Handouts for 'A Randomized Controlled Trial of a … · Web viewA Randomized Controlled Trial of a Spiritual-Wisdom-Based Program To Enhance Caregiving Self-Efficacy and Reduce Stress

This file contains handouts to accompany the paper entitled:

A Randomized Controlled Trial of a Spiritual-Wisdom-Based Program To Enhance

Caregiving Self-Efficacy and Reduce Stress and Burnout

Reporting on work by

Doug Oman, PhD(presenter)

John Hedberg, MDCarl E Thoresen, PhD

Presented at

131st Annual Meeting of theAmerican Public Health Association

San Francisco, California, USA November 18, 2003

Information in subsequent pages of this file:1 A copy of the online abstract for the paper presentation at the American Public

Health Association (2003)1

page

2 Primary handouts distributed at the paper presentation at the American Public Health Association (2003)

5 pages

4 A fuller description of the intervention. These materials were prepared for a workshop entitled "A Comprehensive Non-Sectarian Program for Integrating Spirituality into Health Practice" for the (fifth annual, 2002) conference on spirituality and medical education sponsored by the Association of American Medical Colleges (http://www.aamc.org/meetings/past/spirituality02/agenda.htm, accessed December 26, 2003). These materials were prepared by John Hedberg, Jeanne Bowden, and Doug Oman.

30 pages

http://www.aamc.org/meetings/past/spirituality02/agenda.htm

Online Abstract(http://apha.confex.com/apha/131am/techprogram/paper_60781.htm

accessed December 26, 2003)

131st Annual Meetings of the American Public Health Association

4021.0: Tuesday, November 18, 2003 - 8:50 AM

A randomized controlled trial of a spiritual-wisdom-based program to enhance caregiving self-efficacy and reduce stress and burnout

Doug Oman, PhD1, John Hedberg, MD2, Carl E Thoresen, PhD3.

(1) Public Health Institute, 2001 Addison Street, Second Floor, Berkeley, CA 94704-1103, 707-878-2573, [email protected].

(2) University of Colorado Health Sciences Center, Denver, CO. (3) Stanford University, Stanford, CA.

BACKGROUND AND PURPOSE:To evaluate the effects on caregiving self-efficacy, stress and burnout of an eight week, 2 hour per week training for health professionals in spiritual-wisdom-based self-management tools. Drawing extensively on spiritual wisdom traditions, the program may be practiced by adherents to any major religious faith, as well as those outside of all traditions.

DESIGN AND METHODS:Participants (N=61) were recruited through hospitals in Colorado, and included physicians, nurses, chaplains and other health professionals actively involved in patient care. After a pretest, participants were randomly allocated to an intervention condition (n=30) and a wait-list comparison group (n=31). The training program was based on a previously researched adaptation for health professionals of a comprehensive nonsectarian program from Easwaran (1991/1978). Participants were offered continuing professional education credits through the host hospital education department. Pretest, posttest, and 8-week followup data were gathered on spirituality, caregiving self-efficacy, perceived stress, and burnout (emotional exhaustion, depersonalization, and personal accomplishment).

RESULTS:Beneficial treatment effects trends were observed at posttest for all measures except depersonalization, and were statistically significant for increased caregiving self-efficacy (p<0.05) and reduced stress (p<0.05). Beneficial effects became even stronger and more statistically significant at followup for increased caregiving self-efficacy (p<0.01), reduced stress (p<0.001), reduced emotional exhaustion (p<0.05), and increased personal accomplishment (p<0.05). Participants also reported increases at posttest and followup in self-reported spirituality (p<0.05).

CONCLUSION: Evidence suggests this program enhances caregiving self-efficacy, reduces stress and burnout, and may merit inclusion in continuing education curricula for healthcare professionals.

http://apha.confex.com/apha/131am/techprogram/paper_60781.htm

APHA 2003 Meetings - Primary Handouts 1

_________________________________COMMENT_________________________________A pilot study describing this program and the caregiving self-efficacy measure is available (Oman, Hedberg, Downs, & Parsons, 2003). In comparison with other nonsectarian programs, this program is seen as more systematically including a wider range of material from the “wisdom traditions” of the great religions, especially through promoting observational learning from spiritual exemplars, which has been suggested as a major source of spiritual and religious growth (Bandura, 2003; Oman & Thoresen, 2003). According to Bandura’s highly influential social cognitive theory, observational learning of all types of human skills and behaviors typically involves the four processes of attention, retention, reproduction, and motivation (Bandura, 2003). By memorizing and meditating upon the words of spiritual exemplars who have composed such passages, practitioners give attention to pertinent modeling information (i.e., information about the lives and thought processes of the authors of the passages). Meditating upon the information in these passages fosters its retention, thereby facilitating its reproduction in behavior later during the day (e.g., when a meditator remembers St. Francis’ words “where there is hatred let me sow love”). Since passages are selected to inspire and motivate (Easwaran, 1991/1978), this form of meditation is hypothesized to foster all four of the processes that are theorized as central to spiritual modeling (Oman & Thoresen, 2003). Other components of the EPP, such as spiritual fellowship (Point 7), spiritual reading (Point 8), and frequent repetition of a sacred/holy name or mantram (Point 2 – see also Oman & Driskill, 2003) are also likely to foster spiritual modeling experiences, either by providing additional modeling information, or by facilitating its assimilation.

REFERENCE LIST:Bandura, A. (2003). On the psychosocial impact and mechanisms of spiritual

modeling. The International Journal for the Psychology of Religion 13 (3), 167-174.

Easwaran, E. (1991/1978). Meditation: A simple eight-point program for translating spiritual ideals into daily life, 2nd ed. Tomales, CA: Nilgiri Press (full text: http://www.nilgiri.org).

Oman, D., & Driskill, J.D. (2003). Holy name repetition as a spiritual exercise and therapeutic technique. Journal of Psychology and Christianity 22 (1), 5-19.

Oman, D., Hedberg, J., Downs, D., & Parsons, D. (2003). A transcultural spiritually-based program to enhance caregiving self-efficacy: Findings of a pilot study. Complementary Health Practice Review. 8 (3), 201-224.

Oman, D., & Thoresen, C.E. (2003b). Spiritual modeling : A key to spiritual and religious growth? The International Journal for the Psychology of Religion 13 (3), 149-165.

CONTACT INFORMATION: [email protected] 2003 Meetings - Primary Handouts 2

Intervention

Eight Point Program (EPP)(Easwaran, 1991/1978; introduced 1960)

* 1. “Passage” Meditation } Foundation

See Oman & Driskill (2003)* 2. Holy Name / Mantram

Repetition }3. Slowing Down }

Min

dful

-ne

ss

4. One-Pointed Attention5. Training the Senses6. Putting Others First7. Spiritual Association Everyday

Exemplars* 8. Inspirational Reading

*Points 1, 2, 8 foster daily attention to Exalted Exemplars from Spiritual Wisdom Traditions;

Point 1 fosters retentionSeveral points foster reproduction in behavior

APHA 2003 Meetings - Primary Handouts C

Points 1, 7, 8 foster motivation

APHA 2003 Meetings - Primary Handouts D

Inspirational Passages for Meditation23rd Psalm

The Lord is my shepherdI shall not want....

Prayer of Saint Francis:Lord, make me an Instrument of

Thy peace;Where there is hatred, let me sow

love...

Discourse on Good Will: May all beings be filled with joy

and peace...

More information: http://www.nilgiri.org

APHA 2003 Meetings - Primary Handouts

Memorize a passage Recite slowly in mind (30 min) Use multiple passages

E

Self-TailoringIndividual selects meditation passages and other materials

nonbelievers often use passages from Buddhism, Taoism

Corollary:

EPP usable in any religious tradition or outside all traditions

Grassroots Multicultural Interest Independent Publication 20+ languages

Black: Countries of Independent Publication (Gray: Available in official language)

Info. for health practitionersHedberg, J., Bowden, J., & Oman, D. (2002). A comprehensive non-sectarian program for integrating spirituality into health practice. (Materials prepared for workshop at Conference on Spirituality, Culture and End-of-Life in Medical Education, sponsored by the Association of American Medical Colleges, Kansas City, MO, September 14); Available online

APHA 2003 Meetings - Primary Handouts F

APHA 2003 Meetings - Primary Handouts G

A Comprehensive Non-Sectarian Program for Integrating Spirituality into Health Practice

John Hedberg, M.A., M.D.University of Colorado Health Sciences Center, [email protected]

Jeanne Bowden, Ph.D., R.N., M.P.H., F.A.A.N.Oregon Health Sciences University, La [email protected]

Doug Oman, Ph.D.School of Public Health, University of California, [email protected]

Pre-Printed Materials for Workshop to be presented at

Spirituality, Culture and End-of-Life in Medical Education Conference

Jointly sponsored by the Association of American Medical Colleges,George Washington University School of Medicine, and

Harvard Medical School, Department of Continuing Education

Kansas City, MissouriSeptember 14, 2002

ContentsSection Description Page

Contents 11 Introduction 22 Unusual Features of EPP 53 Description of the Eight Points 64 Examples of Meditation Passages 105 Examples of Mantrams / Prayer Words 126 Similar Practices in Well-Known Health Interventions and

Religious Traditions13

7 Research Bibliography 148 Adapting EPP to Specific Spiritual / Religious Groups 219 Support Systems for using EPP 2210 Applying the EPP to Healthcare Practice 2411 Examples of Potential EPP Course Uses 2912 Appreciations of the EPP 30

___________________________Acknowledgements: Dr. Oman’s contribution to the workshop was supported in part by Grant T32 HL07365-21 (U.S. NIH/NHLBI).

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§1 Introduction

The Eight Point Program developed by Easwaran (1991/1978) is completely nonsectarian, yet brings participants into close daily contact with the spiritual ‘wisdom traditions’ of the great religions, providing a fully integrated program for daily living that can be practiced within any major religion or no religion at all.

These eight points offer an affirming set of experiences that evidence suggests promote improved quality of life and foster subjective well-being, i.e., perceived life satisfaction, increased positive emotions, and reduced negative emotions (Diener, 1999). Because of its comprehensiveness and other special features (see section 2), this program may have advantages over widely used spiritual practices and interventions for improving health and quality of life.

Originally developed for spiritual and religious purposes, the Eight Point Program (EPP) was introduced to the United States in 1959 by its developer, Eknath Easwaran (1911-1999), at that time a visiting Fulbright scholar from India. Later, the program was the focus of what was perhaps the first course in the theory and practice of meditation to be offered for credit at a major American university (Easwaran, 1991/1978, p. 3). More recently the program has also been used for a variety of health-related purposes.

Applications in Medicine and Medical Education

What?

The Eight Point Program has been found useful for... Managing Stress Managing Caregiver Burden Coping with Chronic and Life-Threatening Diseases Coping with End-of-Life Issues

Who?

The Eight Point Program has been found useful by... Physicians Psychologists Medical Educators Hospice Workers Nurses Social Workers Healthcare Administrators Patients

(continued)

(A Comprehensive Non-Sectarian Program for Integrating Spirituality into Health Practice, 2002: John Hedberg,[email protected]; Jeanne Bowden, [email protected]; Doug Oman, [email protected])

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How?

The Eight Point Program has been... Taught to groups of patients Incorporated in professional and staff training (hospitals, universities, long-term-care

facilities) Shared informally with patients and colleagues Used personally by health professionals to improve professional effectiveness

Why?

According to its developer... The Eight Point Program operates by training attention. Through refocusing attention, all eight points converge in helping a person become more

concentrated, empowered, and guided by uplifting spiritual wisdom.

Where?

The wide cross-cultural appeal of the Eight Point Program is demonstrated by itsinternational dissemination by mutually independent publishers in 20 European, Asian, and Middle Eastern languages (see figure, next page).

ReferencesDiener, E., Suh, E. M., Lucas, R. E., & Smith, H. L. (1999). Subjective well-being: Three

decades of progress. Psychological Bulletin, 125(2), 276-302.Easwaran, E. (1991/1978). Meditation: A simple eight-point program for translating spiritual

ideals into daily life (2nd ed.). Tomales, CA: Nilgiri Press.

_______________________This section (text & graphic) adapted from Oman, D. (2000), A comprehensive non-sectarian program to promote spirituality and health. (poster presented at Conference on Spirituality in Health Care: Issues of Culture and End of Life in Medical Education, Dallas, TX: Sep. 16, 2000); additional information used from Nilgiri Press (August 2001), Foreign editions of the books of Eknath Easwaran [annually prepared for distribution at Frankfurt book faire - available upon request], Tomales, CA: Nilgiri Press.


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World-Wide Cross-Cultural InterestThe wide cross-cultural appeal of the Eight Point Program is demonstrated by itsinternational dissemination by mutually independent publishers in 20 European, Asian, and Middle Eastern languages .

Figure: Countries in which books describing how and why to practice the Eight Point Program are...

black - Published within the country by an indigenous publishing house

or gray - Published (somewhere in the world) in the country’s official language

European languages:Dutch English French German GreekHungarian Italian Lithuanian Portuguese Russian Slovenian Spanish

Middle Eastern languages:Hebrew

Asian languages:Bahasa Indonesian Chinese (PRC) Chinese (Taiwan) Japanese KoreanMalayalam (India)Marathi (India) Telugu (India)

Works published independently in multiple languages include more than one dozen supportive texts in addition to the basic instructional text (Easwaran, 1991/1978, Meditation).


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§2 Unusual Features of EPP

The EPP has several features that make it broadly applicable across cultures and religions, and

allow it to be embraced without having to alter one’s religious views (or lack of religious views).


Universality: The Eight Point Program follows a nonsectarian

approach. The points can be used comfortably by persons practicing

any major world religion, as well as by those practicing no religion at

all. These tools already exist in some form in all the major religions

— this program’s special contribution is to organize and present them

in a form readily usable by people living ordinary lives in the modern

world.

Comprehensiveness: The Eight Point Program provides a

comprehensive program for spiritual living, lending support and

assistance to the struggles and choices a person faces in all aspects of

life. (For example: while the first point, daily meditation, helps a

person to develop focused attention, the other seven points help to

integrate that focus and poise into daily living).

Wisdom-Based: Using the eight points brings a person into direct

daily contact with the words of the world’s great wisdom traditions

(see examples, section 4).

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§3 Description of the Eight Points

The following information is adapted from Easwaran (1991a, 1998) and from Oman (2000). Fuller information can be found in EPP publications (Easwaran, 1991a, 1991b/1978).

Brief Description of the Eight Point Program (EPP)

1. “Passage” Meditation. Memorize an “inspirational passage” such as the 23rd Psalm, the Prayer of Saint Francis, or the Discourse on Good Will of the Buddha’s Sutta Nipata (see below). Meditate for a half an hour each day, preferably in the morning. Meditate by sitting with back straight, eyes closed, and reciting the passage slowly in one’s mind with concentration. Focus the mind as completely as possible on the words of the passage; when distractions come, do not resist them, but give more attention to the words of the passage. If the mind strays from the passage entirely, bring it back gently to the beginning and start again. When the passage is completed, begin another memorized passage or slowly and silently repeat the same passage until the time for meditation is completed.

2. Repetition of a Holy Word or Mantram. Each practitioner selects a single short word or phrase from a major religious tradition. Suitable words or phrases include “Jesus”, “Ave Maria”, “Om mani padmé hum” (a Buddhist mantram referring to the “jewel in the lotus of the heart”), “Barukh attah Adonai” (means “Blessed art thou, O Lord” in Jewish tradition), “Allah”, or “Rama” (which was Mahatma Gandhi’s mantram). The chosen holy word is to be repeated as often as possible at spare moments during the day (e.g., when walking, waiting, or doing mechanical chores like dishwashing), and, once decided on, is not to be changed.

3. Slowing Down. Guard against hurry and the attendant stress by simplifying life and refraining from filling time with more than what can be done. When beginning to speed up, repeat the holy word as an aid to slowing down.

4. Focused or One-pointed Attention. Do only one activity at a time. Everything we do benefits from receiving our full attention. For example, refrain from driving and dictating or calling at the same time. Multi-tasking drains energy and leads to mistakes, whereas one-pointed attention conserves energy, leading to efficiency and poise.

5. Training the Senses.Develop freedom of choice in what we eat, what we read, and what we watch, and use that ability to choose by eating, reading, and watching things that strengthen our bodies and minds. Training the senses begins by forgoing things that injure the body. But because our habits are so deeply entrenched, we should not expect too much too fast. We have to assess just what we are capable of at any time.


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6. Putting Others First. Think and act first for the needs of others rather than dwelling on our own likes and dislikes. When we can promote the true best interests of the whole family, society or world, our own true personal needs will thereby be included.

7. Spiritual Association. Gather together regularly with others who share similar goals and practice these same disciplines; offer each other mutual support by meditating, reading inspiring books, or sharing times of entertainment together.

8. Inspirational Reading. Read inspiring books from the world’s sacred scriptures and mystics, especially works that reflect an author’s authentic personal experience of unified consciousness. Examples of recommended nonscriptural sources include The Way of the Pilgrim, The Autobiography of St. Teresa of Avila, Footprints of Gautama the Buddha (Byles, 1967), The Gospel of Sri Ramakrishna, and Mysticism (Underhill, 1911).

(above descriptions adapted from Oman, 2000)

FAQsHere we offer responses to some frequently asked questions about how to practice the Eight Point Program:

Question 1: “Do I meditate on the mantram? What’s the difference between meditation and the mantram?”

Be sure that you understand the difference between repeating a mantram and using an inspirational passage in meditation. The passage should be at least a few lines long – and may be many verses long. It is inspirational and positive, and is changed to suit changing needs. The mantram may be just one word or a short phrase. Once chosen carefully, it is used as often as possible and never changed. It becomes a familiar friend and support. The passage is used during your meditation period, while you are seated erect, eyes closed, for a certain period of time. When your attention wanders from it, you return your attention to the passage. The mantram can be used at any time of the day or night, whenever you have an opportunity: walking, doing mechanical chores, waiting in line, falling asleep, when you feel anxiety, anger, or fear coming on.

Question 2: “Does Point 6, ‘Putting Others First’, mean making myself a doormat?”

Someone once asked me in very graphic language if putting the other person first all the time doesn’t mean making yourself into a doormat. Not at all. We are not really putting others first if we connive at their mistakes, or if we let them have their way when they want to go in some wrong direction. It is a sign of great love and great maturity to be able to oppose the other person tenderly and resolutely when he or she is going in the wrong direction. When it seems


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necessary to say no, we should be able to say it gently and without the slightest trace of resentment or retaliation. We can all learn to disagree without being disagreeable.

(From Easwaran, 1998, p. 197)

Question 3: “Can I make up my own mantram?”

Occasionally someone will ask, “Can I make up my own mantram? How about Peace?” “Peace” is a beautiful word, I know, but not any word will do as a mantram. I strongly urge you to choose a mantram that has been sanctified by long use — one of proven power, that has enabled many men and women before you to realize the unity of life. The roots of such a mantram go far deeper than we can ever know when we begin to use it. This profundity enables it to grow in our consciousness.

(from Easwaran, 1991b/1978, pp. 69-70)

Question 4: “Can I alter a meditation passage?”

An inspirational passage turns our thoughts to what is permanent, to those things that put a final end to insecurity. In meditation, the passage becomes imprinted on our consciousness. As we drive it deeper and deeper, the words come to life within us, transforming all our thoughts, feelings, words, and deeds.

For this reason, please don’t try to improve upon the words of the Prayer or change them in any way. Just as they stand, they embody the spiritual wisdom of Saint Francis. When Ali Baba wanted to enter the cave of the forty thieves, he had to have the right password. He could yell out, “Open, brown rice” or “Open, shredded wheat” forever, but nothing was going to happen until he said, “Open, sesame.” Meditate upon Saint Francis’s own words, and you will find that you begin to resonate with the spirit of self-forgetfulness and love that the words contain.

(from Easwaran, 1991b/1978, p. 39)

Beginning practitioners of the Eight Point Program are likely to develop many other questions. A wide variety of issues relevant to EPP practice are addressed in books written by the program’s developer, Eknath Easwaran. We suggest Meditation (1991b/1978) as an excellent starting point for resolving most practical questions related to the EPP.

ReferencesEaswaran, E. (1991a). God makes the rivers to flow: Selections from the sacred literature of the

world / chosen for daily meditation. Tomales, California: Nilgiri Press.Easwaran, E. (1991b/1978). Meditation: A simple eight-point program for translating spiritual

ideals into daily life (2nd ed.). Tomales, CA: Nilgiri Press.Easwaran, E. (1998). Mantram handbook (4th ed.). Tomales, CA: Nilgiri Press.Oman, D. (2000). A comprehensive non-sectarian program to promote spirituality and health.

(poster presented at Conference on Spirituality in Health Care: Issues of Culture and End of Life in Medical Education, Dallas, TX: September 16, 2000).


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§4 Examples of Meditation Passages

The Prayer of Saint FrancisLord, make me an instrument of thy peace.Where there is hatred, let me sow love;Where there is injury, pardon;Where there is doubt, faith;Where there is despair, hope;Where there is darkness, light;Where there is sadness, joy....

23rd PsalmThe Lord is my shepherd I shall not want.He maketh me to lie down in green pastures: He leadeth me beside still waters.He restoreth my soul:He leadeth me in the paths of righteousness for his name’s sake.Yea, though I walk through the valley of the shadow of death,I will fear no evil: for thou art with me...

The Path (Mahatma Gandhi)I know the path: it is straight and narrow.It is like the edge of a sword. I rejoice toWalk on it. I weep when I slip. God’s word is:“He who strives never perishes.”I have implicit faith in that promise. Though,Therefore, from my weakness I fail a thousand

times,I shall not lose faith.


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Discourse on Good Will (Buddhism)May all beings be filled with joy and peace.May all beings everywhere,The strong and the weak,The great and the small,The mean and the powerful,...May all be filled with lasting joy...

A Prayer of Saint Teresa of AvilaLet nothing upset you;Let nothing frighten you.Everything is changing;God alone is changeless.Patience attains the goal.Who has God lacks nothing;God alone fills every need.

Let Me Walk In Beauty (Native American)O Great Spirit, whose voice I hear in the winds and whose breath gives life to all the world, hear me.I am small and weak. I need your strength and wisdom.Let me walk in beauty and let my eyes ever behold the red and purple sunset...I seek strength not to be greater than my brother or sister but to fight my greatest enemy, myself.Make me always ready to come to you with clean hands and straight eyesSo when life fades as the fading sunset my spirit may come to you without shame...

(Passages reprinted with permission from God Makes the Rivers to Flow, Nilgiri Press, 1991; some images © 2001-2002 by www.arttoday.com)


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§5 Examples of Mantrams / Prayer Words

(Explanation )ChristianJesusLord Jesus Christ have mercy on me The Jesus Prayer Lord Jesus Christ have mercy on us “ “ “Hail Mary or Ave MariaMy God and my All (Used by St. Francis of Assisi in his prayers)Kyrie Eleison Lord have mercy. Om Yesu Christu

Hindu/Indian Rama (Mahatma Gandhi’s mantram) Eternal joy withinOm Namah Shivāya An invocation to beauty and fearlessness.Om Sri Rām Jai Rām Jai Jai Rām An invocation to joy.

Buddhist Om Mane Padmé Hum An invocation to the jewel (the Self) in the lotus

of the heartNamo Amida Butsu I bow to the Buddha of Infinite Light

Jewish Barukh Attah Adonai Blessed art thou, O Lord.Ribono Shel Olam Lord of the Universe

Islamic/Arabic Alláh Lord God, the OneAlláhu akbar God is GreatBismillāh Ir-Rahmān Ir-Rahīm In the Name of God, Merciful, Compassionate

Baha’i Allá-u-abhá God the Most GloriousYá Bahá’u’l-Abhá O Thou the Glory of Glories!

EPP supporting publications recommend using a traditional mantram or prayer word (rather than making up a mantram) in order to obtain the full benefit of the Eight Point Program. However, traditional mantrams and prayer words that are not on this list may also be fully beneficial, according to EPP publications.


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§6 Similar Practices in Well-Known Health Interventions and Religious Traditions

Element of EPP

Similar Existing Health Interventions

Similar Practices in Religious Traditions

1 Meditation Benson’s Meditation, Transcendental Meditation

Raja Yoga, Kavvanah, Prayer of the Heart, higher Lectio Divina

2 Mantram Affirmations Jesus Prayer; Dhikr, Japa Yoga

3 Slowing Down

Treating Type A (alleviate sense of time urgency, e.g., Friedman and Ullmer, 1984), Mindfulness - Informal Practices (e.g., Kabat-Zinn, 1993, p265)

Right Mindfulness

4 One-pointed Attention

Treating Type A (avoid polyphasic thinking), Mindfulness - Informal Practices

Right Mindfulness

5 Training the Senses

Pervasive (e.g., Twelve-Step Programs)

Pervasive (e.g., Middle Way in Buddhism; Temperance in Christianity)

6 Putting Others First

Treating Type A (be compassionate)

Pervasive (e.g., “Love Thy Neighbor” in Leviticus 19:18; Humility)

7 Spiritual Association

Social support, Twelve-Step Programs

Pervasive (e.g., faith communities; scriptural study groups; Sangha)

8 Inspirational Reading

Reading Sacred Writings in Counseling

Pervasive (e.g., Scriptural Study; preparatory Lectio Divina)

Adapted from Oman, D. (2000). A comprehensive non-sectarian program to promote spirituality and health. (poster presented at Conference on Spirituality in Health Care: Issues of Culture and End of Life in Medical Education, Dallas, TX: September 16, 2000) and Oman, D., & Thoresen, C. E. (2001). Using intervention studies to unravel how religion affects health. (Paper presented at North American Conference on Spirituality and Health, Calgary, Alberta, Canada, May 26, 2001).


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§7 Research Bibliography

Several types of empirical research are relevant to the Eight Point Program (EPP) of Easwaran (1991/1978). In this section, we offer a brief overview of the following categories of research literature:

Research on religion and spirituality

Research on meditation (EPP Point 1)

Research on ancillary practices (EPP Points 2-8)

Research on observational learning and modeling influences

Research on the EPP itself or upon adaptations of the EPP

(For a tabular representation of research relevant to the individual EPP points, see Section 6, “Similar Practices in Well-Known Health Interventions and Religious Traditions”)

Religion and SpiritualityThe EPP links practitioners to spiritual and religious wisdom traditions. These traditions

have been drawing increasing attention in major biomedical, public health, psychology, and other social science journals over the past decade (Chatters, 2000; Koenig, McCullough, & Larson, 2001). Increasingly well-controlled studies have associated religious involvement with a wide range of health outcomes including lower all-cause mortality (McCullough, Hoyt, Larson, Koenig, & Thoresen, 2000), lower mortality due to a wide spectrum of specific causes (Hummer, Rogers, Nam, & Ellison, 1999), lower blood pressure, lower incidence of physical disability (Idler & Kasl, 1997), lower depressive symptomatology, greater well-being, less spousal abuse (Ellison & Anderson, 2001), better health practices among adolescents (Wallace & Forman, 1998), and reduced alcohol and substance abuse (Gorsuch, 1995; Miller, 1998) (see reviews in Koenig et al., 2001). Other studies have found that religious involvement mitigates the effects of unemployment (Shams & Jackson, 1993), and is associated with reduced racial self-stigmatization (Brega & Coleman, 1999), and reduced dependence upon physical self-concepts (Idler, 1995). Within the National Institutes of Health, the Office of Behavioral and Social Sciences (Panel on Spirituality, Religion and Health) has been reviewing the scientific evidence linking spiritual and religious factors in health and disease (Miller & Thoresen, in press). According to a recent published review, studies to date suggest that “religion, in a broad sense, represents a protective factor that offers a small but significant primary-preventive effect against morbidity in populations” (Ellison & Levin, 1998).

Several mechanisms have been proposed by which religious involvement may promote better individual health (Oman & Thoresen, 2002). The emphasis that many religious and spiritual groups place upon respect for the body could promote better health practices among their members. Longitudinal evidence has been presented that religiously involved persons are more likely than others to adopt and maintain positive health behaviors, such as exercising and not smoking (Strawbridge, Shema, Cohen, & Kaplan, 2001). Religious involvement may also foster greater social support, a well-established health-protective factor (House, Landis, &


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Umberson, 1988). Other recent findings, such as lower mortality rates in religious as opposed to secular kibbutzim (Kark et al., 1996), suggest that psychological factors, such as greater faith (Frank, 1975), a stronger sense of coherence (Antonovsky, 1987), or greater ability to use religious methods of coping (Pargament, 1997), may also play a role in promoting health among religiously or spiritually involved persons. Oman and Thoresen (2002) clarify confusion among diverse interpretations in terms of causal pathways of the question “does religion cause health?”

MeditationSeveral decades of meditation research have linked various forms of meditation to a wide

range of physiological and psychological effects (Murphy, Donovan, & Taylor, 1999). Most meditation research has focused upon physiological outcomes. Evidence suggests that meditation fosters salutary reductions in physiological arousal, such as reduced blood pressure, plasma lactate, oxygen consumption, respiratory rate, and heart rate, and increased skin resistance and alpha waves (Alexander, Robinson, Orme-Johnson, & Schneider, 1994; Benson, 1993; Murphy & Donovan, 1988; Shapiro & Walsh, 1984). One randomized study associated meditation with lower mortality among nursing home residents (Alexander, Langer, Newman, Chandler, & et al., 1989).

Other research has associated meditation with a range of behavioral effects including increased empathy, lowered chemical dependency, reduced anxiety, improved memory and intelligence, and enhanced perceptual ability (Kember, 1985; Levin, 1977; Murphy et al., 1999). However, because of the uneven quality and relatively small amount of research on the psychological effects of meditation, most of these findings should be regarded as provisional from the standpoint of modern empirical science.

Ancillary practices (EPP Points 2-8)The value to health of Point 5, training the senses, is supported by decades of research on

the benefits of avoiding overeating, smoking, heavy drinking, and sedentary lifestyles. Similarly, the value of Point 7 (spiritual association) is supported by a large amount of empirical research on the benefits of social support (e.g. House et al., 1988; Spiegel, Bloom, Kraemer, & Gottheil, 1989).

Less research addresses the effects of most other EPP points, although some research fields and programs are relevant to multiple EPP points. Mortality reductions have been produced by interventions to reduce Type A behavior patterns (Friedman et al., 1986). Treatment of Type A behavior pattern often involves practices that are similar to Point 3, one-pointed attention (e.g. avoid polyphasic thinking - Friedman & Ulmer, 1984, p. 189); Point 4, slowing down (e.g. alleviate sense of time urgency - Friedman & Ulmer, 1984, §11); and Point 6, putting others first (e.g. be compassionate - Friedman & Ulmer, 1984, p. 219). Similarly, research on mindfulness meditation supports the value of Points 3 and 4 (e.g. informal practices -Kabat-Zinn, 1993, p. 265). Other work supports the benefits of Point 6, putting others first (e.g. altruism - Oman, Thoresen, & McMahon, 1999) or Point 8, spiritual reading (e.g. reading sacred writings in counseling - Richards & Bergin, 1997).


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Of all EPP points, perhaps the least amount of research literature directly addresses Point 2, repetition of the mantram or prayer word, although this practice has a certain similarity to the “affirmations” that are sometimes used in clinical practice (e.g. Benson & Stark, 1997, pp. 275-6). Nevertheless, the complaint by Hausherr (1978, p. 175) that “[w]e have left the exploitation of this psychological law [of repetition] to the science of propaganda and to the art of advertising” is still largely valid. Oman and Driskill (in press) present a research agenda, discuss historical and theological background and clinical applications, and review a variety of empirical and theoretical evidence for the efficacy of the frequent repetition of a mantram / prayer word for spirituality and health. As they point out, research in associative network theory (Hill, 1994) has established that attention to a particular word facilitates recognizing and responding to semantically related words and ideas, suggesting that repetition of a mantram / prayer word is likely to facilitate spiritual strivings (Emmons, 1999).

Direct evidence for the value of repetition of a mantram is provided by Bernardi and colleagues (2001), who found that repetition of a mantram or the rosary led to “striking, powerful, and synchronous increases in existing cardiovascular rhythms” (p. 1446), and to increases in baroreflex sensitivity, a marker of improved cardiovascular health. Evidence of benefit is also provided by Bormann and colleagues in research on both veterans (n=33) and healthcare staff (n=36) at a Veterans Administration facility (Bormann & Becker, 2002; Bormann, Becker & Gershwin, 2002). Using Easwaran (1998) as a course text, these investigators taught participants the repetition of the mantram and two other EPP practices (Points 3 and 4, slowing down and focused or one-pointed attention). Preliminary statistically significant pretest to posttest improvements included reductions in perceived stress, insomnia, anxiety, helplessness and trait anger, and increases in feelings of control, overall life satisfaction, and existential spiritual well-being (Bormann & Becker, 2002; Bormann, Becker et al., 2002). Preliminary results also included statistically significant increases in existential spiritual well-being among veterans (n=14 due to belated inclusion of scale, Jill Bormann, personal communication, Aug. 7, 2002).

Observational Learning and Modeling InfluencesThe EPP may promote spirituality in part through supporting what might be called

“spiritual modeling” and “observational spiritual learning” (Oman & Thoresen, 2001, in press; Bandura, in press). In the language of modern psychological theory, much of spirituality and religion appear likely to be transmitted by “behavioral modeling” and “observational learning” (Bandura, 1986, in press; Oman & Thoresen, 2001, in press). “A great deal of information about human values, thinking patterns, and behavior is gained from models portrayed symbolically through verbal or pictorial means”, notes Bandura (1994, p. 66), and religious and spiritual groups foster the assimilation of such information by representing or enacting vicarious incentives, repeatedly narrating key events, offering interpretive schema, and encouraging other components of vicarious learning (Bandura, 1986, p. 60-61). Potentially influential spiritual models include the founders and other figures from religious traditions, as well as members of a person’s own society, community or family (see Myers, 2002, for discussion of a neglected 20th Century Islamic leader who was “a monumental figure in the history of nonviolent achievement, an equal of Mahatma Gandhi and Martin King”). Organized tutelage may also contribute to the


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assimilation of religion and spirituality, although its effectiveness may be undermined if the instructors’ words differ from their modeled actions (Bandura, 1986, p. 344).

Modern psychological theories of behavioral modeling and observational learning are supported by much empirical research (Bandura, 1986). While none of this supporting research has directly investigated the EPP, the EPP appears likely to support assimilation of spiritual modeling information through Points 1 (passage meditation), 2 (repetition of the mantram/prayer word), 7 (spiritual fellowship) and 8 (inspirational reading). Inclusion of meditation passages reflecting direct personal transcendent experiences and their positive application to daily living may enhance vicarious incentives for continued adherence to salutary spiritual practices (Bandura, 1986, 1994). For some persons, a culturally diverse set of available exemplars may provide vicarious efficacy information that heightens determination (Bandura, 1986, p. 402).

Research on the EPPThe limited empirical research on the EPP to date is consistent with the research and

theory, described above, that relates to spirituality and religion, observational learning, meditation, and analogues to other individual points of the EPP. A small randomized intervention study conducted at Stanford University found that beginning schoolteachers who were trained in an abbreviated version of the EPP experienced reduction in perceived stress relative to a control group (Winzelberg & Luskin, 1999). Another small randomized intervention sponsored by the Centers for Disease Control found that an abbreviated version (points 1-4) of the Eight Point Program was more effective than psychotherapy, stress management, community service, or a control condition in reducing risky sexual behaviors among gay men (Flinders et al., 1991). A third study of an abbreviated form of the EPP found that subjects randomly assigned to the EPP had consistent improvement across all scales of depression, hostility, anxiety, phobic anxiety and paranoia, whereas those assigned to traditional psychotherapy, traditional stress management, or a control condition had improvement on only some of the scales. A fourth study found that training in the EPP enhanced the caregiving ability of health professionals (Oman, Hedberg, Downs, & Parsons, 2001, in press). In this study, caregiving ability was measured as “self-efficacy”, which is a widely studied construct in the social sciences, and may be defined as a person’s confidence that they are able to perform a certain kind of action. Self-efficacy is typically among the strongest predictors of objective performance for any type of activity, and is increasingly used to evaluate programs for education, training, and behavioral modification (Bandura, 1997). In this study, mean pre/post caregiving increases were large (Cohen’s d>0.80), statistically significant (p<0.01), and associated with greater use of specific program practices.

References / Bibliography

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Alexander, C. N., Robinson, P., Orme-Johnson, D. W., & Schneider, R. H. (1994). The effects of


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Transcendental Meditation compared to other methods of relaxation and meditation in reducing risk factors, morbidity, and mortality. Homeostasis in Health & Disease, 35(4-5), 243-263.

Antonovsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well. San Francisco, CA, US: Jossey-Bass Inc, Publishers.

Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice Hall.

Bandura, A. (1994). Social cognitive theory of mass communication, Media effects: Advances in theory and research. (pp. 61-90). Hillsdale, NJ, USA: Lawrence Erlbaum Associates, Inc.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W. H. Freeman.Bandura, A. (in press). On the psychosocial impact and mechanisms of spiritual modeling. The

International Journal for the Psychology of Religion.Benson, H. (1993). The relaxation response. In D. Goleman & J. Gurin (Eds.), Mind / body

medicine: How to use your mind for better health (pp. 233-257). Yonkers, NY: Consumer Reports Books.

Benson, H., & Stark, M. (1997). Timeless healing: The power and biology of belief. New York: Fireside.

Bernardi, L., Sleight, P., Bandinelli, G., Cencetti, S., Fattorini, L., Wdowczyc-Szulc, J., & Lagi, A. (2001). Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: Comparative study. British Medical Journal 323, 1446-1449.

Bormann, J., & Becker, S. (2002). Outcomes of a mantram intervention in veterans and staff. (Poster presented at the 2002 Annual Western Institute of Nursing Assembly / Communicating Nursing Research Conference, Palm Springs, CA, April 19, 2002); 10, 351.

Bormann, J., Becker, S., & Gershwin, M. (2002). Efficacy of a mantram intervention on anger, spirituality, and quality of life in veterans and staff. (Poster {to be} presented at the 2002 State of the Science Congress : Advancing Nursing Practice Excellence, Washington DC, September 26, 2002).

Brega, A. G., & Coleman, L. M. (1999). Effects of religiosity and racial socialization on subjective stigmatization in African-American adolescents. Journal of Adolescence, 22(2), 223-242.

Chatters, L. M. (2000). Religion and health: Public health research and practice. Annual Review of Public Health, 21, 335-367.

Emmons, R.A. (1999). The psychology of ultimate concerns: Motivation and spirituality in personality. New York: Guilford.

Earl, W., Flinders, R., Flahive, M., Bartholow, B., Kobayashi, J., & Cohn, D. (1990). Psychosocial adjustment to hiv infection: Efficacy of different group interventions in gay and bisexual men (abstract presented at the sixth International AIDS Conference, June 21, 1990, San Francisco). In T. Flinders, M. Gershwin & R. Flinders (Eds.), The RISE response: Illness, wellness, and spirituality (pp. 211-212, 218). New York: Crossroad (1994).

Easwaran, E. (1991/1978). Meditation: A simple eight-point program for translating spiritual ideals into daily life (2nd ed.). Tomales, CA: Nilgiri Press.

Easwaran, E. (1998). Mantram handbook (4th ed.). Tomales, CA: Nilgiri Press.Ellison, C. G., & Anderson, K. L. (2001). Religious involvement and domestic violence among

U.S. Couples. Journal for the Scientific Study of Religion, 40(2), 269-286.Ellison, C. G., & Levin, J. S. (1998). The religion-health connection: Evidence, theory, and


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future directions. Health Education and Behavior, 25(6), 700-720.Flinders, R., Cohn, D., Ruppenthal, B., Martindale, C. J., Freeman, E. M., Cole, V. J., & Flahive,

M. (1991). Reduction of risky sexual behavior in gay and bisexual men (abstract presented at the seventh International AIDS Conference, June 17, 1990, Florence, Italy). In T. Flinders, M. Gershwin & R. Flinders (Eds.), The RISE response: Illness, wellness, and spirituality (pp. 213-214, 218). New York: Crossroad (1994).

Frank, J. (1975). The faith that heals. Johns Hopkins Medical Journal, 137(3), 127-131.Friedman, M., Thoresen, C. E., Gill, J. J., Ulmer, D., Powell, L. H., Price, V. A., Brown, B.,

Thompson, L. T., Rabin, D. D., Breall, W. S., Bourg, E., Levy, R., & Dixon, T. (1986). Alteration of Type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: Summary results of the recurrent coronary prevention project. American Heart Journal, 112(4), 653-665.

Friedman, M., & Ulmer, D. (1984). Treating Type A behavior - and your heart. New York: Knopf.

Gorsuch, R. L. (1995). Religious aspects of substance abuse and recovery. Journal of Social Issues, 51(2), 65-83.

Hausherr, I. (1978). The name of Jesus. Kalamazoo, MI: Cistercian Publications.Hill, P.C. (1994). Toward an attitude process model of religious experience. Journal for the

Scientific Study of Religion 33 (4), 303-314.House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health. Science,

241(4865), 540-545.Hummer, R. A., Rogers, R. G., Nam, C. B., & Ellison, C. G. (1999). Religious involvement and

U.S. Adult mortality. Demography, 36(2), 273-285.Idler, E. L. (1995). Religion, health, and nonphysical senses of self. Social Forces, 74(2), 683-

704.Idler, E. L., & Kasl, S. V. (1997). Religion among disabled and nondisabled persons II:

Attendance at religious services as a predictor of the course of disability. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 52(6), S306-S316.

Kabat-Zinn, J. (1993). Mindfulness meditation: Health benefits of an ancient Buddhist practice. In D. Goleman & J. Gurin (Eds.), Mind / body medicine: How to use your mind for better health (pp. 259-275). Yonkers, NY: Consumer Reports Books.

Kark, J. D., Shemi, G., Friedlander, Y., Martin, O., Manor, O., & Blondheim, S. H. (1996). Does religious observance promote health? Mortality in secular vs religious Kibbutzim in Israel. Am J Public Health, 86(3), 341-346.

Kember, P. (1985). The Transcendental Meditation technique and postgraduate academic performance. British Journal of Educational Psychology, 55(2), 164-166.

Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion and health. New York: Oxford University Press.

Levin, S. (1977). The Transcendental Meditation technique in secondary education. Unpublished PhD in Education, University of California, Berkeley.

McCullough, M. E., Hoyt, W. T., Larson, D. B., Koenig, H. G., & Thoresen, C. (2000). Religious involvement and mortality: A meta-analytic review. Health Psychology, 19(3), 211-222.

Miller, W., & Thoresen, C. E. (in press). Spirituality and health: An emerging research field [special issue from the NIH/OBSSR panel on spirituality, religion and health: State of the


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scientific evidence]. American Psychologist.Miller, W. R. (1998). Researching the spiritual dimensions of alcohol and other drug problems.

Addiction, 93(7), 979-990.Murphy, M., & Donovan, S. (1988). The physical and psychological effects of meditation. San

Rafael, CA: Esalen Institute Study of Exceptional Functioning.Murphy, M., Donovan, S., & Taylor, E. (1999). The physical and psychological effects of

meditation : A review of contemporary research with a comprehensive bibliography 1931-1996 (2nd ed.). Sausalito, California: Institute of Noetic Sciences.

Myers, D. (2002). “Reclaiming the great khan for history”. SparksTribune, Fri. Mar. 8, 4A (full text: http://www.svn.net/dougoman/Nonviolent_Exemplars_in_Islam/myerspub.htm).

Oman, D., & Driskill, J.D. (in press). Holy name repetition as a spiritual exercise and therapeutic technique. Journal of Psychology and Christianity, in press, scheduled for Spr. 2003, 22 (1).

Oman, D., Hedberg, J., Downs, D., & Parsons, D. (2001). A nonsectarian spiritually-based program to enhance professional caregiving self-efficacy. (Paper presented at the conference of the American Public Health Association, Atlanta, Georgia, October 25, 2001).

Oman, D., Hedberg, J., Downs, D., & Parsons, D. (in press). A transcultural spiritually-based program to enhance caregiving self-efficacy: Findings of a pilot study. Complementary Health Practice Review.

Oman, D., Thoresen, C., & McMahon, K. (1999). Volunteerism and mortality among the community-dwelling elderly. Journal of Health Psychology, 4(3), 301-316.

Oman, D., & Thoresen, C.E. (2002). “Does religion cause health?”: Differing interpretations and diverse meanings. Journal of Health Psychology 7 (4), 365-380.

Oman, D., & Thoresen, C.E. (in press). Spiritual modeling : A key to spiritual and religious growth? The International Journal for the Psychology of Religion.

Pargament, K. I. (1997). The psychology of religion and coping : Theory, research, practice. New York: Guilford.

Richards, P. S., & Bergin, A. E. (1997). Religious and spiritual practices as therapeutic interventions (chapter 9), A spiritual strategy for counseling and psychotherapy (pp. 201-228). Washington, D.C.: American Psychological Association.

Shams, M., & Jackson, P. R. (1993). Religiosity as a predictor of well-being and moderator of the psychological impact of unemployment. British Journal of Medical Psychology, 66(4), 341-352.

Shapiro, D. H., & Walsh, R. N. (1984). Meditation, classic and contemporary perspectives. New York: Aldine Pub. Co.

Spiegel, D., Bloom, J. R., Kraemer, H. C., & Gottheil, E. (1989). Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet, 2(8668), 888-891.

Strawbridge, W. J., Shema, S. J., Cohen, R. D., & Kaplan, G. A. (2001). Religious attendance increases survival by improving and maintaining good health practices, mental health, and stable marriages. Annals of Behavioral Medicine, 23(1), 68-74.

Wallace, J. M., Jr., & Forman, T. A. (1998). Religion's role in promoting health and reducing risk among American youth. Health Education and Behavior, 25(6), 721-741.

Winzelberg, A. J., & Luskin, F. M. (1999). The effect of a meditation program on the level of stress in secondary school student teachers. Stress Medicine, 15(2), 69-77.


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§8 Adapting EPP to Specific Spiritual / Religious Groups

The Eight Point Program (EPP) has been found useful by persons of all major religious and spiritual traditions, as well as by persons of no tradition at all. Persons who practice within a specific faith tradition may want to choose a mantram / prayer word from their own tradition. They also may wish to give special attention to meditation passages from their own tradition, although practice of the EPP does not require that they meditate only upon passages from their own tradition (if comfortable, practitioners are encouraged to choose passages from a variety of traditions).

Atheists and agnostics are likely to prefer an impersonal, non-theistic mantram, such as certain mantrams from the Buddhist tradition (e.g., Om mane padmé hum). The Buddhist tradition is also rich in meditation passages that have been found acceptable by atheists and agnostics (page references refer to God Makes the Rivers to Flow; see also section 9, below):

Twin Verses (page 43, from the Dhammapada)

Our life is shaped by our mind; we become what we think. Suffering follows an evil thought as the wheels of a cart follow the oxen that draw it.

Our life is shaped by our mind; we become what we think. Joy follows a pure thought like a shadow that never leaves.

“He was angry with me, he attacked me, he defeated me, he robbed me” — those who dwell on such thoughts will never be free from hatred.

“He was angry with me, he attacked me, he defeated me, he robbed me” — those who do not dwell on such thoughts will surely become free from hatred.

For hatred can never put an end to hatred; love alone can. This is an unalterable law...

Discourse on Good Will (page 60; from the Sutta Nipata)(excerpted in section 4, above)

Atheists and agnostics may also find inspiration in Taoist passages:

The Best (page 132, from the Tao Te Ching)

The best, like water,Benefit all and do not compete...In their dwelling, they love the earth;In their heart, they love what is deep;In personal relationships, they love kindness;In their words, they love truth,In the world, they love peace...

(Passages reprinted with permission from God Makes the Rivers to Flow, Nilgiri Press, 1991)


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§9 Support Systems for using the EPP

General Support

Books, videotapes, audiotapes, audiobooks, a newsletter, and weekend workshops (in various cities in the United States and Canada): Blue Mountain Center of Meditation / Nilgiri Press, (800) 475-2369,

http://www.nilgiri.org

In addition to offering a wide collection of supporting materials, this website offers free online access to electronic versions of two basic texts:

Meditation (Easwaran, 1991b/1978), which presents each of the eight points;

God Makes the Rivers to Flow (Easwaran, 1991a), a collection of over 100 meditation passages from all the world’s great religious and spiritual wisdom traditions.

Further supporting materials for the EPP, mostly published by Nilgiri Press, aim to show how to use the tools of the EPP to solve problems in daily living, and to provide inspiration for persisting in using the tools. Commentaries are available upon selected passages from sacred scriptures and from great spiritual and religious figures. Some supportive materials are listed in a bibliography (below), and include

commentaries on scriptures and saints from Christianity (Classics of Christian Inspiration 1996a), Hinduism and Buddhism (Classics of Indian Spirituality, 1989);

a commentary on EPP tools that avoids theistic language (Conquest of Mind, 1988); and

spiritual biographies of two recent spiritually oriented sociopolitical leaders who dedicated their lives to the public good (Gandhi the Man, 1978; Nonviolent Soldier of Islam, 1999).

Other publications

focus on the use of the mantram / prayer word (Mantram Handbook, 1998),

offer daily readings (Words to Live By, 1996c),

describe applications of the EPP for

slowing down the harried pace of modern life (Take Your Time, 1994) and

dealing with end of life issues (The Undiscovered Country, 1996b),

and include an adaptation of the EPP for

managing chronic diseases (The RISE Response, Flinders, Gershwin, & Flinders, 1994).


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Groups regularly meet for spiritual fellowship based upon the EPP in many locations in the United States, Canada, and several other countries (for more information, contact the Blue Mountain Center of Meditation, website above).

Health Professionals

For information about resources for medical and other health care applications, published research, ongoing research projects, and informal networks of professionals, contact Doug Oman, PhD, (707) 878-2573,

[email protected]

or either of the other presenters of this workshop.

Bibliography

Easwaran, E. (1978). Gandhi the man (2nd ed.). Tomales, CA: Nilgiri Press.Easwaran, E. (1988). Conquest of mind. Tomales, CA: Nilgiri Press.Easwaran, E. (1989). Classics of Indian spirituality [3 volumes translation/commentary:

Bhagavad Gita, Dhammapada, Upanishads]. Tomales, CA: Nilgiri.Easwaran, E. (1991a). God makes the rivers to flow: Selections from the sacred literature of

the world / chosen for daily meditation. Tomales, California: Nilgiri Press.Easwaran, E. (1991b/1978). Meditation: A simple eight-point program for translating

spiritual ideals into daily life (2nd ed.). Tomales, CA: Nilgiri Press.Easwaran, E. (1994). Take your time: Finding balance in a hurried world. Tomales, CA:

Nilgiri Press.Easwaran, E. (1996a). Classics of Christian inspiration [3 volumes: Love never faileth, seeing

with the eyes of love, original goodness]. Tomales, CA: Nilgiri.Easwaran, E. (1996b). The undiscovered country. Tomales, CA: Nilgiri Press.Easwaran, E. (1996c). Words to live by : Inspiration for every day (2nd ed.). Tomales, CA:

Nilgiri.Easwaran, E. (1998). Mantram handbook (4th ed.). Tomales, CA: Nilgiri Press.Easwaran, E. (1999). Nonviolent soldier of Islam (2nd ed.). Tomales, CA: Nilgiri Press.Flinders, T., Gershwin, M., & Flinders, R. (1994). The RISE response: Illness, wellness, and

spirituality. New York: Crossroads.


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§10 Applying the EPP to Healthcare Practice

Health professionals may find that the Eight Point Program (Easwaran, 1991b) can benefit healthcare practice in a number of different ways. Very broadly, the ways that the Eight Point Program (EPP) can help may be divided into:

helping patients through helping the professional

helping patients directly.

We discuss each of these applications in turn.

Helping Patients by Helping the ProfessionalThe EPP can help health professionals in at least two ways that do not directly involve

patients: by (i) facilitating stress management and work effectiveness, and by (ii) helping the professional to acquire an integrated and intuitive understanding of a variety of spiritual and religious traditions — to acquire a sort of “spiritual multilingualism”.

Stress Management and Work Effectiveness

Healthcare professionals who directly interact with patients face many challenges as professional caregivers (Oman, Hedberg, Downs, & Parsons, 2001, in press). Tasks facing professional caregivers may include:

managing relationships with patients and their families

managing relationships with coworkers and supervisors

managing boundaries between work and other parts of life.

The importance and difficulty of these caregiving tasks is reflected in ongoing studies of stress management techniques in medical education (Shapiro, Shapiro, & Schwartz, 2000). Like other meditation programs studied as stress management techniques, the EPP may be used by health professionals, and shared with colleagues and students, as a stress management technique.

Also like other methods of meditation, the EPP may enhance health professional effectiveness by fostering the training of attention. According to Goleman (1988), systems of meditation worldwide may be understood as “in essence, the effort to retrain attention” (p. 169), and that concentrated attention “amplifies the effectiveness of any kind of activity” (p. 168). A century ago, William James wrote that “the faculty of voluntarily bringing back a wandering attention over and over again is the very root of judgment, character and will....An education which should include this faculty would be the education par excellence” (James, 1992, pp. 219-220, italics in original). The primacy of attention is supported by recent work that reports attentional processes are “dynamically and reciprocally related” to coping processes (Matthews & Wells, 1996, p. 574), and “determine what is selectively observed in the profusion of modeling influences” (Bandura, 1994, pp. 67-68). Some recent authors argue for a recognition


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of meditation as an aid to general education (Kember, 1985; Levin, 1977). Consistent with these views, recent work has linked EPP training to enhanced caregiving abilities among physicians, nurses, psychologists, and other healthcare professionals (Oman et al., 2001, in press).1

Practical Spiritual “Multilingualism”

Other applications of the EPP are suggested by its comprehensiveness (e.g., eight points), and by its systematic inclusion of cognitive material from spiritual wisdom traditions (e.g., meditation passages). According to Barnard and colleagues (1995), writing in Academic Medicine,

“An important task of care for the physician is to elicit patients’ explanatory frameworks, and to seek accommodations where necessary (and where possible) between medical and nonmedical interpretations....The social support and the content of prayer, ritual, and other manifestations of spirituality are significant dimensions in the dynamics of faith and healing. The ability to recognize and mobilize these resources on a patient’s behalf is thus an important part of the physician’s healing role” (p. 807).

Such considerations underlie the development of brief counseling interventions that can be used by physicians to support spiritual and religious coping (Kristeller & Cripe, 2000; Rhodes & Kristeller, 2000), as well as increasing recommendations for taking spiritual histories and other spiritual assessments (Anandarajah & Hight, 2001; Koenig, 2000; Maugans, 1996; Puchalski & Romer, 2000).

Experience suggests that using the EPP can greatly assist health professionals in recognizing the practical dynamics and common elements of spiritual practices from a wide range of religious traditions. Also, to a much greater extent than some mindfulness-based stress management techniques, the EPP directly fosters a familiarity with Christian and other theistic forms of devotion that are common in the United States (e.g. see Easwaran, 1991a). The program’s eight points capture, in a tightly integrated manner, a wide range of practices that are widespread or universal among major religious traditions (Walsh, 1999). And since academic instruction can seldom substitute for practical experience in any domain of life, we suspect the same is true of spiritual disciplines: Experience of the actual practice of spiritual disciplines (however labeled) seems likely to produce a greater intuitive understanding and empathy for patient spirituality and religiosity than could be obtained by purely theoretical instruction. Consistent with this view, some persons have reported that practice of the EPP helped them better understand and appreciate the religious traditions in which they were raised, whether or not they rejoined those traditions (Flinders, Gershwin, & Flinders, 1994).

Helping Patients DirectlySome health professionals report successfully sharing the EPP with patients (Oman,

2000; below, section 11). While the universality of the EPP practices suggests that many patients might find something useful in the EPP, we urge health professionals to exercise very


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careful circumspection about sharing the EPP with patients. Careful attention to professional boundaries must be observed because of power imbalances and other problematic features of relationships between health professionals and their patients or clients (Astrow, Puchalski, & Sulmasy, 2001; Post, Puchalski, & Larson, 2000; Richards & Bergin, 1997). Respect for the integrity of the client’s or patient’s personal experience must be maintained at all times. In many circumstances, referrals to pastors or other religious professionals may be appropriate.

Depending upon the nature of their work, some professionals may never encounter any situation in which they could appropriately share even one of the eight points with a patient. For example, health professionals working with extremely vulnerable populations, such as highly disabled accident victims, will almost always do best by using the EPP to help patients only indirectly, i.e., by using the EPP to help themselves (e.g., by managing stress or becoming more spiritually multilingual), as described in the previous section.

Nevertheless, tremendous variability exists in the work situations of different health professionals, and in the types of relationships that they naturally and appropriately develop with clients. And in as much as the EPP can be validly conceptualized as a toolkit consisting of several interrelated techniques for managing stress and gaining control over the mind, sharing elements of the EPP may to some extent be governed by the same principles that govern the sharing of any other technique in a clinical setting. For example, a professional should maintain (i) an ongoing awareness of alternative techniques that may be more appropriate for accomplishing particular objectives, as well as (ii) the knowledge and emotional detachment necessary to select the most appropriate technique.

Among the EPP techniques, the most easily shared tool in many situations is Point 2, the repetition of the mantram/prayer word (Easwaran, 1998). To use this technique, a patient or client must select a word or short phrase from a congenial wisdom tradition. Many clinicians and other health professionals have become accustomed to recommeding such a choice in the context of the well-known form of meditation popularized by Herbert Benson, often known as the "Relaxation Response", in which a person meditates upon a single word or short phrase. Initially Benson (1975) recommended meditating upon the word “one”, but later (1993) urged people to use a word or phrase adopted from their own spiritual traditions. Appropriately and ethically offering Point 2 of the EPP (the mantram/prayer word) demands many of the same skills in relating to patients and clients as are demanded by offering the recent version of Benson's form of meditation.

In an appropriate institutional context – perhaps most obviously in a faith-based healthcare organization – additional applications of the EPP may be appropriate. For example, in wellness-oriented health promotion settings, where staff professionals increasingly assist clients in formulating and pursuing personalized health/fitness goals, the EPP and supporting materials may offer a particularly rich and flexible approach to smoothly combining broader efficacy goals, or even spiritual goals, with a health focus. For example, a client might draw upon EPP ideas and writings about Point 5 (training the senses) in order to (i) formulate a specific goal for improving a health behavior such as diet, (ii) identify a set of strategies for success that draw in part from the full EPP attentional retraining toolkit, and (iii) receive onsite social support for implementing that strategy (e.g., Point 7). Similar steps might be applied to wellness goals related to exercising, managing stress, or enhancing personal concentration or caregiving skills.


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There is a great diversity of circumstances in which health professionals work — ranging from emergency rooms and intensive care units to long term psychotherapy. Therefore, we shall not in this brief section attempt any further generalizations about appropriate occasions for sharing elements of the EPP with patients or clients. Such questions are optimally addressed with due consideration to individual and situational factors, and in light of the knowledge, skills and attitudes developed by a systematic training about spiritual issues that is tailored to a specific health profession (Dombeck, 1998; Puchalski & Larson, 1998; Puchalski, Larson, & Lu, 2000; Sierpina & Boisaubin, 2001).

Notes1. In these studies, caregiving ability was measured as “self-efficacy”, which is a widely studied

construct in the social sciences, and may be defined as a person’s confidence that they are able to perform a certain kind of action. Self-efficacy is typically among the strongest predictors of objective performance for any type of activity, and is increasingly used to evaluate programs for education, training, and behavioral modification (Bandura, 1997).

References

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Astrow, A. B., Puchalski, C. M., & Sulmasy, D. P. (2001). Religion, spirituality, and health care: Social, ethical, and practical considerations. American Journal of Medicine, 110(4), 283-287.

Bandura, A. (1994). Social cognitive theory of mass communication, Media effects: Advances in theory and research. (pp. 61-90). Hillsdale, NJ, USA: Lawrence Erlbaum Associates, Inc.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: W. H. Freeman.Barnard, D., Dayringer, R., & Cassel, C. K. (1995). Toward a person-centered medicine:

Religious studies in the medical curriculum. Academic Medicine, 70(9), 806-813.Benson, H. (1975). The relaxation response. New York: William Morrow.Benson, H. (1993). The relaxation response. In D. Goleman & J. Gurin (Eds.), Mind / body

medicine: How to use your mind for better health (pp. 233-257). Yonkers, NY: Consumer Reports Books.

Dombeck, M. T. (1998). The spiritual and pastoral dimensions of care in interprofessional contexts. Journal of Interprofessional Care, 12(4), 361-372.

Easwaran, E. (1991a). God makes the rivers to flow: Selections from the sacred literature of the world / chosen for daily meditation. Tomales, California: Nilgiri Press.

Easwaran, E. (1991b/1978). Meditation: A simple eight-point program for translating spiritual ideals into daily life (2nd ed.). Tomales, CA: Nilgiri Press.

Easwaran, E. (1998). Mantram handbook (4th ed.). Tomales, CA: Nilgiri Press.Flinders, T., Gershwin, M., & Flinders, R. (1994). The RISE response: Illness, wellness, and

spirituality. New York: Crossroads.Goleman, D. (1988). The meditative mind : The varieties of meditative experience (1st ed.). Los

Angeles / New York: J.P. Tarcher Inc. / Distributed by St. Martin's Press.James, W. (1992). Psychology: Briefer course (chapter xiii, attention). In G. F. Myers (Ed.),

Writings, 1878-1899 / William James (Vol. 58, pp. 210-228). New York: Literary Classics of the United States.


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Kember, P. (1985). The transcendental meditation technique and postgraduate academic performance. British Journal of Educational Psychology, 55(2), 164-166.

Koenig, H. G. (2000). Religion, spirituality, and medicine : Application to clinical practice. Journal of the American Medical Association, 284(13), 1708.

Kristeller, J. L., & Cripe, L. (2000). Brief patient-centered spirituality counseling.Unpublished manuscript, Dallas, TX.

Levin, S. (1977). The transcendental meditation technique in secondary education. Unpublished PhD in Education, U California, Berkeley.

Matthews, G., & Wells, A. (1996). Attentional processes, dysfunctional coping, and clinical intervention. In N. S. E. Moshe Zeidner (Ed.), Handbook of coping: Theory, research, applications. (pp. 573-601): John Wiley & Sons, New York, NY, US.

Maugans, T. A. (1996). The SPIRITual history. Archives of Family Medicine, 5(1), 11-16.Oman, D. (2000). A comprehensive non-sectarian program to promote spirituality and health.

(poster presented at Conference on Spirituality in Health Care: Issues of Culture and End of Life in Medical Education, Dallas, TX: September 16, 2000).

Oman, D., Hedberg, J., Downs, D., & Parsons, D. (2001). A nonsectarian spiritually-based program to enhance professional caregiving self-efficacy. (Paper presented at the conference of the American Public Health Association, Atlanta, Georgia, October 25, 2001).

Oman, D., Hedberg, J., Downs, D., & Parsons, D. (in press). A transcultural spiritually-based program to enhance caregiving self-efficacy: Findings of a pilot study. Complementary Health Practice Review.

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Puchalski, C., & Romer, A. L. (2000). Taking a spiritual history allows clinicians to understand patients more fully. Journal of Palliative Medicine, 3(1), 129-137.

Puchalski, C. M., & Larson, D. B. (1998). Developing curricula in spirituality and medicine. Academic Medicine, 73(9), 970-974.

Puchalski, C. M., Larson, D. B., & Lu, F. G. (2000). Spirituality courses in psychiatry residency programs. Psychiatric Annals, 30(8), 543-548.

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Richards, P. S., & Bergin, A. E. (1997). Ethical issues and guidelines (chapter 7), A spiritual strategy for counseling and psychotherapy (pp. 143-169). Washington, D.C.: American Psychological Association.

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§11 Examples of Potential EPP Course UsesHere are some examples of how the EPP has been used in various kinds of courses in various

kinds of institutions. Applications that involve teaching “about” the EPP require little or no prior instructor experience or training in the EPP. Examples include using the EPP as:

Discussion MaterialEPP supporting materials that comment on the wisdom traditions can be used to generate class discussions. Students are often easily engaged by the practical focus of the EPP writings. The nonsectarian universality of the EPP’s approach can help minimize controversy and misunderstandings about sectarian issues, allowing discussions to stay focused on spiritual issues of common interest. Jeanne Kristeller of Indiana University has successfully used an EPP-attuned collection of daily readings (Easwaran, 1996, Words to Live By) as an adjunctive text for a psychology of meditation course, reporting that students from a wide range of religious backgrounds, including more fundamentalist backgrounds, were positively engaged by the readings.

Supplemental Reading in Clinical Supervision SeminarsEPP materials have been recommended as supplemental reading to students receiving clinical supervision. For example, Carl Thoresen of Stanford University has recommended Meditation (Easwaran, 1991/1978) to psychology doctoral students in first year clinical supervision. The book was presented as potentially useful for assisting clients by helping students to (i) improve their own performance, e.g., avoid rushing, as well as (ii) better understand resources available to clients through their religious traditions. Many but not all students found the book beneficial.

Teaching “how” to practice the EPP requires instructors with sustained experience in using the EPP tools themselves. Prospective instructors will also benefit from associating with persons with relevant experience (e.g., experienced EPP teachers and other health professionals who have used EPP tools). Examples of courses that involve teaching how to practice the EPP:

Healthcare Organization InserviceAn eight week course on the EPP for medical professionals was sponsored by the Denver Veterans Administration Hospital, and attended by physicians, nurses, and psychologists. Participants reported large and statistically significant increases in self-perceived effectiveness in caregiving abilities (for more information contact Dr. Hedberg: [email protected]).

Health Education / Stress Management for the General PublicAn eight week university-sponsored course in health education and stress management was offered to the general public. Meeting for two hours each week, participants were offered a supportive environment in which to learn the EPP and adopt its tools according to their individual needs. Many class participants reported developing inner strength, discovering meaning in their lives, and finding ways out of suffering (course sponsored by both Oregon Health Sciences University and the Blue Mountain Center of Meditation; for more information contact Dr. Bowden: [email protected]).

We have found the Blue Mountain Center of Meditation highly useful as a source of EPP training and related supporting materials (see section 9).


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§12 Appreciations of the EPP

“I consider the Eight Point Program the most thorough and comprehensive perspective I've yet encountered with regard to spirituality and health. I have taught variations of this eight point program for the past 10 years at Stanford and cited this program as an example of a comprehensive program to promote spiritual health and well-being in several articles and chapters.”

– Carl E. Thoresen, PhD,Professor of Education, Psychology, and Psychiatry, Stanford UniversityPrincipal Investigator, Stanford Forgiveness Project (clinical trial) and of

Spiritual Experiences in Depressed/Socially Isolated Coronary Patients (Ancillary Study of ENRICHD clinical trial, NHLBI)

Member, OBSSR/NIH Panel on Spirituality, Religion and Health: State of the Science (1999–)

“I work with a broad spectrum of women aged seventeen to over seventy, and many of them have stress-related problems. I talk with them about prioritizing and taking time for themselves, and often we discuss if they've ever considered meditation. In many cases, I write down on a prescription pad the names of two of Easwaran’s books on the Eight Point Program, Meditation and Take Your Time.”

– Jessica Byron, MD, Practicing Obstetrician/Gynecologist for 20 yearsCoordinator for Women's Health, University of Arizona

“Easwaran showed me the great value of learning a sacred text by heart and repeating it slowly in the mind, word by word, sentence by sentence. In this way, listening to the voice of love becomes not just a passive waiting, but an active attentiveness to the voice that speaks to us through the words of the Scriptures.”

– Henri Nouwen,Prominent Roman Catholic theologian (1932-1996)

___________________________________________________________________________________________________________________Henri Nouwen’s quote is from his book, Life of the beloved: Spiritual living in a secular world. New York: Crossroad; 1992, page 64; quotes of Carl Thoresen and Jessica Byron are from Oman, D. (2000), A comprehensive non-sectarian program to promote spirituality and health (poster presented at Conference on Spirituality in Health Care: Issues of Culture and End of Life in Medical Education, Dallas, TX: Sep. 16, 2000)


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Documents

Handouts for 'A Randomized Controlled Trial of a … · Web viewA Randomized Controlled Trial of a Spiritual-Wisdom-Based Program To Enhance Caregiving Self-Efficacy and Reduce Stress