Screening for Spiritual Struggle - Professional Chaplains

Screening for Spiritual Struggle

Association of Professional Chaplains

September 23, 2009

Rev. James L. Risk III BCCGeorge Fitchett DMin PhD BCC


Rev. James L. Risk III [email protected] DirectorBishop Anderson House andAssistant ProfessorDepartment of Religion, Health, and Human ValuesRush University Medical Center, Chicago, IL

George Fitchett DMin PhD [email protected] Professor and Director of Research, Department of Religion, Health, and Human ValuesRush University Medical Center, Chicago, IL

Workshop Outline

Challenges for ChaplainsVignettes about Spiritual StruggleResearch about Spiritual StruggleYour Questions about the ResearchSpiritual Struggle Screening ProtocolYour Questions about Screening for Spiritual Struggle

3

In what type of institution do you work? (Please select one.)

teaching hospital

community hospital

specialty hospital (e.g. peds, oncology, rehab, behavioral med)

hospice

long term care

other

(Only one answer allowed)(Only one answer allowed)

4

Where is your workplace located? (Please select one.)

East

South

Midwest

West


5

How many people are participating in this Webinar at your center? (Please select one.)

1-2 people

3-4 people

5 or more people


6

Challenges for Chaplains

• 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?

7

• Spiritual Struggle is recognizable as loss of meaning and purpose, despair, anger at God, grief or loss, hopelessness, feeling punished or abandoned by God, guilt or reconciliation…

8

• “My sister died six months ago. Why did God take her and leave me? I’m just taking up space (tearfully). I have done everything I’m supposed to, but this disease…” 76-year-old patient with Parkinson’s disease

9

• “Why has God done this? I’ve been a good person…What did I do to deserve so much suffering?.. (sobbing) Oh, I’m so confused. I’m angry at God. Why did I have to lose my leg? And thankful, too. I’m alive. Oh, (muffled sobs) I don’t know.”

42-year-old mother with bone cancer

10

• “I have asked ‘Why me’ many times in the past year. Why is God doing this?..I know He doesn’t give us more than we can handle…If you just fix the problem with my incontinence, I’ll take all the pain that recovery dishes out.”40-year-old cancer patient after six-month hospitalization.

11

Anger with God and Rehabilitation Recovery

9.2 8.9

10.7

14.5

0123456789

1011121314151617

Anger (n=6) No anger (n=89)

Som

atic

Aut

onom

y (A

DL)

AdmissionFollow-up

Fitchett et al, 1999. 12

Negative Religious Coping (Brief RCOPE) not

at all some-

what quite

a bit a

great deal

8. I wondered whether God had

abandoned me. 0 1 2 3

9. I felt punished by God for my

lack of devotion. 0 1 2 3

10. I wondered what I did for God to

punish me. 0 1 2 3

11. I questioned God’s love for me. 0 1 2 3 12. I wondered whether my church

had abandoned me. 0 1 2 3

13. I decided the devil made this

happen. 0 1 2 3

14. I questioned the power of God. 0 1 2 3

Pargament et al, 199813

Perceptions of Spiritual Struggle in Your Patients1. Among the patients you visited in the past two weeks, in what proportion did you observe spiritual struggle? (Please select one.)

None

Between 1% and 9%

Between 10% and 24%

Between 25% and 49%

50% or more

Not applicable (didn't visit patients)


14

2. Among patients you visited in the past two weeks who expressed spiritual struggle, was it:(Please select one.)

Spiritual struggle related to their illness/hospitalization.

Spiritual struggle that pre-dated this illness and/or hospitalization

Both

Neither


15

3. Ken Pargament describes three types of spiritual struggle. If you heard patients express spiritual struggle in the past two weeks, which of these types did your patients express? (Please check all that apply.)

Struggle with the Divine. (e.g. feeling abandoned by God, punished by God, angry with God)

Spiritual struggle with other people (e.g. conflict with people with religious/spiritual authority, betrayal by people with religious authority)Intrapersonal spiritual stuggle (e.g. religious doubts, guilt)

(Multiple answers allowed)(Multiple answers allowed)

16

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

Negative Religious Coping

Depressed Mood

Quality of Life

Self-Rated Health

Punishing reappraisal

Demonic reappraisal

Reappraisal of God's Power

Passive religious deferral

Self-directed religious coping

Spiritual discontent

Interpersonal religious discontent

Pleading for direct intercession

.25***

.17***

.15***

.09*

.22***

.22***

.27***

.10*

-.17***

-.10**

-.16***

-.06

-.19***

-.18***

-.21***

-.04

-.12**

-.12**

-.12**

-.14**

Values are standardized betas from regression models that included demographic variables, and for depressed mood and quality of life, severity of illness. *p<.05, **p<.01, ***p<.001 Koenig et al., 1998, Jnl of Nervous and Mental Disorders

17

Any Religious Struggle At

Group Baseline 2 Year

Follow-Up Number PercentOutcome at Follow-Up*

No Struggle No No 94 39% reference group

Transitory Struggle Yes No 40 17% ns

Acute Struggle No Yes 44 18% ns

Chronic Struggle Yes Yes 61 26%

> depression > functional limitations < quality of life

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 18

Religious Struggle as a Predictor of Mortality (n=567)

Model 1. Positive religious coping, religious struggle, demographic factors, physical health, mental health

Adjusted RR = 1.06 95% CI = 1.01 - 1.11

Model 2. Model 1, plus frequency of church attendance

Adjusted RR = 1.05 95% CI = 1.00 - 1.10

Pargament et al., 2001, Arch Intern Med 19

Religious Struggle among Stem Cell Transplant Patients

*Models adjusted for baseline value of outcomeN=94 myeloma patients who received autologous stem cell transplantAverage time between pre and post-transplant was 3.4 months (SD 2.9).Sherman et al, J Behav Med, 2009

Post-Transplant Outcome Predictors* β

Anxiety Neg Relig Cope .21*

Depression Neg Relig Cope .26*

Emotional WB Neg Relig Cope -.22*

20

Increases in Religious Struggle and Post-Transplant Outcomes

aRegression coefficient for patients with increased negative religious coping (21%) compared with those whose negative religious coping decreased (23%) or was stable (56%). Models adjusted for baseline values of outcome. N=94 myeloma patients who received autologous stem cell transplantSherman et al, J Behav Med, 2009

Outcome βaAdj R2 for

Model

Depression .21* .31

Functional WB -.23** .29

Emotional WB -.20* .20

Physical WB -.29* .12

21

Religious Struggle and Emotional Distress

Diabetic Outpatients

CHF Outpatients

Oncology Inpatients

psychological distress (PAID) .31*depressed mood (CMDI) .35**emotional symptoms (LHFQ) .30*depression (POMS) .42*** .22*anxiety (POMS) .32* .16hostility (POMS) .29* .16emotional well-being (FACT-G) -.23**p<.05, **p<.01, ***p<.001Values are partial correlations, adjusted for age and gender.

From Fitchett et al, 2004

22

Prevalence of Religious Struggle

None 7 items scored "not at all" 123 52%

Low

1 item scored "quite a bit" or "a great deal," or 1 or more items scored "somewhat" 80 34%

Moderate2 items scored "quite a bit" or "a great deal" 17 7%

High3 or more items scored "quite a bit" or "a great deal" 18 8%

From Fitchett et al, 2004

23

Religious Struggle and Depression

neg cope recode 3 gps3+1-20

Mea

n of

Dep

ress

ion-

Dej

ectio

n (P

OM

S)

7

6

5

4

3

Religious Struggle recoded into 3 groups

None (56%)

1-2 points (11%)

3+ points (33%)N=100 oncology in-patients 24

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.

25

Summary

Religious/spiritual struggle compromises emotional adjustment to illness and quality of lifemay compromise recovery may increase risk of mortality

26

Discussion

27

Three Levels of Clinical Inquiry About Religion/Spirituality

• screening for religious struggle• religious/spiritual history taking• spiritual assessment

Massey, Fitchett, and Roberts, 2004

28

Screening for R/S Struggle

Screening for R/S struggle is an attempt to identify patients who may be experiencing R/S struggle.

Screening for R/S struggle employs a few simple questions that can be asked by health care colleagues.

29

Others Chaplain Models for Screening• Older Models

• Stoddard, 1993• Derrickson, 1994-1995• Berg, 1994, 1999• Hodges, 1999• Wakefield & Cox• Fitchett Review, Chaplaincy Today, 1999

• Newer Models• Grossoehme, 2008• Ledbetter, 2008

30

Spiritual Distress: NANDADefinition

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 tiesChallenged belief and value system (e.g., result of moral or ethical

implications of therapy or result of intense suffering)

Defining characteristicsExpresses concern with meaning of life and death and/or belief systemAnger toward God (as defined by the person)Questions meaning of sufferingVerbalizes inner conflict about beliefsUnable to choose or chooses not to participate in usual religious practicesRegards illness as punishmentDoes not experience that God is forgiving

31

Religious Struggle and DSM-IVAdditional Conditions that May Be a Focus of Clinical

AttentionV62.89 – Religious or Spiritual Problem

“This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution” (emphasis added).

32

Screening Protocol

33

Results from Spiritual Struggle Screening Protocol

Study Phase

Screening Administered

By

Number (%) of New

Admissions Screened

Cases of Spiritual Struggle Identified

by Screening

Cases of Spiritual Struggle

Confirmed by Chaplain Assessment

Request Chaplain

VisitRequest

Communion

Phase I (January-March) PCT 78/159 (49%) 4/78 (5%) 4/4 (100%) 51/78 (65%) 22/78 (28%)

Phase II (July & August)

Medical Resident 10/46 (22%) 0/10 (0%) N/A 2/10 (20%) 0

Phase III (September-December)

Psychology Intern 85/108 (79%) 8/85(9%) 7/8 (88%) 52/85 (61%) 8/85 (9%)

Other Spiritual Care Requests

Table 1. Results from Spiritual Struggle Screening Protocol

Fitchett and Risk, Journal of Pastoral Care and Counseling, 2009 34

Patient/Family Satisfaction Scores Before and During Pilot Study

87%79%

93%93% 96%91%

0%

25%

50%

75%

100%

Staff addressedemotional needs

Staff addressedspiritual needs*

Chaplain (satisfactionwith)

Survey Items

Perc

ent o

f Sur

vey

Res

pons

es

'Goo

d' o

r 'Ve

ry G

ood'

Before Pilot Study (Jan 2004-Dec 2005)During and After Pilot Study (Jan 2006-Jan 2007)

*Difference in Before vs During responses is marginally significant (2-sided Fisher’s Exact Test, p=0.06).Fitchett and Risk, Journal of Pastoral Care and Counseling, forthcoming

35

Compare Rush Screening Protocol and Social Work Assessment

N=100 HSCT patientsWith appreciation to Chaplain Stephen King, Seattle Cancer Care Alliance.Watch for his workshop on this project at 2010 APC annual meeting.

Social Work Assessment

Interest in Chaplain Visit

Religious Struggle Yes No Total

Religious Struggle 2 (8%)a 8 (31%) 16 (62%) 26 (26%)

Yes 0 (0%) 27 (100%) 0 (0%) 27 (27%) Rush Screening Protocol

Interest in Chaplain Visit No 0 (0%) 2 (4%) 45 (96%) 47 (47%)

Total 2 (2%) 37 (37%) 61 (61%) 100 aPercents in the body of the table are row percents. That is, the percent of each Rush Screening Protocol group in each social work assessment category.

36

Two-Tier Model for Spiritual Care

A two–tier process of screening and, if indicated, spiritual assessmentResponsible screening and intervention

37

38

The 7 x 7 Model for Spiritual Assessment

Published in 2002 Available from Academic Renewal Press, Lima, Ohiowww.arpress, 1-800-537-1030

Holistic Assessment Spiritual Assessment Medical Belief and Meaning Psychological Vocation and Obligations Family Systems Experience and Emotions PsychoSocial Courage and Growth Ethnic, Racial, or Cultural Ritual and Practice Social Issues Community Spiritual Authority and Guidance

39

Discipline for Pastoral Care Giving –Arthur Lucas, 2001

Profile• Concept of Holy• Meaning• Hope• Community

40

Pastoral Responses to Religious Struggle

Assesssource of struggleduration: new, transient, leading to growth, chronicavailable resources

Giving Voice, Being Heard muteness, lament, companionship

Finding Meaningcreating a new narrative, a new future storyIncluding pt’s positive coping strategies, increased awareness of effect on internal and external environment, and capacity forliving in tension with new reality posed by diagnosis, illness, and loss.

41

Conclusions• The screening protocol had a high level of

accuracy (specificity) for identifying patients in the midst of Spiritual Struggle.

• The screening protocol had a high level of effectiveness in identifying patients who were interested in receiving pastoral care.

• PCTs and Resident Physicians appeared not to be the appropriate staff to administer the protocol in this institution.

• Screening questions can be simplified to reduce protocol non-compliance.

• Screening Protocol subject to false negatives when patient has underdeveloped spirituality.

42

• This screening protocol was highly effective in directing limited pastoral care resources to patients who could most benefit from pastoral care during hospitalization.

43

Screening for Spiritual Struggle and Aims for Quality Improvement

Aim Screening ProtocolAim #2: Care is Effective A) The protocol is based on research(evidence based) indicating the harmful effects of spiritual

struggle. B) A pilot study has tested the effectiveness of the protocol.

Aim #3: Care is Patient-Centered Use of the protocol increases the likelihood that patient's preferences for spiritual care servicesare respected.

Aim #4: Care is Timely The protocol reduces the time betweenadmission and referral for spiritual careor assessment.

Aim #5: Care is Efficient The protocol makes efficient use of nonchaplain healthcare staff to reducethe time chaplains spend in case finding

Aims for quality improvement from the Institute of Medicine 2001 report, Crossing the Quality Chasm. The protocol does not explicitly address Aim #1: Care is Safe, or Aim #6: Care is Equitable.A summary of the report is available at http://iom.edu/CMS/8089/5432/27184.aspx.

44

Describe screening at your center. 1. Does your workplace have any process for screening and referrals to chaplains?

(Please select one.)

No

Yes


45

2. If yes, who does the screening? (Please select one.)

46

RN

Social Worker

Other staff

Volunteer

Patient self-assessment

(Multiple answers allowed)(Multiple answers allowed)

3. If yes, what is the process for screening and referral? (Please select one.)

Automatic referral from data entered in computer.

Staff records data (paper or electronic) and notify chaplain (electronic or phone).

Staff records data (paper or electronic) and chaplain checks records on units.


47

Discussion 2

– Questions about the Screening Protocol

48

Implications for Health Professionals

Clinicians should be alert to indicators of religious struggle, and inquire about it in their initial assessments.

“Is religion or faith important to you?”

If no, “Has that always been the case?”

Where patients’ responses indicate possible religious struggle, consider referral to a chaplain.

49

Further Research on Spiritual Struggle

Descriptive• Conceptualization and measurement• Screening• Prevalence in specific populations• Correlates• Trajectory Spiritual Care• Intervention

What, if anything, helps people resolve R/S struggle?

50

Challenges for Chaplains

• 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?

51

Further Information about Religious Struggle at the 2010 APC Annual MeetingPlenary Speaker

Kenneth PargamentPre-Conference Workshop

Introduction to Pastoral Research - G Fitchett & P Murphy

90 Minute WorkshopScreening for Religious/Spiritual Struggle in Stem Cell Transplant Patients - S King & G Fitchett

52

Questions and AnswersDiscussion

• Participant Questions• Other definitions of Spiritual Struggle?• Spiritual Struggle - effective

interventions?

53

Thank you for participating in today’s Professional Chaplaincy Webinar.

You will be e-mailed a link to a brief evaluation form within the next two days, along with a link to the downloadable audio recording and presentation materials.

54


References – Spiritual Struggle September, 2009

Ano GG, Vascolcelles EB. Religious coping and psychological adjustment to stress: A meta-analysis. Journal of Clinical Psychology 2005;61(4):461-480.

Boscaglia N, Clarke DM, Jobling TW, Quinn MA. The contribution of spirituality and spiritual coping to anxiety and depression in women with a recent diagnosis of gynecological cancer. Int J Gynecol Cancer 2005;15(5):755-761

Balboni TA, Vanderwerker LC, Block SD, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol. 2007;25(5):555-560.

Berg, Gary E. (1994). The Use of the Computer as a Tool for Assessment and Research in Pastoral Care. Journal of Health Care Chaplaincy 6(1):11-25.

Berg GE (1999). A Statement on Clinical Assessment for Pastoral Care. Chaplaincy Today 14(2): 42-50.

Bradshaw, A and Fitchett, G. "God, Why Did This Happen to Me?": Three Perspectives on Theodicy. Journal of Pastoral Care and Counseling 2003;57(2):179-189.Derrickson, Paul E. (1994-1995). Screening Patients for Pastoral Care: A Preliminary Report. The Caregiver Journal 11(2):14-18.

Exline JJ, Rose E. Religious and Spiritual Struggles. In RF Paloutzian and CL Parks (Eds.) Handbook of the Psychology of Religion and Spirituality (New York: The Guilford Press, 2005, pp. 315-330).

Exline, Julie J., Yali, Ann M., and Lobel, Marci. When God Disappoints: Difficulty Forgiving God and its Role in Negative Emotion. Journal of Health Psychology 1999;4(3): 365-279.

Exline, Julie J., Yali, Ann M, and Sanderson, William C. Guilt, Discord, and Alienation: The Role of Religious Strain in Depression and Suicidality. Journal of Clinical Psychology 2000;56(12):1481-1496.

Fitchett, G. (1993) Assessing spiritual needs: A guide for caregivers (Minneapolis: Augsburg; reprint edition Lima, Ohio: Academic Renewal Press, 2002).

Fitchett G. Screening for Spiritual Risk. Chaplaincy Today 1999;15(1): 2-12. Fitchett G. Selected Resources for Screening for Spiritual Risk. Chaplaincy Today

1999;15(1):13-26.Fitchett G, Meyer P, and Burton LA . Spiritual Care: Who Requests It? Who Needs

It? Journal of Pastoral Care 2000;54(2):173-186.Fitchett, G., Murphy, PE, Kim, J, Gibbons, JL, Cameron, JR, and Davis JA.

Religious Struggle: Prevalence, Correlates and Mental Health Risks in Diabetic, Congestive Heart Failure, and Oncology Patients. International Journal of Psychiatry in Medicine2004;34(2):179-196.

Fitchett, G., and Risk, J. (2009). Screening for Spiritual Struggle. Journal Of Pastoral Care & Counseling, 63(1,2). Retrieved from http://journals.sfu.ca/jpcp/index.php/jpcp/article/view/71/57

Fitchett, G., Rybarczyk, BD, DeMarco, GA, Nicholas, JJ. The Role of Religion in Medical Rehabilitation Outcomes: A Longitudinal Study. Rehabilitation Psychology1999;44(4):333-353.

Grossoehme DH. Development of a spiritual screening tool for children and adolescents. Journal of Pastoral Care & Counseling. 2008;62(1-2):71-85.

Hodges, S (1999). Spiritual Screening: The Starting Place for Intentional Pastoral Care. Chaplaincy Today 15(1):30-40.

Jacobson CJ, Luckhaupt SE, Delaney S, Tsevat J (2006). Religio-biography, Coping, and Meaning-Making Among Persons with HIV/AIDS. Journal for the Scientific Study of Religion 45(1):39-56.

Koenig, HG, Pargament, KI, and Nielsen, J. Religious Coping and Health Status in Medically III Hospitalized Older Adults. Journal of Nervous and Mental Disease 1998;186:513-521.

Ledbetter, Timothy J. (2008). Screening for pastoral visitations using the Clinical+Coping Score. Journal of Pastoral Care & Counseling, 62(4):367-374.

Lucas, Arthur M. (2001). Introduction to the Discipline for Pastoral Care Giving. In Larry VandeCreek and Arthur M. Lucas (Eds.) The Discipline for Pastoral Care Giving (Binghamton, NY: Haworth Press, Inc.), pp. 1-33.Mako C, Galek M, Poppito SR. Spiritual pain among patients with advanced cancer in palliative care. J Palliat Med. 2006;9(5):1106-1113.

Manning-Walsh, J. Spiritual struggle: effect on quality of life and life satisfaction in women with breast cancer. Journal of Holistic Nursing 2005;23(2):120-140, with discussion on pp. 141-144.

Massey, K, Fitchett, G, and Roberts, PA. (2004). Assessment and diagnosis in spiritual care. In Mauk, K.L. and Schmidt N.K. (Eds.) Spiritual care in nursing practice, Philadelphia, PA: Lippincott, Williams and Wilkins, pp 209-242.

NANDA International. NANDA-I Nursing Diagnoses: Definitions and Classification, 2007-2008. Philadelphia: NANDA International; 2007.Oxman TE, Freeman DH Jr., Manheimer ED. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosomatic Medicine 1995; 57:5-15.

Pargament, KI. The Psychology of Religion and Coping: Theory, Research, Practice. (New York: The Guilford Press, 1997).

Pargament, KI, Koenig, HG, Tarakeshwar, N, and Hahn, J. Religious Struggle as a Predictor of Mortality among Medically Ill Elderly Patients: A Two-Year Longitudinal Study. Archives of Internal Medicine 2001;161:1881-1885.

Pargament, K. I., Koenig, H. G., Tarakeshwar, N. and Hahn, J. Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: a two-year longitudinal study. Journal of Health Psychology 2004;9(6): 713-730.

Pargament, KI, Smith, BW, Koenig, HG, Perez, L. Patterns of Positive and Negative Religious Coping with Major Life Stressors. Journal for the Scientific Study of Religion 1998;37:710-724.

Pargament, KI, Zinnbauer, BJ, Scott, AB, Butter, E.M., Zerowin J, and Stanik, P. Red Flags and Religious Coping: Identifying Some Religious Warning Signs Among People in Crisis. Journal of Clinical Psychology 1998;54:77-89.

Sherman AC, Plante TG, Simonton S, Latif U, Anaissie EJ. Prospective study of religious coping among patients undergoing autologous stem cell transplantation. J BehavMed 2009;32:118-28.

Sherman AC, Simonton S, Latif U, Spohn R, Tricot G. Religious struggle and religious comfort in response to illness: Health outcomes among stem cell transplant patients. J Behavioral Med 2005;28:359-67.

Stoddard, Gregory A. (1993). Chaplaincy By Referral: An Effective Model for Evaluating Staffing Needs. The Caregiver Journal 10(1):37-52.

Taylor EJ, Outlaw FH, Bernardo TR, Roy A (1999). Spiritual conflicts associated with praying about cancer. Psycho-Oncology, 8:386-394.

Wakefield JL, Cox D, Forrest JS (2001). Seeds of Change: The Development of a Spiritual Assessment Model. Chaplaincy Today 15(1):41-50.

Additional References

Bay PS, Beckman D, Trippi J, Gunderman R, Terry C. (2008). The Effect of Pastoral Care Services on Anxiety, Depression, Hope, Religious Coping, and Religious Problem Solving Styles: A Randomized Controlled Study. Journal of Religion and Health, 47:57-69.

Iler WL, Obenshain D, Camac M. (2001). The Impact of Daily Visits from Chaplains on Patients with Chronic Obstructive Pulmonary Disease (COPD): A Pilot Study. Chaplaincy Today 17(1):5-11.

Documents

Screening for Spiritual Struggle - Professional Chaplains