episode (Mullis, 2000). Paranormal experiences associated with transformation are well described (Harpur, 1996). Explanations may include the projection of the bicameral mind and the metaphysical interaction of mind and matter. I am not suggesting that you have to be a mystic or have spiritual experiences to be a genius, but I am proposing that many innovators who derive new and eccentric ideas, have described various paranormal episodes which can include a sense of Divine awe, unity with all that is, dissociation, conversing with an imaginary character, out-of-body experiences, telepathy, and clairvoyance. Often conventional ideas are transcended, and the subject may be accused of being a maverick, a heretic, or even psychotic. However, from a neurobiological perspective, the holistic fusion of cognitive domains may assist the evolution of novelty. The boundary between spiritual revelation and psychopathology is subtle. The schizotypal personality may be predisposed to spiritual and supernatural experiences. The schizotypal mind is characterized by magical ideation, easy distraction, tendency to fantasize, looseness of thought, impulsive non-conformity, unusual experiences, introversion, social anhedonia, and ambivalence. Interestingly, many of these characteristics were manifest in the personality of Joan of Arc (Pernoud & Clin, 1999) and other visionary mystics and gnostics. The Nobel Laureate John Nash, who was an expert in complex mathematics, had a schizotypal personality and became schizophrenic. He was a genius when it came to the analysis and synthesis of complex systems, especially in deriving the whole picture rather than over-focusing on the parts (Nasar, 1999). There also appears to be an association between manic-depressive illness (bipolar disorder) and artistic creativity. The manic phase may result in a “flight of ideas,” which is often expressed within an inflated

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cosmic context. This euphoric phase is usually followed by severe melancholy and an existential crisis or “darkness of the soul,” in many cases severe enough to precipitate a focus on suicide. An extensive review of the historical literature suggests that many famous authors and poets, such as William Blake, Samuel Taylor Coleridge, Edgar Allan Poe, and Virginia Woolf, suffered from manic-depresssive illness or a cyclothymic personality (Jamison, 1993). The book Shadow Syndromes describes many mild personality extremes that are incomplete forms of dysfunctional pathological mental states and may confer adaptive advantages (Ratey & Johnson, 1998). It is important to have a spiritual counsellor to ensure a measured and gradual transformation, since mystical experience and paranormal phenomena can result in psychological distress and inappropriate behaviour if not grounded, and could potentially develop into a dysfunctional psychosis such as schizophrenia or mania that requires medical treatment. An example of the potentially harmful consequences of spiritual evolution is the paranormal experience described as sidhis in Eastern mysticism. The sidhis, such as telepathy, clairvoyance, and out-of-body experiences, may accompany the transformative process. The wise advice of Eastern mystics is not to pursue these paranormal experiences for their own sake but to treat them as inconsequential side effects on the road to enlightenment. If they cause distress or dysfunction then expert help might be needed from a psychiatrist with expertise in spirituality and mysticism. Spiritual intelligence can also include the ability to forego attachment, the ability to forgive, to show compassion, and to transcend negative emotions such as anger and envy. These could have an evolutionary survival advantage in the modern world by reducing chronic sympathetic nervous system over-activity that can be associated with depression, cardiac disease, and cancer (Gann, Daviglus, Dyer, & Stamler, 1995; Dekker et al., 1997; Nemeroff, Musselman, & Evans, 1998). In many traditions, a focus on the heart with the mindful experience of love is ritually used to dissolve toxic emotions. The reduction in the sympathetic component of the autonomic nervous system, balanced by the parasympathetic component, appears to reduce mental illness, such as depression, and physical illness, such as heart disease and cancer (McCraty, Barrios-Choplin, Rozman et al., 1998; Dardik, 1996; Childre, Martin, & Beech, 2000). This can be measured and assessed through an analysis of the electrocardiogram called power spectrum analysis or heart rate variability (Kobayashi, Ishibashi, & Noguchi, 1999). We now

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know that there is a psychosomatic association with the improved health outcome that is consistently documented in individuals who practice the rituals of religion (Koenig, McCullough, & Larson, 2000). Some of these rituals have powerful effects on transforming irregular respiration and incoherent heart rate variability to a normal state, through a process called entrainment. For example, the rosary and yoga mantras can synchronize heart rate variability and result in a power spectrum (proportion of sympathetic to parasympathetic nervous system activity) that is more conducive to health (Bernardi et al., 2001). Efforts are being made to measure spiritual intelligence and to assess the characteristics of spiritual personality types (Jones & Sagar, 2001; Wolman, 2001; Zohar & Marshall, 2001). This is especially important for stratification in studies of health outcome and to determine the psychotherapeutic approach to counselling the patient. CAN SPIRITUAL INTELLIGENCE CONTRIBUTE TO HEALING?

I believe that spiritual counselling or transpersonal psychotherapy can contribute to the healing of both the mind and body. However, systematic clinical evidence for this is lacking, since there is a dearth of high-quality studies. In view of the intimate, unique, complex, and holistic nature of the healing relationship between practitioner and client, evaluation and abstraction by reductionist science may not be feasible. The healing relationship is a complex combination of art and science. That is not to say that we should not honestly evaluate progress in healing within an individual therapeutic relationship, but that reconciliation of population-based empirical knowledge with individual clinical experience is indeed a dialectic that within itself requires a spiritual synthesis (Soldz & McCullough, 2000). Spiritual counselling is particularly helpful in resolving abnormal psychodynamics that have led to suffering. The unhealthy psychodynamics often result from unresolved trauma from the past that can result in a post-traumatic stress syndrome. Since the preconscious mind is intimately connected to the physiological function of the body, unresolved psychodynamic trauma may eventually manifest as physical disease. In addition, the existential trauma of chronic or life-threatening physical disease may result in suffering, from the threat of disintegration or annihilation, which can exacerbate the physical illness. The psychosomatic connection has been evaluated scientifically over the last three decades (Sternberg, 2001).

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I have discussed how preconscious dynamics can influence the balance of the autonomic nervous system, change levels of neurotransmitters, hormones, and growth factors, such as the neuropeptides. Moreover, the body and brain are parallel simulators of our external reality. Imagination reprocesses previous memories and integrates emotions into conscious awareness. The brain simulates future scenarios and compares with past experience. During these cerebral dynamics, messages are continuously being sent to somatic structures such as our skin, muscles, and viscera that, in turn, feed back to the central nervous system (Damasio, 1995, 1999). When cerebral dynamics are integrated and resolved, health can be improved, but inadequate resolution of cerebral dynamics may be associated with illness. The mind can both precipitate physical illness and be a means of treating disease (Pelletier, 1992; Watkins, 1997). Past abuse and psychological trauma result in an increased incidence of ill health later in life (Felitti et al., 1998). Many of these subjects develop dissociation or, in other words, a fragmentation and a splitting of the mind that results in autonomic nervous system dysregulation (Scaer, 2001). Religious rituals, such as prayer and positive affirmation, can have a profound effect on the autonomic nervous system. There are many portals into the mind state of meditation, but the net effect is a relative increase in the parasympathetic component of the autonomic nervous system, the so-called relaxation response (Benson, 1997). The neurobiological effects of Zen Buddhism have been extensively explored and reviewed (Austin, 1999). The normalization of the sympathetic to parasympathetic relationship of the autonomic nervous system seems to have profound effects on improving health outcome. This is reflected by more coherent heart rate variability. The brain appears to influence the heart, and the heart also feeds back to the brain. This is manifested by the heart’s powerful effect in entraining the electrical activity of the brain (Song, Schwartz, & Russek, 1998). The mathematician Blaise Pascal declared, “The heart has its reasons that reason does not know,” and, “It is the heart which experiences God and not the reason.” The Sufi religion romantically emphasizes a focus on the heart. The Sufi mystic Rumi declared, A heart that circles round the door of love Will die, at last, by the dagger of love. This point is written in the book of love: He has no head at all whose head holds love.

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Heart, if you sit amongst thorns and don’t choose To pick flowers all day from the garden, What can I do? His face lights the whole world, But if you can’t see it, what can I do?

States of compassion, forgiveness, love, and Divine awe are all heartcentred emotions that are now scientifically proven to influence the electrophysiological communication system between the heart and the brain. In addition, the heart–mind communication system generates creativity, integration of complex information, and resolution of conflicts through the process of intuition. At the chemical level, this is reflected by a reduction in stress hormones, such as cortisol and epinephrine, and is associated with an increase in immunity (Rein, McCraty, & Atkinson, 1995; McCraty et al., 1998). CONCLUSION

Recent explorations in neurobiology have shown that spiritual states of mind can be powerful generators of creativity and can catalyze the resolution of conflicts. Manipulation of the spiritual mind, utilizing rituals originating from ancient shamanism and further developed by the religions of the world, can be powerful therapeutic tools in resolving health-threatening psychodynamic conflicts. Recent epidemiological studies have shown that appropriate application of religious culture and rituals can be associated with improved health outcome (Koenig et al., 2000). The neurobiological scientific evidence suggests that this may partially be achieved through a mind-body communication system that influences the balance of the autonomic nervous system, neurotransmitters, hormones, and neuropeptides. The communication system is bound together by electromagnetic information that some healers term energy. We are also discovering that communication between molecules and cells and the evolution of consciousness could have its origins in quantum physics (Satinover, 2001). At the clinical level, there is a need for more well-designed prospective studies into the efficacy of various spiritual counselling techniques that are being integrated into clinical practice (Scotton, Chinen, & Battista, 1996; Richards & Bergin, 1997; Sperry, 2001). In my specialty, oncology, the psychologist Lawrence LeShan has pioneered transformative counselling techniques for cancer patients (LeShan, 1999). In order to further this important work, we require some of the evaluation tools of science. In particular, we need better definitions of spirituality, and we

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require tools for measuring spiritual profiles. The Spiritual Evaluation and Research into Complementary Care (SEARCH) research program at the Hamilton Regional Cancer Centre has already made assessment tools a priority, and continues to develop and validate the Spiritual Quotient (Jones & Sagar, 2001). In conclusion, the rapprochement of spirituality and science in health care has begun, driven by the revelation that they are the opposite sides of the same coin, a metaphor for being human. The scientific laws of quantum physics have more in common with Buddhism and mysticism than our familiar classical physics (Ricard & Thuan, 2001). In the era of quantum physics, spirituality and science reflect each other in the same mirror, namely, the mirror of human consciousness or even possibly the soul. REFERENCES Austin, J.H. (1999). Zen and the brain. Cambridge, MA: MIT Press. Benson, H. (1997). Timeless healing. NewYork: Fireside. Bernardi, L., et al. (2001). Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: Comparative study. British Medical Journal, 323, 1446–49. Bohr, N. (1957). Atomic physics and human knowledge. New York: John Wiley. Bolen, J.S. (1998). Close to the bone. New York: Touchstone. Buckman, R. (2000). Can we be good without God? Toronto, ON: Viking. Caporale, L.H. (2002). Darwin in the genome. New York: McGraw-Hill. Childre, D.L., Martin, H., & Beech, D. (2000). The HeartMath solution. San Francisco, CA: Harper. Damasio, A.R. (1995). Descartes’ error. New York: Avon. Damasio, A.R. (1999). The feeling of what happens. New York: Harcourt Brace. D’Aquili, E.G., & Newberg, A.B. (1999). The mystical mind. Minneapolis, MN: Fortress. Dardik, I.I. (1996). The origin of disease and health. Heart waves: The single solution to heart rate variability and ischemic preconditioning. Cycles, 46, 67–77. Dekker, J.M., et al. (1997). Heart rate variability from short electrocardiographic recordings predicts mortality from all causes in middle-aged and elderly men. American Journal of Epidemiology, 145, 899–908. Descartes, R. (1999). Discourse on method and related writings (D.M. Clarke, Trans.). London: Penguin. Dickens, P. (2000). Social Darwinism. Cambridge: Open University Press. Dürr, H-P. (2003). Sheldrake’s ideas from the perspective of modern physics. Frontier Perspectives, 12, 10–22. Edelman, G.M., & Tononi, G. (2000). A universe of consciousness. New York: Basic. Eliade, M. (1972). Shamanism (W.R. Trask, Trans.). Princeton, NJ: Princeton University Press.

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Engebretson J., & Wardell, D.W. (2002). Experience of a Reiki session. Alternative Therapies in Health and Medicine, 8, 48–52. Felitti, V.J., et al. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14, 245–58. Frattaroli, E. (2001). Healing the soul in the age of the brain. New York: Viking Penguin. Forte, R. (Ed.). (2000). Entheogens and the future of religion. San Francisco, CA: Council on Spiritual Practices. Gadamer, H.G. (1982). Hegel’s dialectic (P.C. Smith, Trans.). New Haven, CT: Yale University Press. Gann, P.H., Daviglus, M.L., Dyer, A.R., & Stamler, J. (1995). Heart rate and prostate cancer mortality: Results of a prospective analysis. Cancer Epidemiology, Biomarkers, Prevention, 4, 611–16. Harpur, P. (1996). Daimonic reality. New York: Penguin. Heisenberg, W. (1930). The physical principles of the quantum theory. New York: Dover. Jacobs, B.L., van Praag, H., & Gage, F.H. (2000). Depression and the birth and death of brain cells. American Scientist, 88, 340–45. Jamison, K.R. (1993). Touched with fire. New York: Free Press. Jaynes, J. (2000). The origin of consciousness in the breakdown of the bicameral mind. New York: Mariner. Jones, G., & Sagar, S.M. (2001). Measurement: Spiritual quotient, a developing measure of core spirituality for patients with cancer. Proceedings of the First North American Conference on Spirituality and Health. Calgary, AB: University of Calgary. Jung, C.G. (1959). The archetypes and the collective unconscious. New York: Routledge and Kegan Paul. Jung, C.G. (1989). Memories, dreams, reflections. New York: Vintage. Kobayashi, H., Ishibashi, K., & Noguchi, H. (1999). Heart rate variability: an index for monitoring and analyzing human autonomic activities. Applied Human Science, 18: 53–59. Koenig, H.G., McCullough, M.E., & Larson D.B. (2000). Handbook of religion and health. Oxford: Oxford University Press. Kübler-Ross, E. (1997). On death and dying. New York: Scribner. Kurzweil, R. (2000). The age of spiritual machines. New York: Penguin. Lewicki, P., Hill, T., & Czyzewska, M. (1992). Nonconscious acquisition of information. American Psychologist, 47, 796–801. Maslow, A.H., Frager, R., & Fadiman, J. (1987). Motivation and personality. Boston: Addison-Wesley. Maslow, A.H. (1994). Religions, values and peak experiences. New York: Viking. McCraty, R., Barrios-Choplin, B., Rozman, D., Atkinson, M., & Watkins A.D. (1998). The impact of a new emotional self-management program on stress, emotions, heart rate variability, DHEA and cortisol. Integrative Physiological and Behavioral Science, 33, 151–70. Metzner, R. (1999). Ayahuasca. New York: Thunder’s Mouth Press. Mitchell, E. (1996). The way of the explorer. New York: Putnam. Mitchell, S.A., & Black, M.J. (1996). Freud and beyond. New York: Basic.

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Mullis, K. (2000). Dancing naked in the mind field. New York: Vintage. Nagel, E., & Newman, J.R. (2002). Gödel’s proof (D.R. Hofstadter, Ed.). New York: New York University Press. Nasar, S. (1999). A beautiful mind. New York: Touchstone. Nemeroff, C.B., Musselman, D.L., & Evans, D.L. (1998). Depression and cardiac disease. Depression and Anxiety, 8 Supplement 1, 71–79. Newberg, A.B., D’Aquili, E.G., & Rause V. (2001). Why God won’t go away. New York: Ballantine. Palombo, S.R. (1999). The emergent ego. Madison, WI: International Universities Press. Pelletier, K.R. (1992). Mind as healer, mind as slayer. New York: Delta. Pernoud, R., & Clin, M.V. (1999). Joan of Arc (B. Wheeler, Ed.; J. Adams, Trans.). London: St. Martin’s. Persell, S.M. (1999). Neo-Lamarckism and the evolution controversy in France, 1870–1920. Lewiston, NY: Edwin Mellen. Ratey, J., & Johnson, C. (1998). Shadow syndromes. New York: Bantam. Rein, G., McCraty, R., & Atkinson, M. (1995). The physiological and psychological effects of compassion and anger. Journal of Advancement in Medicine, 8, 87–105. Ricard, M., & Thuan, T.X. (2001). The quantum and the lotus. New York: Crown. Richards, P.S., & Bergin, A.E. (1997). A spiritual strategy for counseling and psychotherapy. New York: American Psychological Association. Sagar, S.M. (2001). Restored harmony. Hamilton, ON: Dreaming Dragonfly Communications. Satinover, J. (2001). The quantum brain. New York: J. Wiley. Scaer, R.C. (2001). The neurophysiology of dissociation and chronic disease. Applied Psychophysiology and Biofeedback, 26, 73–91. Scotton, B.W., Chinen, A.B., & Battista, J.R. (Eds.). (1996). Textbook of transpersonal psychiatry and psychology. New York: Basic. Sheikh, A.A., & Sheikh, K.S. (1996). Healing east and west. New York: John Wiley. Sheldrake, R. (1995). The presence of the past. Rochester, VT: Park Street Press. Soldz, S., & McCullough, L. (Eds.). (2000). Reconciling empirical knowledge and clinical experience. New York: American Psychological Association. Song, L.Z.Y.X., Schwartz, G.E.R., & Russek, L.G.S. (1998). Heart-focused attention and heart-brain synchronization: Energetic and physiological mechanisms. Alternative Therapies in Health and Medicine, 19, 54–58. Sperry, L. (2001). Spirituality in clinical practice. Philadelphia, PA: Brenner/Mazel. Sternberg, E.M. (2001). The balance within. New York: W.H. Freeman. Strassman, R. (2001). DMT, The spirit molecule. Rochester, VT: Inner Traditions. Teilhard de Chardin, P. (1975). The phenomenon of man. Toronto, ON: Harper Collins. Watkins, A. (Ed.). (1997). Mind-body medicine. New York: Churchill Livingstone. Vickers, B. (Ed.). (2002). Francis Bacon: The major works. Oxford: Oxford University Press. Winkelman, M. (2000). Shamanism. Westport, CT: Bergin and Garvey. Wolman, R. (2001). Thinking with your soul. New York: Harmony. Zohar, D., & Marshall, I. (2001). SQ. London: Bloomsbury.




Index

Page numbers in italics refer to illustrations. Aboriginal communities: leadership, as needed by, 182–83; and need to confront abuse and violence issues, 184– 85; government cutbacks, as affecting, 183; and residential school system, 169, 185; self-sufficiency, as goal of, 183–84; women, as central figures/ healers in, 180–81. See also alcoholism; child abuse; sexual abuse; substance abuse; wholistic approach, to healing Aboriginal peoples, 66; and alcoholism, 167–70, 174–77, 179; child/sexual abuse, as experienced by, 170–72; labyrinth, as used by, 155–56; Native identity of, as rediscovered by, 177–78, 182; as oppressed culture, 178; government cutbacks, as affecting; 183; racism towards, 170; and residential school system, 169, 185; suicide attempts by, 174, 175; women, as central figures/ healers, 180–81. See also alcoholism; child abuse; sexual abuse; substance abuse; wholistic approach, to healing abuse, alcohol. See alcoholism abuse, child: in Aboriginal community, 170–72; acceptance of survivors, by congregations, 81–82; confronting issue of, 184–85; corporal punishment, as form of, 169; home settings of, as

unsafe places, 75–77; as leading to alienation from God, 77; as leading to upheaval within churches, 81–82; male victims of, as not receiving support, 178; revictimization of survivors, by congregations, 77–81; telling stories of, 78–79, 82; unwillingness of churches/congregants to deal with, 77–78, 80–81, 82; as violation of friendship/trust, 170–71; within church families, 77–78. See also home abuse, child, survivors of: as accepted/ assisted by congregations, 81–82; as revictimized by congregations, 77–81; support for, as not always available to men, 178; as telling their stories, 78–79, 82. See also home abuse, sexual: in Aboriginal community, 170–72; confronting issue of, 184–85; as leading to upheaval within churches, 81–82; male victims of, as not receiving support, 178; shame/guilt of, 172; as violation of friendship/trust, 170–71 abuse, sexual, survivors of: as accepted/ assisted by congregations, 81–82; as revictimized by congregations, 77–81; shame/guilt of, 172; support for, as not always available to men, 178; as telling their stories, 78–79, 82

307

308 Index abuse, substance, 12, 129; in Aboriginal community/family, 168, 172–74 addiction: categories of, 129; community, as important to overcoming, 135–36; definition of, 129; denial of, 129–31, 134–35, 175, 179; as disease/illness, 129, 132, 132–36, 175; as linked to longer working hours, 123; and personal values, 126; as problem of modern Western society, 123; process addictions, 129; screening instruments for, 130–31; spirituality, as fundamental to overcoming, 124–25; treatments for, 132–36; view of, as moral problem, 132. See also alcoholism; substance abuse addiction, recovery from: behavioural interventions, as used in, 133, 135; case study of, 133–36; family help, as important to, 175–77, 179–82; as new life, 179–80, 181; as ongoing process, 125, 132, 136, 175–77, 179–82, 186; physical interventions, as used in, 132–33, 135; spiritual aspect of, 133–34, 134; therapeutic relationship model of, 124–29, 126. See also wholistic approach, to healing Alcoholics Anonymous, 124, 136 alcoholism, 12; in Aboriginal family/community, 167–70, 174–77, 179; case study of, 133–36; denial of problem with, 129–31, 175, 179; as disease, 175; as drug abuse, 132; family help, as important to overcoming, 175–77, 179–82; as leading to suicide attempts, 174, 175; lifestyle changes needed to overcome, 135; recovery from, 175–77, 179–82; screening test for, 130–31; seeking treatment for, 175–77, 179–80; as used to boost self-esteem, 174, 176; and violence, 170. See also addiction Alzheimer ’s disease, 106, 107. See also dementia American Psychological Association (APA), 25–26; Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 26, 129, 131, 132; Division 36 (Psychology of Religion), 25; Ethical Principles of Psychologists and Code of Conduct (1992), 25–26 Anishinabe nation, 177–78

arthritis and suffering (study), 229–38; graphs illustrating, 234–236; measurements, 230–32; methodology, 229–30; results, 232–37; suffering, as continuing on discharge, 234, 237; suffering and pain, as separate entities, 232–34. See also pain; suffering Avicenna (medieval Islamic physician), 94 ayahuasca (plant), 295, 296 Beck, Aaron, 32–33, 37 being, 193–94. See also ontology Bible, Books of: Acts of the Apostles, 290–91; Isaiah, 3, 116; Jeremiah, 207; Mark, 191; Matthew, 13; Revelation, 3; 2 Corinthians, 194 biographies, as used in care of dementia patients, 114–15 brain, and spiritual neurobiology, 292–94 Buddhism, 28, 156; Zen Buddhism, 302 CAGE screening instrument, for addiction, 130 Canadian Association for Pastoral Practice and Education (CAPPE), xviii Canadian Association of Occupational Therapists (CAOT): Canadian Model of Occupational Performance (CMOP), 140, 141, 141–42; Enabling Occupation (publication), 140, 145; Person-Environment-Occupation Model, 142, 142–43; spirituality, as defined by, 144–45 Catholic Church. See Roman Catholic Church chaplains: articles on, as cited in PubMed, 201–204, 206–207; as different from health care professionals, 12; as helping patients overcome spiritual distress, 224; and “history” of spiritual care, 207; as link to patients’ pastors or faith group, 222–23; as needing to reinvent their roles, 208; and pastoral counsellors, as segregated, xviii; as presumed to be Christian, 85; religious role of, as falling into disfavour, 192; as ritual coordinators, xviii-xx; as “spiritual caregivers,” 86; as working with family medicine professionals, 68–69

Index Chartres Cathedral, labyrinth of, 149, 150, 153, 154 child abuse: in Aboriginal community, 170–72; acceptance of survivors, by congregations, 81–82; confronting issue of, 184–85; corporal punishment, as form of, 169; home settings of, as unsafe places, 75–77; as leading to alienation from God, 77; as leading to upheaval within churches, 81–82; male victims of, as not receiving support, 178; revictimization of survivors, by congregations, 77–81; telling stories of, 78–79, 82; unwillingness of churches/congregants to deal with, 77–78, 80–81, 82; as violation of friendship/trust, 170–71; within church families, 77–78. See also home; sexual abuse child abuse, survivors of: as accepted/ assisted by congregations, 81–82; as revictimized by congregations, 77–81; support for, as not always available to men, 178; as telling their stories, 78–79, 82. See also home; sexual abuse, survivors of Chinese medicine, traditional, 16 Christianity: chaplaincy, as associated with, 85; as linking sickness and sin, 13–14; as predominant in Canada, 62; and spiritual care of sick, 13–14, 191 CINAHL (database), 15, 44 clergy, and role of physician, 64, 65 Clinical Pastoral Education (CPE), 85, 192 cognitive model for treatment of depression (Beck), 32–33, 37–38 collective unconscious (Jung), 287 communication models, of aging: enhancement model, 109, 113; predicament model, 108 congregations, church: as accepting/ assisting abuse survivors, 81–82; as dealing with abuse survivors’ stories, 78–79; as revictimizing abuse survivors, 77–81; as unwilling to deal with abuse revelations, 77–78, 80–81, 82 control trials, as used in science, 11, 12, 16 crises, 265–68; crisis intervention theory, 265–66, 267–68 cultural diversity, 65–66, 67

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databases, health care, 15, 44; spirituality research found in, as increasing, 15–18 dementia, 106; in Alzheimer ’s disease, 106, 107; as assault on personhood, 107–108, 110; behaviours associated with, 108, 109, 117; and decreased social interaction, 108–109; memory/ communication skills affected by, 106–108, 110; stages of, 107 dementia, people with: communication/ social interaction, as important for, 108–109; communication strategies for, 111–15; as dependent on caregivers, 108, 109; individuality/personhood of, 108, 109–110, 112; labelling of, as stigmatizing, 108; music, as important to, 109, 116, 117; pastoral care for, 115–16; remaining competencies of, promoting, 109–110; religious participation by, 115–17; spiritual needs of, 110, 115–17, 118; telling/recording life stories, as beneficial for, 112–15 depression: cognitive model for treatment of (Beck), 32–33; and distance healing, 16; spirituality, in treatment of, 17, 35; theology of client, as addressed in treatment of, 35–41 Descartes, René, 289, 290; on separation of body and soul/mind, 289 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 26, 129, 131, 132 distance healing, 16 DMT (dimethyltryptamine), 295 domestic violence, 12, 180; confronting issue of, 184–85 double-blind control trials, as used in science, 11, 12, 16 Drug Abuse Screening Test (DAST), 130– 31 DSM-IV (Diagnostic and Statistical Manual of Mental Disorders), 26, 129, 131, 132 Enabling Occupation (CAOT publication), 140, 145 End of the Affair, The (Greene), 34 entheogens, 295, 296 epilepsy: conversion of Saul, as attributed to, 291; spiritual experience considered as, 297

310 Index evidence-based research, 11–12: control trials, as used in, 11, 12; qualitative research as form of, 16–17; and spiritual care, 16–17; Extreme Unction, sacrament of, 14 faith, distinctions of, in theology, 36, 38 family medicine, 61–62; and chaplaincy, 68–69; holistic approach of, 62; incorporating spirituality into, 66; increased spirituality in, 15–16, 62; and need to ask patients for spiritual information, 64–65 Family Medicine, Department of (McMaster University), 68–69 family practitioners: as affected by painful life experiences, 64, 67; and cultural diversity, 65–66, 67; as distinguished from clergy, 65; HOPE questions, as suggested for, 67–68; and need to ask patients for spiritual information, 64–65; as providing spiritual counsel, 63–64; self-care program for (St. Paul’s Hospital, Vancouver), 70–71; selfawareness program for (McMaster University), 69–70; spirituality of, 66, 67, 69–71 fibromyalgia, 241–42; as considered psychosomatic, 242; interdisciplinary approaches to, 242; pain and suffering of, 241–42, 257, 258; spiritual dimension, of recovery from, 246–47 fibromyalgia recovery, as psychospiritual process (case study): chronology of, 249–50; content analysis of steps involved in, 250, 257–61; essential elements of, 250; as explained by psychosynthesis, 253–57; and faith in God, 253–57, 258; and forgiveness, 250, 253, 259; imagery and prayer, as components of, 250, 251, 259; intentionalities of, 251; and refusal to give up hope, 250, 253, 258; stages of journey towards, 251–52 Frei, Hans, 48–49 Freud, Sigmund: on conflict in human psyche, 243–44, 288–89; on religion, 17, 25; on spiritual experience, as pathological, 297 fundamental theology (Tracy), 30–32

gasoline sniffing, in Aboriginal communities, 168, 172–74 God: as allowing suffering, 211, 221, 278; alienation from, of child abuse victims, 77; basic propositions about, 38–39; belief in, 33–35, 62, 75; concept of, in religion, 28; connecting with, in times of stress, 160; dealing with, as sometimes problematic, 128–29; as Everything, 255; as experienced by dementia patients, 116; faith in, 253–57; grace, as communication from, 212; healing/protective powers of, 97, 100; health, as blessing from, 89, 99–100; as all-important to Islam, 88; relationship with, as central to spirituality, 46, 124; as revealed through Jesus Christ/ Word, 51, 125; speaking about, in context of suffering, 211–12, 219, 221–22; trust in, 254, 279 God-talk: in therapeutic setting, 40; in context of suffering, 211–12, 219, 221–22. See also palliative care patients (study) Good: as central to spirituality, 54–57; subjectivization of, in modern Western civilization, 54–55; tolerance/toleration, as antithetical to, 54–55. See also spirituality grace, 212, 225 Grant, George, 54–55 Greene, Graham, 34 Gutierrez, Gustavo, 212, 217–18 hadiths (sayings of Muhammad), 90, 92– 93 health care literature: spirituality, as discussed in, 44–48. See also PubMed keywords (study) health care profession: awareness of spirituality by, 1–3, 12, 15–18, 62, 192, 204; and need for self-awareness by, 126–28, 136–37; and relationship of science with religion, 11–12 HealthSTAR (database), 15, 44 holistic approach, to health care: in family medicine, 62; in Islam, 93–95; in nursing, 15–16. See also wholistic approach, to healing home: body as, 76; creating, in church, for abuse survivors, 81–82; dementia

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patients, as disconnected from, 108; life-threatening illnesses, as taking away sense of, 277, 278; as metaphor for spirituality, 74–75; as safe place, 74–75; as unsafe place for child abuse victims, 75–77. See also child abuse; safety and security HOPE questions, for spiritual assessment, 67–68 hospices, history of, 14 hospitals: as Christian in origin, 14; in medieval Muslim world, 95–96

by, 13; suffering and lament of, 212; as Word, 51 Joan of Arc, 298, 299 Joint Declaration on the Doctrine of Justification, 18 Judaism, 156 Jung, Carl, 7; on active imagination, 298; on collective unconscious, 287; on concept of spiritual mind, 289

institutional ministry. See chaplains intelligence, spiritual, 286–87: and Divine/ supernatural knowledge, 298–99; and mystical or paranormal experiences, 298–99; negative emotions, as transcended by, 300; and personality disorders, 299–300; as source of creativity, 286; as source of strength, during lifethreatening illness, 289, 298; as synthesis of dialectics, 297–98; theories of, 286–89. See also neurobiology, of spiritual consciousness Islam: body, soul, and spirit, as integrated in, 86–89, 93–95, 99–100; and concept of human identity, 88–89; health, as blessing in, 89, 99–100; holistic approach to health care in, 93–95; labyrinth, as used in, 156; meaning of spirituality in, 86–89; medical treatment, as obligatory in, 92–93, 99–100; principle of Oneness in, 88; safety and security, as concepts central to, 88; spiritual care, as obligatory in, 86, 90 Islamic spiritual care: early practitioners of, 94; as holistic, 93–95; hospitals, as important part of, 95–96; medical treatment, as obligatory in, 92–93; in modern times, 96–99; music therapy, as used in, 96; prayer, as important part of, 89, 91–92, 94–95, 96, 97–98, 100; as prescribed by Qur ’an and Sunnah, 89–90; spiritual medicine, double meaning of, 98; visiting the sick, 90, 91–92, 99

labyrinth, 149; as based on circle, 151; in Buddhism, 156; of Chartres Cathedral, 149, 150, 153, 154; as Christian symbol, 153–54; Cretan labyrinth, 152, 152–53, 163–64, 164; creation of, as therapeutic, 162–63, 163–64; and dance, 156; as distinguished from maze, 150; in health care context, 158–63; history of, 151; in Islam, 156; in Judaism, 156; of medieval era, 149, 153, 155; movement within, 157–58, 159; in myth of Theseus and the Minotaur, 152, 153, 154; in Native North American culture, 155–56; and palliative care, 160, 162; and prayer, 158, 160; and ritual, 154, 158; Roman labyrinth, 150, 153–55; and “sacred geometry,” 155; as sacred place, 160; spiral pattern of, 151, 154, 155, 157; as spiritual tool, 150; as symbol of Divine Feminine, 154; as symbol of wholeness, 150, 151, 157, 162; as symbol of life’s journey, 151, 152–53; use of, across cultures and religions, 155–56; use of, in health care settings, 161–63; walking, as form of therapy, 158–63 life-threatening illnesses: and age of patients, 280; and appraisal process, 268, 279; coping with, 216–17, 223–25, 265–67, 276–77, 279–81; as crises, 265–68; as “dangerous opportunities” for personal growth, 265, 271; and desire to help others, 277; experiences of, 275–76; and families, 276, 277; and meaning-making, 266–67, 270–71, 276–77; and new self-image/lifestyle, 270, 275, 276, 280; and patients’ bodies, 275–76, 280; and post-traumatic stress

James, William, 24 Jesus Christ: healing of sick by, 191; humanity of, 125; miracles performed

Kairon Centre (St. Paul’s Hospital, Vancouver), 70–71

312 Index disorder, 280; and reappraisal process, 270–71; and relationships, 277; religion and spirituality, as factors in, 269–70, 278, 279–80; and shattered assumptions, 270; and social supports, 267, 268, 276, 277; and survival instincts, 281; trauma of, 275–76, 301. See also palliative care patients (study) life-threatening illnesses (study): methodology, 272–74, 273; patients’ earlier experiences, as important to, 279–80; as qualitative research, 271; questions raised by, 279–80; results, 274–78. See also palliative care patients (study) love: as central to spirituality, 54–57; as openness to “others,” 56–57; tolerance/ toleration, as antithetical to, 54–55 Lutheran World Federation, 18 manic-depressive illness, and spiritual intelligence, 299–300 Maslow, Abraham, 7, 246, 289 McMaster University: evidence-based research, as developed at, 11–12; family medicine/chaplaincy pilot project at, 68–69; occupational therapy program at, 139; physician self-awareness program of, 69–70 Medical Subject Heading (MeSH) keywords, 196, 197, 201 medicine, family, 61–62; and chaplaincy, 68–69; holistic approach of, 62; incorporating spirituality into, 66; increased spirituality in, 15–16, 62; and need to ask patients for spiritual information, 64–65 medicine and religion, separation of, 191–92 MEDLINE (database), 15, 44, 196 Mennonite church, 77–78, 83 Michigan Alcohol Screening Test (MAST), 130–31 mind-body connection: as central belief of Oriental cultures, 289–90; as refuted by Descartes, 289 miracles, 13, 14 Mitchell, Edgar (Apollo 14 astronaut), 298–99 morphic field, theory of (Sheldrake), 287 Muhammad, 88, 100; empowerment and forgiveness of sick by, 91; on health as

blessing, 90–91; illness of, 93; on obligation to seek medical treatment, 92–93, 100; sayings and actions of, as recorded in Sunnah, 89, 90; on visiting and praying with sick, 91–92 Mullis, Kary (Nobel laureate), 299 Muslim spiritual care. See Islamic spiritual care mystical experiences, and spiritual intelligence, 298–99 narrative: of child/sexual abuse survivors, 78–79, 82; of dementia patients, 112–15; as used in addiction recovery therapy, 126–29; as used in palliative care study, 215–22 Nash, John (Nobel laureate), 299 National Library of Medicine, 196 Native communities. See Aboriginal communities Native peoples. See Aboriginal peoples neurobiology, of spiritual consciousness, 286, 302–303; as allowing intuitive decision making, 290; in context of brain functions, 292–94; philosophy of Descartes, as antithetical to, 289; and Zen Buddhism, 302. See also spiritual intelligence New Age movement, 146 non-Medical Subject Heading (MeSH) keywords, 196, 197, 201 nursing: as holistic, 15–16; and pastoral care, 207; qualitative research, as used in, 16; spirituality, in literature of, 207 nursing homes, and care of dementia patients, 113–15, 116–17 occupational life course, 143–44, 144 occupational therapy: Canadian Model of Occupational Performance (CMOP), 140, 141, 141–42; Canadian Occupational Performance Measure (COPM), 140; client-centred approach to, 140, 141–42; definition of, 143; evolution of spirituality in 16, 140, 141–42, 144–46; history of, 140; occupational performance, as key concept of, 142–43; Person-Environment-Occupation Model of, 142, 142–43 Oedipus complex, 17, 243

Index ontology: religion and medicine in context of, 194–95; and self-creation, as dynamic process, 207; spirituality as redefined through, 193–94 “others”: love, as openness to, 56–57 pain: defiance of, 217–18; as emotional, 218–19; endurance of, as aided by support and faith, 218, 219, 220–21; and loss, 218, 220; as physical, 217–18; and relationship with God, 219; as spiritual, 219; suffering, and relationship to, 227–28, 232–34. See also arthritis and suffering (study); palliative care patients (study); suffering palliative care patients (study), 212; emotional pain, 218–19; illnesses, 216–17; life stories, 215–16; and narrative therapy, 215; participants in, 212–13; physical pain, 217–18; questions for, 214–15; results of, 215–22; and speaking about God, 211–12, 219, 221–22; spiritual pain, 219; worst experiences, 219–20. See also pain; suffering pastoral care: articles on, as cited in PubMed, 201–204, 206–207; as “cure of souls,” 14; as defined by PubMed, 206; as not exclusively provided by clergy, 206–207; types of, 14 pastoral counsellors: and chaplains, as segregated, xviii; and “history” of spiritual care, 207; as needing to reinvent their roles, 208; religious role of, as falling into disfavour, 192; as ritual coordinators, xviii-xx; as trained in both theology and psychology, 40 Person-Environment-Occupation Model, of occupational therapy, 142, 142–43 physicians: as affected by painful life experiences, 64, 67; clergy acting as, in earliest times, 64; and cultural diversity, 65–66, 67; HOPE questions, as suggested for, 67–68; self-care program for (St. Paul’s Hospital, Vancouver), 70–71; self-awareness program for (McMaster University), 69–70; spirituality of, 66, 67, 69–71 post-traumatic stress disorder (PTSD), 280, 301 prayer: distant, 16; for the sick, as Roman Catholic sacrament, 14; healing aspects

313

of, as subject of research, 16; as important to Islamic spiritual care, 89, 91–92, 94–95, 96, 97–98, 100; as used to overcome illness, 250, 251, 259 priests, and role of physician, 64, 65 Professionalization and Physician SelfAwareness (PPSA) program (McMaster University), 69–70 psyche, human: basic conflict of, as origin of psychosomatic illnesses, 243–46; spiritual forces of, as located in supraconscious, 246–47 psychoanalysis and behaviourism, development of, 24–25 psychology: and measurement of religious phenomena, 26–27; and religion, 24–27; as religion, 29; of religion, 25– 27; separation by, of religion and spirituality, 27, 29; and spirituality, 29; and theology, 23–24, 29, 30–32, 39–41; theology, as competing with, 29, 32 psychosomatic illnesses: as explained by psychosynthesis, 246–47; fibromyalgia, considered as, 242; origins of, as explained by psychoanalysis, 243–46; phenomenological-existential approach to, 247–49; spiritual dimension, of recovery from, 246–47. See also fibromyalgia; fibromyalgia recovery psychospiritual process, of fibromyalgia recovery (case study): chronology of, 249–50; content analysis of steps involved in, 250, 257–61; essential elements of, 250; as explained by psychosynthesis, 253–57; and faith in God, 253–57, 258; and forgiveness, 250, 253, 259; imagery and prayer, as components of, 250, 251, 259; intentionalities of, 251; and refusal to give up hope, 250, 253, 258; stages of journey towards, 251–52. See also fibromyalgia PsycLIT (database), 44 PubMed keywords in health care literature (study): for chaplaincy, 201–204; graphs illustrating, 198–203; MeSH and non-MeSH keywords, 196, 197, 201, 203, 205–206; for pastoral care, 201–204, 206–207; for religion, 199–200, 206; for spiritual care, 200–201; for spirituality, 197–99, 205

314 Index qualitative research: advantages of, 271; as form of evidence-based research, 16–17; on palliative care patients, 212, 214; on patients with life-threatening illnesses, 271. See also life-threatening illnesses (study); palliative care patients (study) Qur’an, 89–90, 95, 96, 100; on healthy diet and lifestyle, 90; on God’s healing powers, 97; on moral and ethical diseases, 90; recitations from, as used in healing process, 90, 93, 94, 98 Rahner, Karl, 212 randomized control trials, as used in science, 11, 12, 16 religion, 62; articles on, as cited in PubMed, 199–200, 206; as based on dogma, 286; as both theistic and nontheistic, 28, 39; as defined by PubMed, 206; as dimension of all human activity, 31; and health care profession, 192, 205; as historical context for evolution of medicine, 64, 191; as illusion, 17; and medicine, separation of, 191–92; and psychology, 24–27; rituals of, as calming and healthful, 300–301; and science, 2, 11–12, 17; and spiritual intelligence, 286; and spirituality, 27, 28, 192, 195, 269; and theology, 28–30; and ultimate meaning, 27–28. See also spirituality; theology religionless spirituality, 27, 29 Remembering Boxes, as used in care of dementia patients, 113–14 residential school system: and effect on Aboriginal communities/families, 185; and use of corporal punishment, 169 Rhazes (Persian physician), 94 ritual coordinators, xviii–xx rituals: of religion, as calming and healthful, 300–301, 302; three phases of, xviii– xix Roman Catholic Church: and education of Aboriginal children, 169; and Joint Declaration on the Doctrine of Justification, 18; Sacrament of the Sick, 14; separation of, from medical profession, 191–92

safety and security: of child abuse victims, as shattered, 75–77; of church, for abuse survivors, 81–82; concept of, as central to Islam, 88; of home, 74–75 Saul, conversion of, 290–92 schizotypal personality, and spiritual intelligence, 299 science: and religion, 2, 11–12, 17; and spirituality, 285–88 screening instruments, as used in addiction therapy, 130–31 sexual abuse: in Aboriginal community, 170–72; confronting issue of, 184–85; as leading to upheaval within churches, 81–82; male victims of, as not receiving support, 178; shame/guilt of, 172; as violation of friendship/trust, 170–71. See also home; child abuse sexual abuse, survivors of: as accepted/ assisted by congregations, 81–82; as revictimized by congregations, 77–81; shame/guilt of, 172; support for, as not always available to men, 178; as telling their stories, 78–79, 82. See also home; child abuse, survivors of Shalom Village Nursing Home (Hamilton), 114–15, 117 shamanism, 294–97 Sheldrake, Rupert, 287 Society for the Scientific Study of Religion (SSSR), 25 Society of Pastoral Counselling Research (SPCR), xvii-xviii Sociofile (database), 44 Sölle, Dorothee, 211–12 spirit (ruh), in Islam, 86–88 spiritual care: articles on, as cited in PubMed, 200–201; chaplains, as givers of, 85; in Christianity, 13–14 concept of, 124; as linked to health care, 15–18; as pastoral care, 14 spiritual consciousness: achieving, through shamanistic rituals/practices, 294–97; conversion of Saul, as illustrative of, 290–92; intuitive decision making, as occurring during, 290; neurobiology of, 286. See also spiritual intelligence spiritual distress, 63, 115; as caused by health/medical concerns, 63–64, 66;

Index and feeling of homelessness, 75; as leading to addiction, 133–34; of palliative care patients, 219, 224 spiritual intelligence, 286–87; and Divine/ supernatural knowledge, 298–99; and mystical/paranormal experiences, 298–99; negative emotions, as transcended by, 300; and personality disorders, 299–300; as source of creativity, 286; as source of strength, during lifethreatening illness, 289, 298; as synthesis of dialectics, 297–98; theories of, 286–89. See also neurobiology, of spiritual consciousness spirituality, 62–63; and adaptation to cultural diversity, 65–66; and addiction recovery, 124–29, 133–34, 134; articles on, as cited in PubMed, 197–99, 205; awareness of, by health care professionals, 1–3, 12, 15–18, 62, 192, 204; benefits of, to health, 15–17; central aspects of, 44–48; of Christian care for sick, 13–14, 191; as defined by PubMed, 206; as defining human beings, 193–95; as discussed in nursing literature, 207; and family medicine, 15–16, 61–71; and God/Transcendent Other, 46; in health care, as favouring “new” concepts over “old,” 207; home, as metaphor for, 74–75; in Islam, 86–89; love, as central to, 54–57; as meaning-making system, 45, 51; of medicine, 195; methodological perspectives on, 48–54; multiple definitions of, in health care literature, 44–48, 55–57; and occupational therapy, 144–46; as personal and private in nature, 47; of physicians, 66, 67, 69–71; as redefined through ontology, 193–94; and religion, 27, 28, 192, 195, 269; and science, 285–88; and suffering, 227–28; and theology, 28–30; and transcendent self, 46; tyranny, as antithetical to, 56–57. See also psychospiritual process; religion; theology spirituality, methodological perspectives on, 48–54, 57; as linguistic, 51–52; as phenomenological, 50–51; as practical, 49–50; as subjective and experiential, 52–53; as unknowable mystery, 53 stories, telling of: in addiction recovery

315

therapy, 126–29; by child/sexual abuse survivors, 78–79, 82; by dementia patients, 112–15; by palliative care patients, 215–22 St. Paul’s Hospital (Vancouver), 70 substance abuse, 12, 129; in Aboriginal community/family, 168, 172–74 suffering: as distinct from pain, 227–28, 229, 232–34, 237–38; as iatrogenic, 70; interventions needed to alleviate, 237–38; and loss, 218; as measurable, 228–29, 234–38; pain, as important component of, 217–19; as province of clergy or psychologists, 227–28; reasons for God’s allowing of, 211, 221, 278; speaking about God in context of, 211–12, 219, 221–22; as spiritual matter, 227–28; three stages of (Sölle), 211–12, 225; and threat to “self,” 228–29. See also arthritis and suffering (study); pain; palliative care patients (study) suicide, among Aboriginal peoples, 174, 175, 183 Sunnah, 89, 90 Tailor, Lucy (nursing home resident), 114–15 Teilhard de Chardin, Pierre, 211, 287 theology: and distinctions of faith, 36, 38; methodological developments in, 30–32; and psychology, 23–24, 29, 30–32; psychology, as competing with, 29, 32; and religion/spirituality, 28–30; and treatment of depression, 35–41; and ultimate meaning, 35, 37; as unaddressed in therapeutic setting, 32, 35, 40–41 theology, fundamental (Tracy), 30–32 therapeutic relationship model, as used in addiction recovery, 124–29, 126 tolerance/toleration, as nihilistic, 54–55 Tracy, David, 30–32, 38 Transcendent Other/God, as central to spirituality, 46 ultimate meaning: and personal theology, 35, 37; and religion, 27–28 Varieties of Religious Experience, The (James), 24

316 Index Weil, Simone, 54–55 wholistic approach, to healing: all-inclusive approach, as required by, 178; and community responsibilities, 182–85; family healing model, 178–79, 179; and family responsibilities, 179–82; and individual’s responsibilities, 176–78; interdependency of, 186

work, longer hours for, as increasing health/addiction risks, 123 World Health Organization (WHO), 1–2