1. George Fitchett December 2006 Religious Struggle and Its Impact on Health: Implications for Ministry

2. Outline Definition Evidence from Research harmful effects prevalence determinants Screening Case Examples Implications for Spiritual Care

3. Religious Struggle A woman in her fifties with advanced cancer told a chaplain, “Why? Why me? I just can’t figure it out. And I get so depressed that I just want to give up on life altogether, you know? And I’m so very angry at God. So angry. I refuse to speak to Him. You know what I mean?”

4. What is Religious Struggle? Religious struggle is having high spiritual needs and low spiritual resources with which to address those needs. Religious struggle is marked by underdeveloped, conflicted, overwhelmed, or negative spirituality.

5. Negative Religious Coping (Brief RCOPE) Pargament et al, 1998

6. Religious Struggle: Other Measures JJ Exline et al, 1999.

7. Religious Struggle: Early Models Stoddard, 1993 spiritual concern, spiritual distress, spiritual despair Berg, 1994, 1999 Spiritual Injury Scale NANDA Spiritual distress (1978) Potential for enhanced spiritual well-being (1994) At risk for spiritual distress (1998) Other Chaplaincy Models Derrickson, 1994-5 Hodges, 1999 Wakefield & Cox, 1999

8. Spiritual Injury Scale

9. Spiritual Distress: NANDA Definition Disruption in the life principle that pervades a person's entire being and that integrates and transcends one's biological and psychosocial nature. Related factors [etiology] Separation from religious and cultural ties Challenged belief and value system (e.g., result of moral or ethical implications of therapy or result of intense suffering) Defining characteristics Expresses concern with meaning of life and death and/or belief system Anger toward God (as defined by the person) Questions meaning of suffering Verbalizes inner conflict about beliefs Unable to choose or chooses not to participate in usual religious practices Regards illness as punishment Does not experience that God is forgiving

10. Anger With God and Rehabilitation Recovery Fitchett et al, 1999.

11. Religious Coping and Health Status in Hospitalized Older Adults (N= 577)

12. Two Year Change in Religious Struggle and Its Effects on Outcomes Among Elderly Medically Ill Patients *Models adjusted for demographic factors and baseline values. Source: Pargament et al, Journal of Health Psychology, 2004

13. Religious Struggle as a Predictor of Mortality (N=567)

14. Religious Struggle and Emotional Distress From Fitchett et al, 2004

15. Conflict About Prayer Unanswered prayer (13/30) Hesitancy about petitionary prayer (10/30) Conflict about control (9/30) Questions about the nature of God (8/30) Questions about meaning and theodicy (8/30) Bargaining (5/30) Doubt about the efficacy of prayer (4/30) Doubt about personal spirituality and worth (4/30) Praying the “right” way (4/30) 20% of patients had four to six types of spiritual conflict associated with praying about their cancer. Taylor, et al., 1999

16. Religious Struggle and Psychological Adjustment Among Cancer Patients

20. Religious Struggle and Psychological Adjustment Among Cancer and Other Patients

24. Religious Struggle and Emotional Distress Down Under 36 medical/surgical patients, Melbourne; F (2,35) = 3.7, p =.03.

25. Source: Ano and Vasconcelles, Journal of Clinical Psychology, 2005. Correlation Between Negative Religious Coping And Negative Psychological Adjustment NumberCumulative Confidence of Studies Effect Size Interval 22.22*.19 to.24 Meta-Analysis of Negative Religious Coping and Psychological Adjustment

26. Religious Struggle and Recovery from Heart Surgery (n=232)

27. Comfort from Religion and Religious Struggle 149 patients with diabetes or CHF

28. Determinants of Religious Struggle From Fitchett et al, 2004

29. Differences in RS by Patient Group

30. Differences in RS by Age 1998 GSS also found an age difference in negative religious coping (2 items, p<.05); mean scores: < 65: 1.25 > 65: 1.18

31. Differences in RS by Gender No gender differences in GSS study. Gender difference: -negative religious coping, ns -positive religious coping, t = -3.0, p=.003

32. Differences in RS by Level of Worship Attendance

33. Differences in RS by Positive Religious Coping

34. Isn’t Religious Struggle Really Just Depression? The size of the correlations between religious struggle and depression in our study (r from 0.22 to 0.42) suggest religious struggle is associated with but cannot be reduced to depression. Religious struggle predicts both poor recovery and mortality in models which adjust for depression.

35. Prevalence of Religious Struggle From Fitchett et al, 2004

36. Prevalence of Religious Struggle Patients General Population Feel abandoned by God9%5% Feel punished by God11%5% Responses of “quite a bit” or “a great deal.”

37. Prevalence of Religious Struggle

38. Dimensions and Course of Religious Struggle DimensionDescription The Challenge of Suffering Wondering why God permits suffering The Challenge of Cultivating VirtueFacing our sins The Challenge of Supernatural EvilDiabolical attributions The Challenge of Religious Community Experience of betrayal or injury from religious authority or others From Exline and Rose, 2005

39. Screening for Religious Struggle Screening for religious struggle is an attempt to identify patients who may be experiencing religious struggle. Screening for religious struggle employs a few, simple questions, that can be asked by health care colleagues.

40. Aim of Screening: Identifying Lost Sheep (and improving patient satisfaction) PatientResponse Lost SheepRefer for spiritual assessment Hungry SheepRefer for spiritual care Happy Non- BelieverNo further action needed

41. Religious Struggle and Requests for Spiritual Care (percent who request spiritual care) Religious Resources lowhigh Potential Need low9%35% high31%59% Chi-square = 21.19, p <.001 From Fitchett et al, J Pastoral Care, 2000

43. Pilot Study Results

44. Barriers to Screening Phase I, Patient Care Technicians PCTs felt overwhelmed by other tasks and couldn’t administer the protocol because of time constraints. Turnover of PCTs made follow through difficult. The protocol was sometimes misunderstood and not followed. Phase II, Medical Residents The heavy Resident work load was a major barrier. Turnover of Residents made consistency difficult. Resident’s lack of training about the importance of spiritual struggle was a problem.

45. Hershey Medical Center: Questions in Admission Assessment that Trigger Pastoral Services Referral

46. Child/Adolescent Spiritual Screening Tool (CAAST)

47. Others Models for Screening Stoddard Derrickson Berg Hodges Wakefield & Cox GF Review, CT, 1999

48. Three Levels of Inquiry About Religion/Spirituality screening for religious struggle religious/spiritual history taking spiritual assessment

49. Case Example: Alienated from Religion The chaplain was referred to the patient who was a candidate for a heart transplant because he appeared very discouraged. He was also receiving medication for depression. The patient told the chaplain about a negative experience he had with a particular church and pastor. As a result of this experience, the patient was angry with God and alienated from religious institutions. The chaplain helped the patient separate his experience with the church from his relationship with God. She helped him rebuild his relationship with God and find a new church home. As he did these things the patient’s depression resolved and the medication was discontinued.

50. The Case of Mrs. Fisher Mrs. Fisher was a 74 year old women with a history of toe amputation on her left foot. She had an ulcer on a toe on her right foot and had just had an operation to replace a section of the artery in her right leg. Her doctor had recently told her that her prognosis was very good, that she would be able to do all that she had been doing prior to the surgery. As she made a referral to the chaplain, the nurse described Mrs. Fisher as very depressed. From: Whitby, 1999

51. The Case of Mrs. Fisher Chaplain:Sounds like you’re angry with God? Mrs. F:(Looking up sharply) Yes I am. No one has said that to me before. Chaplain:No. Have you told Him? Mrs. F:No. Do you think He’d listen? (Looking over her glasses challengingly.) Chaplain:Yes. I think He would. (Mrs. F. looked intently at the chaplain.)

52. Implications for Spiritual Care ! ! For chaplains ! ! For other health professionals ! ! For congregations

53. Implications for Chaplains ! ! Chaplains come to term with their own religious struggles ! ! Finding the Lost Sheep “I ask God to lead me to the ones who need me.” ! ! A two – step process 1. screening by healthcare colleagues and if indicated 2. indepth spiritual assessment by a trained chaplain ! ! Responsible screening and “intervention”

54. The 7 x 7 Model for Spiritual Assessment

55. Pastoral Responses to Religious Struggle Assess sources of struggle duration: new, transient, leading to growth, chronic available resources Giving Voice, Being Heard muteness, lament, companionship Finding Meaning creating a new narrative creating a new future story

56. Implications for Chaplains: Three Questions How did you decide which patients to see this week? How did the staff you work with determine who to refer and who not to refer? What evidence did you generate this week that your ministry made a difference in measurable patient outcomes?

57. Implications for Chaplains

58. Early identification and follow-up of patients with religious struggle may: improve their adjustment improve their recovery reduce their risk of mortality Documenting the prevalence of religious struggle provides a measure of spiritual acuity and a basis for determining chaplaincy staffing levels

59. Implications for Spiritual Care ! ! For other health professionals ! ! For congregations ! ! Provide narratives and models for lament and religious struggle ! ! Follow-up with lost sheep

60. Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine” “Can You Measure a Sunbeam with a Ruler?” (Lederberg and Fitchett, 1999)

61. Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine” “Can You Measure a Sunbeam with a Ruler?” (Lederberg and Fitchett, 1999) “While such measurement may be possible, it cannot capture the essence of the sunbeam and in fact may distort it” (R Sloan, 2006).

62. Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine” “Can You Measure a Sunbeam with a Ruler?” (Lederberg and Fitchett, 1999) “While such measurement may be possible, it cannot capture the essence of the sunbeam and in fact may distort it” (R Sloan, 2006). “It is our hope that the contents of this special issue will help psycho-oncologists smoothly integrate religion and spirituality into their therapeutic and research pursuits without short-changing their patients with too much uncritical enthusiasm, or too much ignorance, indifference or cynicism” (Lederberg and Fitchett).

63. Acknowledgments Rehabilitation Study Bruce Rybarczyk, Gail DeMarco, John Nicholas Three Patient Groups Study Pat Murphy, Jo Kim, Jim Gibbons, Jacqueline Cameron, Judy Davis Screening Pilot StudyJay Risk, Pat Murphy Mrs. FisherAllison Whitby NIAK08 AG20145