What are your thoughts on the Collaborative Spiritual Care Conversations presented in Craigie?

Positive Spirituality in Health Care

Nine Practical Approaches to Pursuing

Wholeness for Clinicians, Patients, and

Health Care Organizations

Positive Spirituality in Health Care

Nine Practical Approaches to Pursuing

Wholeness for Clinicians, Patients, and

Health Care Organizations

Frederic C. Craigie, Jr., PhD

Maine-Dartmouth Family Medicine Residency, Dartmouth Medical School,

and Arizona Center for Integrative Medicine,

University of Arizona College of Medicine

M i l l C i t y P r e s s

M i n n e a p o l i s , M N

Copyright © 2010 by Frederic C. Craigie, Jr., PhD.

Mill City Press, Inc. 212 3rd Avenue North, Suite 290 Minneapolis, MN 55401 612.455.2294 www.millcitypublishing.com

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author.

ISBN – 978-1-936107-48-3 ISBN – 1-936107-48-1

Cover Design by Wes Moore Typeset by James Arneson

Cover art © 2008 Caren Loebel-Fried www.carenloebelfried.com

Printed in the United States of America

To Heather, Matthew, and Tom Craigie. The spirit and commitments of your lives inspire me

and make the world a better place.

Index of Strategies……………………………………………….. xi

Acknowledgments………………………………………………. xiii

Foreword………………………………………………………….. xvii

Introduction…………………………………………………………. 1

The Context

1. Perspectives on Spirituality……………………………… 17

• Defining spirituality • So what, then, is spirituality? • Dimensions of spirituality • Suffering

2. Why Spirituality Matters………………………………… 53

• Spirituality is intimately related to health, wholeness, and well-being

• Spirituality mediates choices in health behaviors • Spirituality often frames the ways that people

cope with adversity and pursue the journey toward wellness/wholeness

• Spirituality is important because people want to be known in this way by their caregivers

Contents

3. Who Provides Spiritual Care?…………………………. 85 • Patient and clinician perspectives on spiritual care • Contributions to spiritual care by providers

of health and wellness care

4. Three Arenas of Spiritual Care……………………….. 97 • The personal arena • The clinical arena • The organizational arena • Three interlocking pieces

Nine Practical Approaches to Bringing Positive Spirituality into Health

and Wellness Care

Personal: Connections with What Matters to You

5. Stay connected with your purpose………………….. 123 • Spiritual aliveness • Aliveness and purpose • Staying connected with purpose

6. The moments of your life: Cultivate qualities of character…………………………………………………..145 • Positive Psychology • Discovering qualities of character • Working with qualities of character

7. Ground yourself in healing intention and presence….. 163 • Intention and presence • Cultivating intention and presence

Clinical: Connections with What Matters to Your Patients

8. Pick one or two areas to inquire about people’s spirituality……………………………………….. 189

• Two types of spiritual inquiry • Practical clinical approaches to spiritual inquiry • When in the course of human events

9. Partner with patients in pursuing what they care about……………………………………………………. 217

• A template for collaborative spiritual care conversations • Goals: What matters to you and where do you want to go? • Approaches: How are you going to get there? • Next steps

10. Be attuned to recurring themes of transcendence and valued directions……………………………………. .263

• Transcendence and valued directions • Spiritual care toward transcendence and valued directions • Approaches to transcendence • Encouraging patients in valued directions

Organizational: Connecting with the Shared Energy of People Working Together

11. Honor organizational mission and values………… 313

• Mission and values • Developing an understanding of mission and values • Mission and values as part of organizational life • Organizational specialists

12. Cultivate community………………………………………331 • Community in health care organizations • Positive qualities of community in health care

organizations • Cultivating community

13. Exercise empowering leadership……………………… 347

• Leadership and spiritual care • Windows on health care leadership: Voices of clinicians • Qualities of spirited health care leadership • Becoming a leader

Afterword………………………………………………………… 370

Appendix I: A Dozen of Fred’s Favorite Spirituality and Health Websites………………………… 372

Appendix II: A Fiddler’s Dozen of Fred’s Favorite Books on Spirituality and Health Care………………… 376

About the Author……………………………………………… 381

Index……………………………………………………………….. 383

Index of Strategies

1: Find your personal statements 136 2: Write your own origin story 137 3: Create a statement of personal mission 141 4: Describe your own approach to present awareness 143 5: Identify your own signature strengths of character 156 6: Nurture your own character 161 7: Be well 177 8: Pursue a practice of re-focusing and renewal during the day 179 9: Create a personal affirmation 181 10: Use conversational templates for spiritual inquiry 198 11: Identify conversation-openers 206 12: Adapt spiritual inquiry to the circumstances where

you see people 214 13: Get patients talking about what they care about 237 14: Elicit patients’ wisdom and competence 250 15: Express your own wisdom in some new ways 255 16: Collaborate with patients in defining next steps 259 17: Experiment with one or two approaches to transcendence 301 18: Invite patients to define key role values 305 19: Talk about the mission 323 20: Keep talking and develop a wider view of mission

and values 327 21: Define positive qualities of workplace community 340 22: Choose some next steps in building goodness in your

workplace community, and bring a colleague into the conversation 345

23: Be guided by your own evolving definition of leadership for spiritual care 363

24: Pick one or two points of growth for yourself as a leader with soul 367

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Acknowledgments

Anyone who looks back along a journey that has been worth taking can see a remarkable collection of fellow travelers who have offered encouragement and support. This is certainly the case with me.

My closest associates in the work of spirituality and health care in the last several years have been my faculty colleagues at the Arizona Center for Integrative Medicine; Howard Silverman, MD MS, David Rychener, PhD, Victoria Maizes, MD, Tieraona Low Dog, MD, Patricia Lebensohn, MD, Moira Andre and Andrew Weil, MD. Thank you all for your friendship, for the affirmation that spirituality is really central on the path toward healing and wholeness, and for your enlightened conversation about how we invite spirit into the work that we do. I am also particularly grateful to Dr. Maizes for her kind and generous Foreword.

My ideas about spirituality and health care have been greatly en- riched over the years by the stories and dialogue from the fellows in Integrative Medicine at the Arizona Center for Integrative Medicine. Among many hundreds of such exchanges, I have included material (with generous permission) from Barbara L. Bakus, DO, Angela Lynn Barnett, MD, Katherine Bayliss, MD, Suzanne Bertollo, MD, MPH, Trevor M. Braden, MD, Christine Bugas, DO, Rosemarie Butterfield, MD, Gary Conrad, MD, Kathalina A. Corpus, MD, Deborah A. Dunn, MD, MPH, Susana Escobar, MD, Paula Renee Fayerman, MD, FCFP, Vani Gandhi, MD, Janet Lewis, MD, Jill Mallory, MD, Mark D. Moon MD, David Moss, MD, Amy Pabst, MD, Robert A. Pendergrast, Jr., MD, MPH, Mary Ellen Sabourin, MD, Christina Louise Stroup, MD, MS, and Joseph Zirneskie, MD.

Among my local colleagues and friends, I am ever grateful to three people in whom I always find wisdom and inspiration in the conversation about spirituality and health; Diane S. Campbell, MD, Elizabeth B. Hart, MD, and Richard F. Hobbs, III, MD, FAAFP, DABMA.

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My 1996 sabbatical colleagues at the Seton Cove in Austin, Texas, helped with the formation of my ideas about organizational soul and have remained dear to me over the years: Sr. Mary Rose McPhee, DC, Jan and Ed Berger, Leslie Hay, and Travis Froelich.

The leadership and staff of the community health centers in my exemplary practice research will remain anonymous because of the protocols of doing this kind of research. You are still out there, though, providing great health care to Maine people and caring about one another, and you have my sincere respect.

For miscellaneous permissions and words of feedback and support; Amy Madden, MD, Priscilla Abercrombie, RN, NP, PhD, Larry A. Willms, MD CCFP, Harold G. Koenig, MD, MHSc, Sara Roberts, PA-C, Margaret J. Wheatley, EdD, Christina Puchalski, MD, MS (and the George Washington Institute for Spirituality and Health), Everett L. Worthington, Jr., PhD, Robert D. Enright, PhD, Lynn Underwood, PhD, Gowri Anandarajah, MD, Lee G. Bolman, PhD, Kay Gornick (Prairie Home Productions), Renee Anthuis, AAFP, and Douglas Harper (the Online Etymology Dictionary).

Thanks to my community of writers for their feedback and support. Led by the irrepressible Bill O’Hanlon, MS, they also include Mary Beth Averill, LICSW, Ph.D, Sandy Beadle, Adele V. Bradley, MA, LCMHC, Niel Cameron, Hope W. Hawkins, Ryan Nagy, Lisa Robertson, and Robin Temple.

The late David B. Larson, MD was a generous collaborator on early meta-analytic research on spirituality and health, and helped to form my professional direction and passion in this area. The late Thomas Nevola, MD set in motion some conversations in Central Maine that have evolved into a vital Department of Pastoral Care at the Augusta campus of MaineGeneral Medical Center, and a 23-year annual symposium that bears his name.

The cover image, Tree of Life, was graciously provided by the artist, Caren Loebel-Fried. The bird nestled in the tree is a phoenix, the mythical firebird that symbolizes renewal in the traditions of many world cultures. Readers can see more of Caren’s stunning work at http://www.carenloebelfried.com/. Hearty thanks to the broadly-

Acknowlegments

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talented Matthew Craigie for the portrait on the back cover. Thanks also to Mark Levine and the staff at Mill City Press. A

pleasure to work with. My wife, Beth, remained patient and cheerful over the winter of

2008-2009 with her husband impersonating a piece of furniture, planted ten feet away from the pellet stove, staring at the laptop. She is also among the wisest, most spiritually grounded, and up- lifting people I have ever been blessed to know.

xvii

Foreword

Physicians and other health care providers are invited into the most intimate moments of people’s lives. Birth, death, sexuality, and loss of bodily and mental functions are revealed in the therapeutic union created between patient and clinician. Within this context, but often missed or ignored, are spiritual questions. Buried just below the surface of most clinical encounters lie questions related to meaning, to faith, and to larger existential matters. “Why did this happen to me?” “I have been a devout Christian (Jew, Muslim, etc.); why would God give me cancer?” “My father was a good man; how could he now be stricken with Alzheimer’s, with his dignity lost and all that he valued gone?”

Doctors and nurses have often sidestepped these questions as not part of our domain as health care providers. Indeed, many of these questions are not answerable. Rainer Rilke in his timeless book Letters to a Young Poet suggests that we learn to “love the questions themselves.” While this may be good advice for the questioner, how does it relate to the health professional? By bearing witness, by acknowledging the unspoken questions, we provide an oppor- tunity to our patients for growth. Challenges of all kinds hone our development as human beings. They can serve as tests that provoke us to express our finest selves.

Parallel to our human potential for physical prowess and in- tellectual capacity, we have a wellspring of spiritual strength from which to draw. This may be of profound importance not only in times of crisis; it may be the waters that sustain us through our ordinary day to day existence as well. Whether wrestling with pain from osteoarthritis, an addiction to alcohol or drugs, a depression, or even boredom, spiritual resources can help us surface from the depths. Indeed, spiritual answers may serve as our most powerful approach to overcome life’s obstacles, offering us direction, hope, meaning, and renewal.

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Expressions of profound gratitude may also be of a spiritual nature. “I am so deeply grateful for this healthy baby” is not only a common sentiment among new parents; it is often experienced as a spiritual event. The middle-aged woman challenged by years of diabetes may feel similarly blessed to “see my daughter graduate from college.”

Health professionals can certainly refer to others with more training, expertise and even comfort. But they must recognize the subtle hints that are often the only expression of the agonizing questions being asked. Medical educators have suggested sets of questions that can be taught to students and residents so that they take a good spiritual history. While these questions serve to enhance comfort and are a good starting point, they may imply that one can either include or exclude a spiritual history the way one decides on the need for a sexual history or a mental status exam depending on the presenting problem. Like Dr. Craigie, I believe the more ap- propriate model is an embodiment model of spirituality. Framed this way, we acknowledge the presence of the spiritual domain in whatever is going on.

In this wonderfully researched and written book, Dr. Fred Craigie leads by example, weaving together compelling stories that reveal to us how spirituality impacts health. He reviews decades of research and makes a compelling case for health care providers to delve into this part of their patients’ lives. He reminds us, with vivid cases, how these conversations enrich our lives as well as those of our patients. He reminds us that our patients want us to be present, to listen generously and with compassion, and to provide realistic hope. While we may all recognize these attributes of good medicine, he points out that when these elements are present, our patients feel spiritually cared for.

Dr. Craigie then proceeds to teach us nine approaches to bringing spirituality into healthcare. He frames his approaches in three domains: personal, clinical, and organizational. The personal reveals how we can stay connected with a higher purpose, how we

Foreword

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can cultivate our own character, and ways to ground ourselves in the context of a healing intention. The clinical covers practical approaches to working with patients. This includes history taking and partnering with patients as they discover and pursue what is meaningful to them. It also includes learning to recognize and support transcendence in others. Finally, Dr. Craigie challenges us to include the organizational level by honoring mission and values, by cultivating a workplace community that attends to the spiritual domains, and by exercising empowering leadership.

I have worked with Dr. Craigie for a decade now. He has taught spirituality and medicine in the Fellowship Program at the Arizona Center for Integrative Medicine since its inception in 2000. He is beloved by the more than 500 fellows who studied with him and found his teaching of supreme value. I am confident that you will have a similar experience.

Ultimately, Dr. Craigie enriches us with his years of experience teaching spirituality to health providers. He gives us a frame to use and language we need to help us be more comfortable and focused in providing spiritual care. He reminds us of the value of simply sitting with another human being and witnessing their journey. And in the end, it is our patients who benefit by feeling seen and acknowledged for who they are and for what is important to them.

Victoria Maizes, MD Executive Director, Arizona Center for Integrative Medicine Associate Professor of Medicine, Family Medicine, and Public Health University of Arizona

September 2009

1

Introduction

“I know that this is important, but I really can’t picture myself doing it.”

The warm morning sun, along with fresh-roasted Vera Cruz coffee, took the chill out of the air as we sat together in a small outdoor plaza. A circular fountain muffled the sounds of passing cars; craggy mountains were striking against a blue sky in the distance.

My colleague, a family physician, was speaking about her misgivings about incorporating spirituality in her practice of medicine.

“I see how prominent all of this has become…” she said, “… hundreds of articles, courses in medical schools, protocols for spiri- tuality assessment… but it still seems daunting to have those kinds of conversations with the people I see day in and day out.”

“Tell me about a patient you have seen in recent times who has touched you in some way,” I asked.

She paused, watching a cactus wren swoop down to grab a wayward muffin fragment.

I saw an elderly man in the office with two of his middle aged children, a son and a daughter. A new patient, the first time I had met any of them. The man had had a stroke a few months before and was alert but had great difficulty communicating. His kids brought him in because he was sick… he really looked under the weather… and they were concerned about whether he was developing pneumonia.

I took care of the medical business… he was sick but didn’t have pneumonia… and in this visit that was otherwise pretty matter-of-fact, I thought I saw some real tenderness in the way the son helped his father down from the exam table. I said something like “You folks really look fond of your dad… tell me a little about him.”

They immediately brightened, telling me how he had raised them as a single parent after the death of their mother and how he had always insisted on being self-employed so he would have the flexibility of being

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there for them with school and everything else that kids do. We spoke for a short time about a few more details… the dad had worked in the woods, built a modest home, eventually had a small taxi business and was known in his community as someone who would be generous and patient. The daughter concluded, “We never had very much money, but even when we were hungrier than we would want to be, we always knew we were loved.”

Hearing this, the dad broke into a broad smile, too. You could see how much he cherished his children, and I think it really meant something to him to have them tell those things to his doctor. When we left the room, they all heartily shook my hand and the children said how glad they were that I was now his doctor.

“In times like those,” she reflected, “I am reminded about what a privilege it is to be able to be a part of people’s lives.”

“I can see,” I suggested, “that you already know something about good spiritual care.”

HESITATION ABOUT SPIRITUAL CARE This story is far from unique. My experience is that the health care clinicians I have known… physicians, nurses, behavioral health spe- cialists, alternative medicine practitioners and many others… are generally aware of the rising tide of interest in spirituality in health care, but often lack a clear sense of what this might mean for them. They warm to the idea of spirituality in health care, but are not sure how this idea can find its way into the day to day practice of their professional work. Principally, the hesitation about spiritual care that I hear from health care clinicians takes three forms.

Time First, some clinicians say that they are held back by time. The as- sumption is that good spiritual care requires extended conversations that take more time than the fast pace of health care allows. “I’m booked every ten to fifteen minutes all day,” an internist points out;

Introduction

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“How can I make the time to talk with people about their spiritual lives and struggles without ending up staying late into the evening?”

Of course, time can sometimes be an ally in providing spiritual care. The time that clinicians have to get to know someone in a health care visit, and, more broadly, the time that clinicians have to get to know people in continuity relationships can help with the development of healing relationships and the exploration of spiritual issues.

I would argue, however… and we shall discuss… that clock time does not have a necessary relationship with good spiritual care or with healing. In workshops, I sometimes ask participants to identify events in their lives where someone has touched or influenced them in a meaningful way. The stories I hear typically encompass very little time. An unforeseen reaction of charity when someone knew that they had done wrong. A word of recognition about someone’s efforts out of the public eye. A comment pointing to inner resources and inviting someone to let their light shine more brightly.

Medical intuitive Caroline Myss PhD reports a dramatic story that was told to her about a patient who had made his way back from very serious depression.1 The patient said that his healing journey really began when he had decided to kill himself. He had concluded that life was not worth the pain he was feeling and he had worked out plans to end it all. On his way to his appointed demise, he had to walk a few city blocks and found himself stopping at a crosswalk, along with vehicle traffic going the same way. A woman who was driving the first car in line stopped for him and their eyes met. She smiled. He crossed the street and she drove off, but the warmth of that momentary human contact gave him a glimmer of hope and led him to question his plans. The man later recounted that the woman “brought me back to life with that smile.” Dr. Myss’ comment is that the woman “channeled grace” to the dis- traught man. A four-second spiritual intervention!

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Skills The second hesitation I hear from health care clinicians about spiritual care has to do with skills. The assumption is that good spiritual care requires theological sophistication and specialized knowledge and training in models of spiritual assessment and in- tervention. “Chaplains spend years learning these things,” a social worker asks; “How can I do justice to people’s spiritual issues without that kind of background?”

Of course, spiritual care does involve skills. What do you say to a man with a life-compromising illness who tells you that God has abandoned him and he wishes to die? There may not be a single right response to this situation, but some responses are less good or better than others. Skills and approaches to such situations are learnable; perhaps this is why you have picked up this book.

I would suggest, though… as we shall also discuss… that spiritual care by health care givers is not fundamentally defined by skills and techniques. At its foundation, spiritual care by health care givers is about intention and presence. The word I typically use is “embodiment;” the way in which a healing spirit is embodied in the person and presence of the health care giver. You can have the greatest and most sophisticated spiritual skills possible, but without healing intention and compassionate presence, you are likely not to get very far with the abandoned man with the life-threatening illness.

This foundational role of intention and presence should come as good news to health care givers for two reasons. First, there are encouraging data that these things matter in the process of health and healing. Second, most health care givers have these things in spades. I find very consistently that people choose health care careers because it is important to them to make a difference in the lives of other people. The family doctor who was originally a public health nurse in a rural clinic in Guatemala and wanted to learn medicine to be able to serve people in a more substantial

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way. The medical assistant who works at an inner city clinic in the neighborhood where she grew up as an expression of giving back to her community. The physical therapist who was deeply im- pressed and appreciative of the care given him by an older physical therapist… now a mentor… who worked with him after a mo- torcycle accident.

The “origin stories” of people serving in health care often point to events that have cultivated or nurtured a spirit of caring and a commitment to healing. The system of health care, with its admin- istrative demands and productivity requirements, may sometimes dampen this spirit, but in most clinicians, the spirit remains in at least humble form. Even among physicians who are substantially disillusioned with the medical care system, I often hear comments such as, “I really feel bitter and burned out with the superfluous things in my job, but my saving grace is that when I close the door and I’m there with a patient, I feel some of the same energy and joy in connecting with people that I did when I started out.”

I believe that affirming the compassionate values and basic people skills that health care givers bring to their work is essential in the conversation about spirituality in health care. Some of the greatest wisdom comes not from outside, but from within.

This book, then, balances affirmation and skill development. Affirmation of the values and skills that are already there, along with conversation about some specific additional approaches that can enhance the ways that health care givers provide spiritual care.

Fear The final hesitation I hear from health care clinicians about spiritual care has to do with fear. Unlike concerns about time and skills, the hesitation about fear is largely unspoken. Health care givers may express some apprehension or concern that engaging in con- versations about spiritual topics will take up inordinate and un- available amounts of time, but the issue of fear runs deeper than that. I think it has to do with fear of invalidation.

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Most of us who have graduate degrees and health care credentials have been able to be professionally successful because we are good at controlling the world around us. A physician can orchestrate a multidimensional workup of a series of medical complaints and mobilize a large cast of characters to carry it out. An acupuncturist knows the subtleties of depths and qualities of pulses, which, to the rest of us, would be completely incomprehensible. A caseworker knows the eligibility criteria for various types of health care and public assistance and can work with systems to help patients take advantage of the resources that are available. All of us can generally put our personal feelings and distractions aside in order to do what we need to do.

We take pride in our abilities to know what we are doing. It is a source of validation that we know what we are doing.

Venturing into the uncertain territory of spiritual care calls this into question. An oncologist recounts,

The patient and his wife came back for the second visit after his cancer diagnosis and he said that he was so angry at God for doing this to him… and he certainly was angry. I really didn’t have any idea what I could say that would be helpful… do I tell him that God really didn’t cause his cancer? Do I just reflect back to him what he said? I think maybe I’d be pretty angry at God, too. The two of them left just as upset as when they came in, and that’s hard to take.

For most of us, this is a painful place to be… having had the experience of not knowing what to do, and fearing that we were therefore unable to help somebody at a point of their suffering and need.

I’m not sure that fear completely goes away, and I would not make the claim that this book will enable readers to pursue spiritual care with complete confidence, comfort and assurance. After all, fear is often a fellow traveler on any journey that is worth taking. My hope, however, is that the affirmation that you already bring a great deal of wisdom to this enterprise, along with our ex-

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ploring together some additional concrete perspectives and skills, will strengthen and empower you in your own unique approach to spiritual care.

SPIRITED CONNECTIONS The main body of this book is organized into three sections, rep- resenting three interrelated arenas in which we may bring positive spirituality into health and wellness care. They are; our personal spirituality as clinicians and human beings, the clinical approaches we pursue in supporting the spirituality of patients, and the orga- nizational spirituality that is expressed in the culture and values of health care organizations.

The personal arena: Connecting with what matters to you

If the foundation of spiritual care by health care givers is about intention and presence, then our own spirituality holds utmost im- portance. The issue is not that we need to follow some prescribed or formal spiritual path, but rather that we need to connect with the things in our lives that matter the most to us.

We will review data suggesting that pursuing our own deepest values and cultivating personally meaningful qualities of character promote wholeness and well-being. Do you value compassion? Be compassionate. Do you value gratitude? Be grateful. Do you feel most alive when you are serving somebody else? Serve. Do you pride yourself on bringing a spirit of peace to people in conflict? Bring peace. Whatever it is that you most cherish about how you wish to live your life, it is the connection and expression of those qualities that help you to be centered and grounded. When you are centered and grounded, your presence with people… and the spirit that you bring to your work… will be palpably different from when you are not. When you are really present with people, you are already providing good, foundational, spiritual care.

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The clinical arena: Connecting with what matters to your patients

For most of us, our clinical work with people in health and wellness care is the focus of our professional mission. We may bring a variety of personal motivations to our work… a curiosity for science, a passion for leadership, a desire for financial stability, a joy in a camaraderie of caregivers… but ultimately, the work we do is focused on healing suffering people and fostering wellness and wholeness in all of us.

We will consider approaches to spiritual care in the clinical arena in considerable detail. The common theme or direction of these approaches is supporting people on their own unique spiritual journeys by helping them to connect with what matters most to them. Where does the patient in front of you find meaning and purpose? What is her life “about?” What does he hope the legacy of his life would be? What does she consider sacred? What is he really passionate about? What sustains her in hard times? Answers to such questions, as we shall see, provide a vital backdrop for patients’ choices about health practices, a template for patients’ charting the places where they will invest their time and heart, and a wellspring of wisdom and direction in adversity.

The organizational arena: Connecting with the shared energy of people working together

Organizations have souls as much as people do. Organizational soul comes by a variety of names; “spirit,” “atmosphere,” “culture,” “tone,” “environment,” and so forth. Some organizations “have it,” some do not, and the difference is usually palpable.

I suspect that you have experienced (or perhaps heard from other people) about great places to work, and experienced (or heard from others) about places where work was pretty demoralizing. Prac- ticing in and living near the state capital of Maine, I have known a large number of state employees over the years and heard their stories about work. Occasionally I hear about state departments

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where people really believe in what they are doing… protecting a watershed, preserving a historic past, providing educational services for teenage mothers… and work together with a spirit of respect, support and joy. I hear of other state departments or units where people are predominantly putting in their time until they are fully vested in the retirement system, and where the workplace spirit seems to nurture suspicion, micromanaging, backbiting, and pro- tecting one’s own turf. Clearly, the former group of departments will support the health and well-being of employees better than the latter group, and I would bet a pair of Red Sox tickets that the former group of departments would show much better indices of productivity and organizational functioning, as well.

There is, in fact, very substantial literature in the business com- munity about the relationship between organizational spirit and parameters of organizational functioning and success. One of the very early books in this area was “The Soul of a Business” by Tom Chappell, a narrative of the history and evolution of Tom’s of Maine, the organic personal care products company that Chappell founded with his wife, Kate.2 Starting from their home in Kennebunk, Maine, the Chappells built a business that was profitable but, by the late 1970s, had reached a plateau. Tom believed that something was missing, and he negotiated with his board to drop back to half time and to devote the remainder of his time to studying theology at Harvard Divinity School.

He had a blast, studying Martin Buber, Jonathan Edwards and other spiritual writers, and bringing back to Maine a new energy for integration of spiritual wisdom and consciousness in business practice. With his board, he then revisited the kind of organization they wished to lead, in terms of empowerment of employees, stew- ardship of the environment, and substantial engagement with the local community. The results of this undertaking, from a purely business standpoint, were striking.

So, too, in health care. There are good data in this arena, as well, as we will review. The short summary is that health care or-

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ganizations that pay attention to organizational soul… a shared sense of mission, respect and empowerment of employees, a spirit of community and caring among workers… do better than or- ganizations that do not with respect to employee retention and satisfaction, patient satisfaction, performance improvement and process measures, and health care outcomes.

Three interlocking pieces I believe that all three arenas are vital parts of the larger picture of spirituality in health and wellness care. Spiritual care is incomplete without attention to personal spirituality, as well as clinical ap- proaches, as well as organizational soul. Take one in isolation… a common example being good clinical skills in dis-spirited prac- titioners or disempowering organizations… and the challenges of providing good spiritual care over time become formidable and prohibitive.

Stated positively, the possibilities of providing good spiritual care can be exciting in the setting of centered and grounded prac- titioners, with solid and practical clinical approaches, in organi- zations that empower staff and patients alike to bring out the best that is within them.

I tell participants in my workshops that 92 percent of the lit- erature on spirituality and health care addresses the clinical arena, 7.5 percent of the literature addresses the personal arena, with a scattering of publications addressing the organizational arena. I confess that I am making these numbers up, but I suspect that they would come close to the actual emphasis in each of these three arenas.

In the main body of this book, we will consider each of these arenas in detail, exploring what they are, why they matter, how they interrelate, and how they may be nurtured.

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POSITIVE SPIRITUALITY What is “positive spirituality?” Is some spirituality “negative?” What does “Positive Spirituality in Health Care” mean?

Good questions. Thanks for asking. Consider; a parent anguishes over why a loving God would visit

a three year old child with cancer. A man dying of AIDS struggles to reconcile his homosexuality with his lifelong devotion to the Catholic Church. A middle-aged woman is drawn into a sexual re- lationship with her pastor… which she ends… and faces challenges of forgiveness and trust.

These are serious spiritual issues; challenges that call into question people’s core spiritual values about themselves, the world and, indeed, the nature of the Divine. I think that clinicians in health and wellness care can work with people around issues like these to a lesser or greater extent depending on a number of factors, such as our skills and experience, our comfort level, and the kinds of ongoing relationships we have had. Often, however, people struggling with issues such as these can be best served by spiritual care professionals such as chaplains, spiritual directors and clergy.

“Positive spirituality” complements the journey of identifying and healing spiritual issues. Positive spirituality comes at spirituality from the other direction. The question is not “What is wrong?” The question is “What is right?” The question is not primarily how spiritual suffering and spiritual wounds can be healed; the question is more one of identifying and encouraging people’s spiritual values and resources, and bringing those values and resources to bear in people’s journeys toward health, coping, dignity and wellness.

The positive spirituality conversation takes shape along lines I have described above, and will explore in considerable detail.

• What is your life about? • What matters to you? • What do you care about? • What is sacred for you; what do you cherish?

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• What sustains you and keeps you going in adversity? • What are the qualities of character that you most take pride in and

try to express in your life?

As I write this, I saw a patient this week for the first time, who described a lifelong history of abuse and mental health issues. She began the conversation with a recitation of the various psychiatric diagnoses she had accumulated… PTSD, depression, bipolar disorder, and borderline personality disorder… and then proceeded to describe the terrible physical and sexual abuse that had been visited upon her by her father over a number of years. She had had multiple suicide attempts, the most recent three years ago upon the death of a cherished grandfather. One could feel and see the weight of this suffering in her telling the story.

It occurred to me to confirm with her that she had indeed not attempted suicide in the last three years… this was the case… and to ask why. For much of this time, she said, she had been engaged in caring for her widowed grandmother, spending time with her and helping her with her own health problems, until the grand- mother passed away, as well. Did my patient think that her caring for the grandmother had anything to do with her refraining from suicide attempts during this time? Yes, she believed that it did. How would she put into words what it was about caring for the grandmother that helped her to remain on this side of suicide? She paused,

I think it gave me a purpose in my life, a purpose for being on this planet.

We spoke more about the idea of “purpose” and how that had made a difference in her life; one could see and feel the weight of the suffering diminishing. This is “positive spirituality.”

Of course, she has some significant spiritual issues to address. How do you deal with years of sexual abuse at the hands of someone who should be a champion and protector? What does “forgiveness” mean and how might this at some point be a part of the journey?

Introduction

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Important questions; genuine spiritual issues. But it is clear that she is more than the person who has been terribly victimized. She is also a person who has a heart of tenderness for aging grand- parents, and who has made the profoundly important connection that “purpose for being on this planet” can be a vital part of her own healing journey.

Positive spirituality, in other words, affirms that people may have substantial spiritual issues and suffering, but directs energy particularly toward the spiritual values and resources that sustain and empower people as they live their lives.

As a practical matter, what I am calling spiritual “issues” and spiritual “resources” often intersect. You see both in the brief story I have told about my abused patient. We will touch on the subject of spiritual issues and suffering and consider some approaches for providers of health and wellness care, while the over-arching theme of the following chapters will be the understanding and nour- ishment of spiritual values and resources, in personal, clinical and organizational venues.

A LOOK FORWARD The first three chapters of this book provide background material for a clinically-oriented perspective on spirituality and spiritual care. Chapter 1 presents some definitions and perspectives about spirituality, including an introduction to my CAMPS framework for exploring five dimensions of spiritual experience. Chapter 2 describes four reasons why spirituality is important in health and wellness care. Chapter 3 considers the nature of spiritual care, and how health and wellness care clinicians can provide great spiritual care, in partnership with spiritual care specialists. Chapter 4 ex- amines the three arenas of spiritual care… personal, clinical and organizational… in greater detail.

The main body of the book presents nine chapters that explore the “Nine Practical Approaches to Pursuing Wholeness for Cli- nicians, Patients and Health Care Organizations.” Chapters 5

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through 7 consider the personal arena of spiritual care, exploring personal purpose, positive qualities of character, and healing in- tention and presence. Chapters 8 through 10 consider the clinical arena of spiritual care, exploring spiritual inquiry, partnering with patients in pursuing what they care about, and recurring themes of transcendence and valued directions. Chapters 11 through 13 consider the organizational dimension of spiritual care, exploring organizational mission and values, organizations as “community,” and empowering leadership.

Sprinkled throughout are twenty-four practical strategies for building on the ideas and case examples we will be considering. You may also think of these strategies as “exercises,” or suggestions for “active learning.”

Finally, two appendices present a dozen or so helpful websites about spirituality and health, and A Fiddler’s Dozen of Fred’s Fa- vorite Books on Spirituality and Health Care.

May this book affirm the heart and the skill that you already bring to your work, and may we explore together some additional approaches to supporting people on their journeys toward healing and wholeness.

REFERENCES 1. Myss C. Invisible acts of power. In: Church D, ed. Healing the

Heart of the World. Santa Rosa, CA: Elite; 2005:17-21. 2. Chappell T. The Soul of a Business. New York: Bantam; 1993.

The Context

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Chapter One

Perspectives on Spirituality

The spiritual is inclusive. It is the deepest sense of belonging and participation.

We all participate in the spiritual at all times, whether we know it or not. There’s no place to go and be separated from the spiritual… The most

important thing in defining spirit is the recognition that the spirit is an essential need of human nature. There is something in all of us

that seeks the spiritual. This yearning varies in strength from person to person but it is always there in everyone.

And so, healing becomes possible.1

Rachel Naomi Remen, MD

Some time during the second half of the first century of the Common Era, a fisherman and missionary in Asia Minor contrasted spiritual and material pursuits. According to John the Apostle, as he is known in the Christian tradition, “It is the spirit who gives life; the flesh profits nothing. The words I have spoken to you are spirit and are life” (NIV).

The modern literature on spirituality and human experience offers countless perspectives on spirituality. At its core, however, I am drawn to the idea that spirit gives life. Spirit… however

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you think of this and from whatever tradition you come… gives meaning, dignity, direction and passion to life.

As I speak with people about spirituality, I often hear a con- nection between being spiritually engaged and being fully and meaningfully alive:

T.S. was a 34 year old female who complained of a complete loss of libido. At the time of presentation the insufferable complaint had been going on for greater than 3 years without any improvement. Over the course of two years her complaint was not found to be secondary to a hormonal imbalance, an anatomical condition, any metabolic or organic problem, or a primary depression. Psychotherapy, couples counseling, and sensate focus were also tried unsuccessfully. Some time later, I had the opportunity to follow-up with her and she had finally experienced a reso- lution of her symptoms after 5-6 years of suffering. She explained that she had come to realize that several life events had occurred simultaneously that had left her feeling “spiritually dead” and completely detached from her spiritual self and the “experience of God” that she had always known. Apparently, she was not able to realize this previously and no amount of talking or suggestions had led to her reconnecting with her spiritual self. She began her journey of healing after listening to an audio-tape on intuition and love. A suggestion was made to experience getting in touch with all of her senses through self-guided imagery. She began to re- awaken and also began nurturing herself through nature and rest while creating experiences to connect with her senses. Eventually this explo- ration allowed her to redefine a sense of spiritual connection and “being present” in her life. This allowed her to feel whole again and spiritually alive. Her libido followed.

In the framework of this patient, there is a clear distinction drawn between being spiritually “dead” and spiritually “alive,” and this distinction has profound implications for her health and for the ways that she lives her life.

The last eighteen or twenty years have witnessed a substantial increase in the interest in spirituality and health care. When I

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presented a seminar about spirituality at a Society of Teachers of Family Medicine national conference in 1986,2 and when I pub- lished (with the late David Larson) what I believe was the first article about spirituality in the Family Medicine literature in 1988,3 there was clearly a feeling that people interested in this subject were part of a small, ragtag band outside of the mainstream of organized medicine.

How much has changed in the intervening years. One can go to STFM conferences these days and find that seminars and interest group conversations about spirituality consistently spill out into the halls. Thanks to the efforts of Dr. Larson, Dr. Christina Pu- chalski (Founder and Director of the George Washington Institute for Spirituality and Health), the Templeton Foundation, and many others, there are now educational curricula about spirituality at a majority of American medical schools, a number of postgraduate programs, and at least one program (several fellowships in Inte- grative Medicine at the Arizona Center for Integrative Medicine) addressed to mid-career physicians. Dr. Herbert Benson’s Harvard conference on Spirituality and Healing in Medicine has been packing them in for many years. The number and quality of re- search projects about the incorporation of spirituality in health care has increased substantially, as we shall see later, and there have been significant research initiatives (sponsored by the Fetzer In- stitute, among others) in a number of ancillary subject areas such as forgiveness, gratitude, hope, and love. And at a personal level, I talk about this subject with medical students who are applying to our residency program and find lively and engaged interest, in contrast to the quizzical and worried expressions of years past.

Still, there is much more work to be done, and many questions remaining to be explored. What is the larger picture… what does it mean to incorporate spirituality in health care? Where are the points in patients’ lives and in the process of health care where con- versation about spirituality may be helpful? How do we best enter this arena with patients? How can we best approach spirituality in an

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inclusive and respectful way with our patients? As we encounter or elicit spiritual issues in our relationships with patients, what do we as providers of health and wellness care do? What is our unique role… as physicians, nurses, acupuncturists, naturopaths, psychologists, physical therapists, medical assistants and others in the health care world… in strengthening patients’ spiritual resources and amelio- rating spiritual suffering? How can we best collaborate with pastoral care professionals, drawing on their skills and expertise and also being legitimate players in this arena ourselves? How is our own spirituality related to what we do as health care professionals?

PERSPECTIVES ON SPIRITUALITY What do we mean by “spirituality?” Why do we speak of “spiri- tuality,” rather than “religion?” What is the relationship of spiri- tuality and religion? Does reference to “spirituality” imply a par- ticular world view?

Good questions, all. It would certainly be sensible to lay out a clear definition of spirituality, as we embark on an exploration of spirituality and health care.

This is, however, not so easy. My observation is that the word “spirituality” rolls frequently and smoothly off the tongue, but takes on a broad variety of meanings to different people. If you tell me that spirituality is an important part of your life, I may make some assumptions about your having some cherished values or beliefs, or perhaps assume that you engage in some centering or grounding practices. But I would be guessing… and I would certainly need to have a conversation with you about this before I began to have some real appreciation of what this meant to you.

For me, the most succinct statement of the overarching picture of spirituality comes from former Surgeon General Dr. C. Everett Koop. Speaking in 1994 at the annual Maine symposium on spiri- tuality and health that I coordinate, he defined spirituality as

The vital center of a person; that which is held sacred.4

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Along with the observation from John the Apostle, I think that this points to themes that can be profoundly helpful as we care for patients. What is “the vital center” for a middle aged man who has had a serious heart attack? What sustains a grade school teacher who feels overwhelmed and depressed? What is sacred enough for a young mother to energize her efforts to stop smoking? When are the times when a retired person feels really alive? What keeps a high school student who has had suicidal ideas from carrying them out? When, indeed, do we experience something sacred in our professional lives? What sustains and re-orients us when we become overextended and demoralized?

As we understand… for our patients and for ourselves… what “gives life” and what is “vital and sacred,” we glimpse the foundation that underlies the personal meaning of health and wholeness. We understand better the personal nature of suffering. We understand better the personal motivation for change. And we are given the opportunity and the honor of engaging the personally-understood life force that sustains all of us as people on our life journeys.

DEFINING SPIRITUALITY Before we consider further the “content” of spirituality… the aspects of human experience that this broad word embraces… I would like to suggest several ideas about the process of approaching a definition.

Spirituality is personal Spirituality is uniquely experienced and understood by individual people.

There may be common beliefs and practices among groups of people, but ultimately the understanding of what is vital and sacred is uniquely our own. Mennonites may share beliefs about adult baptism. Southern Baptists may share beliefs about the literal in- terpretation of biblical texts. Hasidic Jews may express their faith in common ways in terms of ritual and celebration. Participants

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in Alcoholics Anonymous may embrace together the convention of referring to a “Higher Power.” Activists with the Nature Con- servancy may orient much of their personal and professional lives around sustaining the natural environment. But in each of these cases, an articulation of what is vital and sacred… what gives life… will be in the unique language, drawing on the unique personal experiences, of individual people.

Indeed, any definition of spirituality is itself a personal matter. I am suggesting some core ideas about spirituality that make sense to me, and I will shortly be suggesting several common aspects of spiritual experience. I do this not so much because I think there is a right way to think about spirituality, but because a) I think I owe it to readers to let you know where I am coming from, and b) because much of what I will be describing about how I work with spirituality with patients and health professionals follows from my understanding of spirituality.

In practice, I find that most people who would care to define spirituality have their own definition, and have some emotional attachment to this definition. I would rather honor the framework and language of people’s personal definitions, rather than impose my own. Honoring the unique definition of “spirituality” held by individual people is respectful of them, and empowering as they cultivate and pursue what is vital and sacred for them.

Spirituality as experience Spirituality is, first, experienced. It is secondarily put into words.

I love models and frameworks and paradigms. It warms my heart to draw boxes and arrows that depict directions of influence among aspects of human experience. But the clearest pathway to understanding the spiritual dimension of someone’s life is not found in seeking the words, but in seeking the experiences. As we will consider when we examine spiritual inquiry, a question such as, “When has there been a time when you have experienced something really sacred and powerful in your life?” typically yields

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a much more rich and substantial response than asking people about their theology or belief systems.

I have had two good friends and colleagues, ages 46 and 55, die of cancer in the last couple of years. Both of them, until the very end, were among the most “vital” and “alive” people I have known… caring about other people, learning and growing, cher- ishing their days. One spoke comfortably in spiritual language; one did not. Neither one needed to speak formally about their spirituality. You could see it. You could feel it.

Spirituality as narrative More specifically, the richness of spirituality often resides in stories.

A few years ago, I did a qualitative research project that involved interviewing family physicians about what “spirituality” meant to them and how they incorporated it into their professional and personal lives.5 The subjects were 12 physicians from three regions of the country. Six were male and six female. They were all either in full-time clinical practice, or had had substantial clinical practice experience. All were referred to me because intervening contacts thought that they would have an interest in talking about spiri- tuality and medicine. They were involved, to a greater or lesser extent, with a broad variety of spiritual communities, reflecting both Western and Eastern traditions.

I spoke with all of them about their experiences and perspectives about spirituality and medicine, then processed the interview tran- scripts according to a typical content analysis methodology. The results were striking both for what these physicians did not talk about and what they did talk about.

These physicians did not much speak about religion, spiritual history-taking, chaplains, or spiritually-related techniques such as prayer and meditation. Rather, they told rich and touching stories of patients’ struggles, courage, determination and really coming to grips with issues of what it means to live, and to die. They told stories, as well, about their own lives and, often, what it meant to

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them to be doctors and healers. I had a fellow who started seeing me for some sinus problems and

back problems. As I began to get to know him, he kind of opened up a little and said that his son had been killed in an auto accident about a year or two before. We talked a little bit about it and he kind of closed off the discussion and I wrapped up the medical things and gave him a prescription and he went on.

He came back again about a month later. He was having more back problems and some stress situation reactions. We talked again and I asked him how he was feeling. Was he depressed at all? And how he was dealing with the fact of losing his son? So that gave us the opportunity again to talk a little bit more about that. And he broke down. He said he thought he had begun to turn a corner, but it was still really hard.

He just cried and said, “It was the worst thing I ever had to deal with. I was depressed and I really wanted to kill myself.” I said, “Well, what has started to make a difference?”

And he said, “The last time you talked to me, you know, you were so concerned about how I was doing… I felt like you really understood what it was like to go through what I’d been going through. I remember you asked what I was doing for myself… was I exercising, was I seeing friends, had I been going to church, and things like that. After that, my wife and I sat down and talked. I turned on the TV to one of the religious programs and we listened and we started doing those things again. It’s really made a difference in my life.”

Over the next few months, he got a job at Ignatius house, which is the AIDS program here in town. He put his heart into that and really started talking with those fellows about how they were doing, too. He said it’s made a difference. We got him into counseling. He’s gone back to church. Stopped alcohol, stopped the meds he’d been taking. I really have seen a big change in his life. It’s not like I deserve the credit for all of this, but I think I may have had a role in caring about him and encouraging him about the things that might help him to bring his life back together.

Most healing traditions are deeply rooted in narrative and story- telling. Even in Western medicine, we typically begin our conver-

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sation about people with stories: “I have a 47 year old bank manager who was working in his garden Thursday when he experienced a sharp pain…”. As we hear (and participate in) patients’ stories, spir- ituality “comes alive” and engages the listener. Something happens to us personally and spiritually as we hear people’s stories of pain, suffering, courage, determination and commitment.

Spirituality as “embodiment,” rather than “specialty” Spirituality in health care subsumes, but is not defined by, specific techniques and approaches.

We will consider in the next chapter a substantial research lit- erature on the relationships between spiritual and religious beliefs and practices and health. Much of this research looks at the ben- eficial effects of a variety of observable behaviors and spiritual tech- niques… religious institution attendance, prayer and meditation, spiritual assessment, chaplain consultation, and so forth. As we work with patients, we try to understand and support the spiritual practices that have been helpful to patients, and to find concrete spiritual resources that have been helpful to us.

While we embrace such techniques and approaches in working with patients, however, I believe that the definition of spirituality in health care is broader than techniques and approaches. An inte- grative approach to thinking about spirituality has its roots in the ways in which spirituality informs who we are as people and prac- titioners, and how spirituality informs the mission and culture and spirit of the organizations of which we are a part. It has its roots in the larger picture of how “the spiritual” is embodied, and given life, in the experience of patients and in ourselves. For a patient with metastatic cancer, coming to an understanding of what life will be about and what is “vital and sacred” during their remaining time is the larger picture. The techniques we use, such as prayer, medi- tation or religious participation can be viewed as methodologies in service to this larger picture.

The “landscape” of spirituality, in other words, is large. Specific techniques and approaches dot the landscape, but do not define

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the whole picture. The specialty model. I have proposed two contrasting per-

spectives on the larger picture of spirituality in health care; the “specialty” model and the “embodiment” model.6 What I call the “specialty model” views spirituality as a specific content area, or area of technical expertise, in parallel with countless other content areas (such as cardiology and ENT) that health care practitioners need to make a part of their repertoire. Primary care physicians, for instance, operate from a variety of specialty areas as the clinical situation warrants. Sometimes they may “do” cardiology in working with a patient with heart disease. Sometimes they may “do” neurology, or gastroenterology, or orthopedics. At other times, they do not engage these specialty areas. There is not much need for a textbook of In- ternal Medicine when doing a well-child exam, for instance.

In the “specialty model,” spirituality is incorporated in the process of health care in the same way as any other specialty content area; sometimes you “do it” and sometimes you don’t. In this model, certain clinical situations (such as death and dying or profound disability) lead health care practitioners to shift into a “spirituality mode” and engage this particular content area with specific techniques and approaches. Practitioners may conduct an organized spiritual assessment, recommend prayer, teach medi- tation, and so forth. Apart from clinical situations that trigger the spirituality mode, spirituality content is put away, just as one keeps the Medicine textbook on the shelf during the pediatric exam.

The embodiment model. We may contrast the “specialty” way of thinking about spirituality with what I call the “embodiment model.” In the embodiment model, spirituality lies at the core of what it means to be a provider of health care, acting as an agent of healing in people’s lives.

Spirituality is embodied in everything we do. The work that we do as health care practitioners is informed and guided by how we see ourselves and how we come to understand and give life to our sense

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of vocation, calling and mission. No matter what the content area, there is a spirit in the room as

we work with patients… which we can feel and experience, even if it can’t be adequately put into words. We may try, perhaps with some success, to capture this spirit with a variety of words… calm, compassionate, time-urgent, businesslike, welcoming, honoring, ana- lytical, detached, and so forth.

We will consider later some of the literature on “presence” and “intention” in health care. The thrust of this literature is that our spirits, or the ways in which spirit is visible or experienced in us as health care givers… matters. How spirit is embodied in the work we do, in other words, has a bearing on the healing process.

I have an elderly patient who has struggled for many months with the impending death of her sister from end stage CA. She always included a description (usually tearful) of how her sister was doing at her visits with me, as well as what it was like for her to experience her sister’s decline. She was especially feeling helpless and guilty as the oldest sibling who’d been the one others would always look to for help in the past. At first I was uncomfortable as I felt something more was expected of me besides listening. However at subsequent visits I realized she just needed to tell her story. Even though the telling was not easy she always seemed lifted after and I could sense a deepening spiritual connection between us.

The term, “spiritual connection” signifies to me that a spirit of healing has been embodied in the person and presence of this prac- titioner. I would not be surprised if the patient were to describe this relationship with words like “respect” or “safety” or “compassion” or “caring” or even “love.” It can perhaps be argued that what the practitioner is doing in this relationship is reducible to definable techniques such as active listening, or perhaps qualities of non- verbal behavior like optimal eye contact and physical distance. I don’t doubt that behaviors and techniques at this level could be reliably identified on a videotape of office encounters with this patient, but my belief is that what is happening is not fully re-

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