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Spirit & Soul is an element of Self-Care in the Circle of Health that can mean many things to many different people. When all is said and done, the focus is on what brings meaning and purpose into a person’s life. When an Integrative Health plan is being created, the focus may be on a person’s religious beliefs, their spiritual perspectives (which may or may not be linked to religion) or to other aspects of their lives that tie into “what life is all about.” This overview builds on Chapter 11 of the Passport to Whole Health, focusing on how Spirit & Soul can best be discussed in the case of a specific person.

Key Points

• Always take time to frame care in terms of what really matters to someone. Develop a sense of what gives someone’s life meaning and purpose and let that guide personal health planning.
• Most patients want to talk about their spiritual and religious beliefs with their clinicians, but they do not if they feel their clinicians will not know what to do about their concerns.
• Most clinicians are not trained in discussing spirituality and do not bring it up, unless perhaps end-of-life decisions are being made. Leave room for Spirit & Soul in your conversations.
• When exploring Spirit & Soul, it helps to have a framework for gathering information. There are many mnemonics, like IAMSECURE, that cover a variety of potentially useful topics.
• Research has found that religiosity and spirituality favorably affect coping skills, the severity of many health concerns, coping, and healthy lifestyle choices. Examples of conditions that benefit include depression, anxiety, coronary artery disease, HIV, elevated blood pressure, substance use disorders, and chronic pain.
• Pathologies of the spirit—e.g. spiritual guilt, spiritual anger, and spiritual despair—are important to discuss, when appropriate. The effects of moral injury on someone’s health should also be addressed.
• There are many Spirit & Soul tools and skills you can suggest. It can help to discuss forgiveness, spiritual anchors, and ways a person can start a spiritual practice. Discussing coping helps. To more fully support others (and because your self-care is vital in and of itself), it is vital you explore your own beliefs and truths as a clinician.

Meet the patient: Eric

During a typical hospital workday, the inpatient team stops to round on Eric, a 39-year-old father of three. Eric was admitted with COVID-19 pneumonia a week ago after having increasing shortness of breath over the three days prior to admission, with an accompanying drop in his oxygen levels. He is now improving, avoided intubation, and will likely be discharged in a few days.

Eric is a survivor of an incident in a mall involving an active shooter. He was shot in the left leg. His leg was saved by a vascular surgeon, but he was told that he will walk with a limp for the rest of his life. When you ask him how his leg is doing, he acknowledges that it hurts. Then, in a lower tone of voice, he mentions that “my leg isn’t where I was really wounded.” You ask him what he means, and he just shrugs his shoulders, saying, “Never mind.” He looks away until his team leaves.

Eric’s wife, Julie, who has been unable to be in Eric’s room but has been checking in regularly via phone, mentions that one of the most important things in Eric’s life before “what happened at the mall.” He was involved with his church, and he was “very spiritual.” When you ask what she means, she tells you that he used to get a lot of strength from praying, was always very kind and helpful to others, and was a very hopeful and grateful person. “Now,” she says, taking a quick sideways glance at her husband, “things are different. He withdrew.”

One of your colleagues asked Eric to complete a Personal Health Inventory when he was first admitted. A few of his answers stand out as you review it.

• Eric rates himself quite low on all the Vitality Signs:

• He has a unique answer for the question designed to capture Meaning, Aspiration, and Purpose (MAP):

I just want to put the past behind me. I take it day by day. My wife and kids, and all the people who I care about are all that matters to me.

• Eric gives himself a 3 out of 5 on every self-care item on the PHI, with the exception of Spirit & Soul; for that, he rates himself a 1 out of 3.
• The final question on Eric’s Brief PHI is not particularly revealing:

Mindful Awareness Moment:

Responding to Eric and Julie

Take a moment to consider how you would respond to Julie’s concerns about Eric. Options could include:

• Not pursuing the topic further because you feel uncomfortable
• Telling them to discuss this with his primary care clinician
• Calling in someone from Eric’s religious community, if possible
• Asking the hospital chaplain for help
• As time allows, asking him if the two of you can explore his spirituality in greater depth, either now, or after you have completed rounds, or at some other point
• Some combination of the above
• Something else not listed here

Which answers did you choose, and why?

Introduction

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The twenty-first century will be all spiritual or it will not be at all.

—André Malraux

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Different clinicians choose to approach the topic of spirituality with their patients in different ways. How you choose to approach concerns such as those brought up in the narrative about Eric and Julie will be informed by many factors, including:

• Your level of awareness about research related to spirituality, religion, and health. This is discussed in more detail below.
• How much time you have. Time constraints can be a challenge, especially on a busy inpatient service.
• Your comfort level.
• Knowledge of the resources available to you in your practice, ranging from hospital chaplains and local clergy to online and printed resources focusing on spirituality and health.
• Your own personal beliefs and perspectives surrounding spirituality, and how those have been shaped by your personal experiences and self-exploration. This is not to imply that all clinicians must have a specific perspective, or that it is appropriate to encourage their patients to share those beliefs. However, it is helpful, when working with patients, to have thought through your own ideas about tough questions such as:
  • Why do we exist? What is the meaning of life?
  • Why there is suffering?
  • What do you believe happens (if anything) after a person dies?
  • Would you pray with a patient, if you were asked to?
  • Is there a God or Higher Power?

To explore your beliefs in greater depth use the “Assessing Your Beliefs about Whole Health” tool.

Regardless of your perspective, paying attention to the perspectives of patients and others when it comes to these issues with will enhance your ability to offer whole-person care to your patients, including the ones, like Eric, who have “invisible wounds.”

Why “Spirit & Soul” Matters

Spirit & Soul are linked to personal health planning in many ways:

• Spirituality is an important aspect of self-care. Whole-person care requires that it be included along with all the other aspects of who a person is. It has its own green circle in the Circle of Health (Figure 1).
• Conversations about Spirit & Soul bring more depth and richness to patient visits. Meaning, values, suffering, death, and life purpose–various existential questions–cannot be overlooked in health care without our work losing some of its meaning.
• For many people, Spirit & Soul helps to define mission, aspirations, and purpose (MAP). It is at the core of why they want to be healthy in the first place.
• Spirituality informs therapeutic approaches, particularly those classed as complementary and integrative health (CIH)¹, which are woven into an integrative approach to care.

This overview reviews some of the latest research surrounding spirituality, religiosity and health. It is clear that both have a significant influence. A 2011 meta-analysis compared health effects of high levels of spirituality and religiosity to the effects of a number of other preventive health measures.² The authors reported an 18% reduction in mortality for people who report being religious and/or spiritual. This is equivalent to the cardiovascular benefit one gets from consuming healthy amounts of fruits and vegetables. In fact, having high levels of religiosity/spirituality has as much benefit (or more) as:

• Air bags in automobiles
• Taking angiotensin receptor blockers for chronic heart failure
• Screening for colorectal cancer using fecal occult blood testing
• Prescribing statin therapy for people without heart disease
• Out-of-hospital defibrillation
• Exercising
• Quitting smoking
• Getting a flu shot each year

This is not to downplay the importance of those other interventions; it is simply to say that spirituality matters to health too, and research has found measurable benefits.

Figure 1 highlights some of the topics that could be covered when incorporating Spirit & Soul into a PHP. This overview explores all of them in more detail.

Figure 1. Examples of Topics Related to Spirit & Soul

Defining Spirituality, Soul, and Religion

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Just as a candle cannot burn without fire, men cannot live without a spiritual life.

—Buddha

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Before focusing more on research that might inform your practice, it is important to clarify some definitions. Roger Walsh, MD, author of Essential Spirituality, defines spirituality as the “…direct experience of the sacred.”³ Fred Craigie, PhD, who teaches widely about spirituality in medicine, defines spirituality simply as, “What life is about.”

Soul, in its most general sense, is what makes something or someone alive. For some people, this can be related to a part of something or someone that survives after its body dies. Some people relate it to energy or vitality. For some, it ties into what brings meaning and purpose to existence.

Religion, in contrast, has been described as “…a body of beliefs and practices defined by a community or society to which its adherents mutually subscribe.”⁴ Religiosity, a term used frequently in research studies, is the quality of having strong religious beliefs or feelings.

Religion is important to many people. Among all US adults, 77% subscribe to a religious tradition. Roughly 71% of those are Christian, 5% are other religions (Jewish, Buddhist, Muslim, Hindu), and 23% are unaffiliated (atheist, agnostic, or “nothing in particular”⁵). Of the unaffiliated people, 18% described themselves as religious, 37% said they were spiritual but not religious, and 43% said they were neither.⁶

How are spirituality and religion different? As one religious teacher put it, “Religion is a bridge to the spiritual, but the spiritual lies beyond religion.”⁷ Some people will note that they are spiritual without being religious. Others will describe religion and spirituality, for them, as being the same thing. Of course, there is no expectation that you, as a clinician, need to be spiritual or religious, or that your spiritual and religious paths be similar to those of your patients, in order for you to be able to offer them personalized, proactive, and patient-driven care.

Ultimately, the definition of spirituality is highly individualized; each of us experiences the sacred in different ways. This is even true for people who belong to the same religion. Keeping the definitions of spirituality and religion inclusive allows for a great deal of leeway, which is essential if Whole Health care of “Spirit & Soul” is to be truly personalized to the needs of any given patient.

Mindful Awareness Moment

Aspects of Spirituality

Consider the six aspects of spirituality listed below. These are not mutually exclusive; some people may resonate with more than one of them. There may be others that you think of that are not on this list.

1. Religious spirituality. Closeness and connection to the sacred as described by a specific religion. There may be a sense of closeness to a particular Higher Power. Note that the other elements of spirituality listed next are common to many different religious traditions.
2. Humanistic spirituality. Closeness and connection to humankind. It may involve feelings of love, reflection, service, and altruism.
3. Nature spirituality. Closeness and connection to nature or the environment, such as the wonder one feels when walking in the woods or watching a sunrise. This is an important focus for many traditional healing approaches.
4. Experiential spirituality. Shaped by personal life events. It is influenced by our individual stories.
5. Cosmos spirituality. Closeness and connection to the whole of creation. It can arise when one contemplates the magnificence of creation or the vastness of the universe (e.g. while looking skyward on a starry night).
6. Spirituality of the mysterious. There is much that we simply cannot know or understand; perhaps it is not possible to fully grasp or know, and we must allow for the unknowable.

Which, if any, of these descriptions resonate most with you? Would it be helpful to consider these different aspects when discussing spirituality with patients? Can you think of other aspects not listed above?

Here are some thoughts about the nature of spirituality from various traditions:

Spirituality may be thought of as that which gives meaning to life and draws one into transcendence, to whatever is larger than or goes beyond the limits of the individual human lifetime. Spirituality is a broader concept than religion. Other expressions of spirituality may include prayer, meditation, being in community with others, involvement with the natural world, or relationship with a transcendent reality.⁸

Spirituality is the personal quest for understanding answers to ultimate questions about life, about meaning and about the relationship with the sacred or the transcendent which may (or may not) lead to or arise from the development of religious rituals and the formation of the community.⁹

Spirituality is distinguished from all other things—humanism, values, morals, and mental health—by its connection to that which is sacred, the transcendent. The transcendent is that which is outside of the self, and yet also within the self—and in Western traditions is called God, Allah, HaShem, or Higher Power, and in Eastern traditions may be called Brahman, manifestations of Brahman, Buddha, Dao, or ultimate truth/reality. Spirituality is intimately connected to the supernatural, the mystical, and to organized religion, although it also extends beyond organized religion (and begins before it).¹⁰

The nomadic gatherer-hunters live in an entirely sacred world. Their spirituality reaches as far as all of their relations. They know the animals and plants that surround them and not only the ones of immediate importance. They speak with what we would call “inanimate objects,” but they can speak the same language. They know how to see beyond themselves and are not limited to the human languages that we hold so dearly. Their existence is grounded in place, they wander freely, but they are always home, welcome, and fearless.¹¹

It may be that exploring the relationship between spirituality and Whole Health is more about asking questions than providing answers. Perhaps it is more about providing a context for exploration and helping people discern what they need—and whom they need—to accompany them on their paths. As Rachel Remen puts it in her book, Kitchen Table Wisdom:

I have come to suspect that life itself may be a spiritual practice. The process of daily living seems able to refine the quality of our humanity over time. There are many people whose awakening to larger realities comes through the experiences of ordinary life, through parenting, through work, through friendship, through illness, or just in some elevator somewhere. ¹²

What Do Patients and Clinicians Believe?

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We are not human beings having a spiritual experience, we are spiritual beings having a human experience.

—Pierre Teilhard de Chardin

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Patients and Spirituality

According to Gallup Polls, 89% of Americans believe in God or a universal spirit.¹³ Over the last 20 years, a consistent 54%-58% of respondents note that they consider religion to be “very important” to them. According to a Mayo Clinic study, 94% of all patients regard their spiritual health to be as important to them as their physical health.¹⁴ Forty percent of elderly patients rely on faith for coping with illness.¹⁵ The 2010 Baylor Religion Survey reported that 87% of respondents had ever prayed for other people, 79% had prayed for themselves at some point, and 26% had tried laying on of hands.¹⁶

Depending on the study, between 66% and 83% of patients report that they prefer to have their physicians ask them about their spiritual or religious beliefs.^17-19 The sicker people are, the more they seem to want their physicians to discuss spirituality. A 2001 study of a large sampling of patients found that 19% wanted spirituality and religion to be discussed in a routine office visit, 29% would want it if they were in the hospital, and 50% would want it at the end of life.¹⁹ However, patients report they do not bring these issues up because they do not think their clinicians are prepared to address them.²⁰

Clinicians and Spirituality

Physicians (who are the most studied when it comes to different clinician groups and spirituality) also report a strong spiritual connection. A 2017 study found that 65% of physicians in a multispecialty referral center believe in God.²¹ Forty-five percent reported praying regularly, and 21% had prayed with patients. Seventy-nine percent of family physicians identified themselves as “very” or “somewhat” strong in their spiritual beliefs.²² A survey found that 96% of family physicians feel spiritual well-being is a factor in health.⁸ In one survey, 85%-90% of physicians reported that it was important for them to be aware of their patients’ spiritual orientation.²³

For all that they view it as important, they may not be asking about it, however. In one survey, 80% of respondents reported their physicians “rarely” or “never” discuss spiritual or religious issues.¹⁹ Physicians report asking about spirituality only 50% of the time when end-of-life²⁴ issues arise.

There are several reasons why this might be the case. When asked about barriers to doing spiritual assessments, clinicians responded as follows:²⁵

• 71% noted lack of time as an issue
• 59% cited lack of experience
• 31% were unsure that it was part of their role

Studies related to nonphysician clinicians and spirituality are not as easy to find. A survey of 774 trauma professionals (including nurses, physicians, and others) found that nearly 20% of them (compared to 57% of a sample of 1006 members of the general public) believed that someone in a persistent vegetative state can be saved by a miracle.²⁶ A majority of a sample of 5,500 British social workers acknowledged that spirituality is “a fundamental aspect of being human”²⁷, and many academic social workers mention the need for social work students to have more training in the area of spirituality. A 2006 study found that nurses are very skilled at identifying patients’ spiritual needs but do not necessarily have the skills and resources to respond to those needs once they identify them.²⁸

Integrative Heath Assessment: Spirit & Soul

The goals of the spiritual history include the following:²⁹

• Learn (and share as appropriate) about spiritual and religious beliefs.
• Assess spiritual distress or help patients draw upon their strengths.
• Provide compassionate care.
• Assist with finding inner resources for healing and acceptance.
• Determine spiritual/religious beliefs that could affect treatment choices.
• Identify whether or not someone needs a referral to a chaplain or other spiritual care provider.

Simply asking about spirituality can be an important aspect of drawing it into the personal health planning process. In fact, many who write about spirituality and health argue that, when it comes to this topic, asking questions is much more important than having answers. There is no requirement that a clinician agree with a patient’s beliefs, but it is certainly of benefit to know what those beliefs are, and how they tie in with their overall health.

A review of 11 studies concluded that there are six key aspects of spiritual care that are most fundamental to people and should be high priorities for clinicians to discuss. These include:³⁰

1. What gives them meaning, purpose, and hope
2. Their relationship if they have one–with God (or another Higher Power)
3. Their spiritual practices and how they follow them despite their health issues
4. Religious observances (celebrations, holidays, worship services, and ceremonies) they want to follow, and how they can do so despite their health concerns
5. Interpersonal connections
6. Interactions with health care team members

There are many ways to gather a spiritual history during a conversation with a patient, and a number of assessment tools have been created that help clinicians draw in the key aspects of spiritual care. These include an array of mnemonics, including FICA,³¹ HOPE,³² and SPIRIT,³³ which were ranked among the best of 25 different assessment scales assessed in a 2013 systematic review.³⁴ Choose one method, memorize it, and use it with your Veterans. Here is what some of the various mnemonics stand for:

• FICA reminds clinicians to ask about:^31,35,36
• Faith and Belief—the things that help a person cope with stress and bring meaning to life
• Importance—how belief affects self-care
• Community—role of a spiritual community in a person’s life
• Address in Care—how the care team should address concerns

Note that the creator of this mnemonic, Dr Christina Pulchaski, strongly recommends that people receive training prior to using these questions.

• HOPE focuses on:³²
• Hope—what provides hope
• Organized religion—is one in a community and is that helpful
• Personal spirituality/practices
• Effects on health care needs and end-of-life choices
• SPIRIT emphasizes:³³
• Spiritual belief system
• Personal spirituality
• Integration with a spiritual community
• Rituals and restrictions spirituality requires for health care
• Implications of spirituality and religion for medical care
• Terminal events planning (end-of-life issues)

The I AM SECURE Mnemonic

One tool, which is designed to highlight key topics in the spiritual care of Veterans using an integrative approach, is the I AM SECURE mnemonic. It covers multiple topics, and clinicians can choose which ones are most relevant to ask at any given patient encounter; you do not have to ask them all. The topics, and questions you can ask that relate to them, are as follows:

• Impact of past experiences. How have your life experiences affected your spiritual or religious beliefs? If so, how?
• Approach to your spirituality in a medical setting. How do you want members of your care team to approach this topic? Do you prefer that they bring up spirituality and religion, or not?
• Meaning in life. What gives you a sense of meaning and purpose? What really matters to you? What are your guiding principles? What do you want your health for? (This ties into the fundamental questions related to the Whole Health approach—the MAP questions).
• Spirituality—definitions and practices. What does spirituality mean to you? What are your most important beliefs and values? If spiritual practices are a part of your life, what are those practices, and how are they linked to your health? (This can often be a useful topic when a person does not have a specific religious affiliation.)
• Ease—sources of peace. What gives you ease? What helps you through when times are hard? What gives you hope or peace of mind?
• Community. Do you belong to a specific faith community or religious group?
• Understanding of why this is happening. What do you believe is the cause of your health problems? Why do you think this is happening?
• Rituals, practices, and ceremonies. Are there specific activities or ceremonies you would like to have arranged during hospital stays, or any beliefs that will affect how we take care of you? (Examples might include refusing blood transfusions, eating kosher, or wanting to fast for Ramadan.)
• End of life. What are your perspectives on death? How do your beliefs affect your decisions about end-of-life issues? (A discussion of code status and advanced directives might also be relevant here.)

If you are pressed for time. If you only have time to ask one specific question about spirituality, consider the following:

What gives you your sense of meaning and purpose?

The answers may surprise you, and they add depth and richness to conversations with patients. A number of answers have been reported by various clinicians who have asked this question:

• My faith
• My community
• Connections: my family, my life partner, my children, my friends, my pets, my community
• My meditation practice
• My work
• Doing good for others: Volunteer work, donating to charities, etc.
• Travel and experiencing new places
• Creative pursuits: My music, my dancing, my writing, my photography.

This one question can often take you to the heart of why health matters to a person. It is a “way in” as you work with patients to define their personal health missions.

Using “I AM SECURE” with Eric

With Eric’s permission, you sit down with him in his hospital room and ask him a series of questions, based on some of the most relevant topics covered in the I AM SECURE mnemonic, as described in the previous section of this overview. As you will note, these questions need not be asked in a specific order, and perhaps you will not ask all of them. Even if a person says they are not religious or spiritual, several of these questions are still relevant. Rather, they weave into the flow of the conversation. Eric answers the questions as follows:

Before you start with I AM SECURE, you ask about meaning: “Eric, tell me about your spiritual beliefs. What gives your life meaning?”

I grew up in a very religious family. We went to church every Sunday, and I enjoyed it. I was one of those kids who read the Bible out of interest, not because anyone made me. I used to pray every night before bed. Protecting others gives my life meaning. Doing good for people, whether they are people I love or people I hardly know, makes me feel like I matter. My three children and my wife matter most.

Impact of past experiences. It sounds like you have had some pretty intense experiences in your life. Can you tell me more about that?

I don’t like to talk about it, but what happened to me in the mall shooting a few years ago really screwed me up. I have always tried to help people. I always believed that is why we are here. Then, I saw people get killed, right in front of me. I was shot first, so I was just laying there watching, and people died. Even though it has been a few years since it happened, I still see their faces almost every night when I start to fall asleep. I couldn’t help them. I couldn’t... There are so many emotions. I am so angry. I don’t trust people anymore. If someone can be so evil, how can I possibly trust that the world is a good and safe place?

Mindful Awareness Moment

Reflect on how you would respond to what Eric just said. Some options include the following (and if you do this, you must be absolutely sincere):

• Validate Eric’s feelings. “I can understand why you feel…” This is especially important, because Eric has just revealed extremely personal information. To say nothing could feel like a breach of trust to him.
• Acknowledge the difficulty. “It sounds like this has been very difficult…” It is important to recognize that Eric carries this with him every day.
• Ask how he copes with it. “What helps you handle these challenges? What gets you through the day? What else would be helpful to you?” This can help to identify and invoke a person’s own beliefs/and resources for addressing these concerns. It taps into their resilience.
• Consider whether or not it is appropriate to refer him for additional mental or spiritual health support. “I am wondering, as I hear you describe this, if it would help for you to talk to someone who is very skilled with working with people in your situation…” Be careful, though, not to let it seem as though you are “turfing” him to someone else.

As Eric responds to other questions, consider how you could frame your responses to other statements that Eric makes to his team. The most important thing is to be sincere.

Rituals, practices, and ceremonies. Do your beliefs influence how you take care of yourself? How?

I always believed it was important to take care of the body and the spirit, and every other part of me. I don’t smoke, and I don’t drink very much, because I honor my body. But honestly, I still feel so bad that other people died, and I lived, and I almost feel like it is wrong for me to feel healthy. I am trying to wrap my head around why God would allow that kind of thing to happen, but I can’t. I know I have survivor guilt, but I can’t seem to do much about it.

Community. Are you part of a spiritual or religious community? Is this of support to you? How?

A guy at church heard the story of what happened to my leg, and he came up to me and patted me on the back. He said it was good that God saved me and that the “‘demon’ who did it killed himself.” Another time, a woman from church, who had a family member who died that day asked me how anyone could do something like that. Both times, I didn’t know what to say. Those conversations really shook me up. I have been avoiding church, because I just don’t feel very faithful right now, and I don’t want to talk to anyone else about what it was like. They mean well, but they don’t understand.

Approach to this in a medical setting. How should we draw spiritual issues into your care? Can we explore these issues more?

I don’t know. My spirituality is a part of who I am, so I can’t leave it out. What do you think I should do?

These answers are powerful. In just a few minutes, the conversation has shifted into a much deeper place. Eric’s answers suggests directions he could take as he creates an Integrative Health plan with his care team. What does the research tell us is (or is not) likely to be helpful in situations like Eric’s?

What we know about integrative health care has come to us thanks to the efforts, experiences, and collective wisdom of people from many cultures and backgrounds. We wish to acknowledge all the healers, researchers, patients, and peoples who have informed the content of this tool.

Author(s)

This overview was adapted for the Osher Center for Integrative Health at the University of Wisconsin-Madison from the original by J. Adam Rindfleisch, MPhil, MD.

Originally Created: 2014, Updated: 2018

Modified for UW Integrative Health: 2020

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