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Pathologies of the Spirit & Soul

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Spiritual distress and spiritual crisis occur when individuals are unable to find sources of meaning, hope, love, peace, comfort, strength and connection in life, or when conflict occurs between their beliefs and what is happening in their life. This distress can have a detrimental effect on physical and mental health.¹

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Just as there are physical and mental illnesses, or pathologies, there are spiritual ones. Eric mentioned he has “other wounds that no one can see that hurt the most.” Many people have those wounds. Spiritual pathologies are linked to poorer health outcomes (mental and physical), and addressing them is an important aspect of integrative care.²

Common spiritual problems, and examples of what a person who experiencing them might say, include the following:

• Spiritual alienation. “I feel abandoned by my Higher Power. I feel disconnected from myself, from others.”
• Spiritual anxiety. “I feel unforgivable. There is so much that I don’t know.”
• Spiritual guilt. “I deserve to be punished. I must have done something wrong, to feel this way. I am full of regret.”
• Spiritual anger. “I am angry with God. I hate the Universe. I feel betrayed.”
• Spiritual loss. “I feel empty. I do not care anymore. I am not sure what matters anymore. My sorrow is overwhelming.”
• Spiritual despair. “There is no way a Higher Power could ever care about me. I have lost my hope. Things feel meaningless.”

These pathologies can arise when a person experiences moral injury. Moral injury, which is often described in terms of experiences people have related to combat situations, occurs when a person commits an act, or is unable to prevent an act, that goes against his or her deeply held moral beliefs.³ As one expert describes it, “This construct attempts to capture the constellation of inappropriate guilt, shame, anger, self-handicapping behaviors, relational and spiritual/existential problems, and social alienation that emerges after witnessing and/or participating in warzone events that challenge one’s basic sense of humanity.”⁴ Examples might include incidents relating to death or harm to a civilian, being under friendly fire, being unable to prevent a comrade’s death or suffering, or violating rules of engagement to save a comrade.⁵

In essence, Eric’s experience is similar to the moral injury a soldier might experience. He saw people being harmed, was harmed himself, and had no ability to prevent the horrible events he saw going on. It is not surprising that moral injury is linked to PTSD and other mental health problems, such as depression and suicidal ideation. Other sequelae include social problems, mistrust, existential issues (eg, loss of one’s faith), feeling betrayed, and valuing oneself less.⁶

There are various therapeutic approaches that are being used to help people struggling with moral injury. One way is to explore the mismatch between a person’s meaning system (their values, principles, etc.) and the realities of a morally injurious experience (MIE). Meaning making, which involves trying to give the experience a context in terms of one’s meaning system, has shown promise.⁷ Having conversations about meaning and purpose, which is fundamental to an integrative health approach, may be helpful. This may not be possible for the rounding team in a hospital to do, but chaplains, social workers, psychologists, and others may be able to offer additional support.

Who Are Chaplains?

It can be really hard—or really easy—to explain what I do for a living. Chaplains share academic training with clergy, but we complete clinical residencies and work in health care organizations. Our affinities are with the patient and family, but we may also chair the ethics committee or serve on the institutional review board, and we spend a lot of time with staff. We must demonstrate a relationship with an established religious tradition (in my case, United Church of Christ), but we serve patients of all faiths, and of no faith, and seek to protect patients against proselytizing. We provide something that may be called "pastoral" care, "spiritual" care, or just "chaplaincy"—but even among ourselves, we do not always agree about what that thing is.⁸

During World War II, on February 3, 1943, the US ship Dorchester was torpedoed as it moved through the Atlantic toward Greenland. There were four chaplains on board, from different denominations. They helped to calm the 902 men on board after electrical power was lost. They organized an orderly retreat in lifeboats. When it became necessary, they gave up their own life jackets and were last seen singing hymns as, arm-in-arm, they went down with the ship.

Any health care provider who has worked closely with a skilled chaplain likely recognizes qualities in them that they share with the “Four Chaplains of the Dorchester.” Most chaplains seem to innately “get” what care of the whole person truly means, and they make incredible contributions to enhancing it every day.

Modern health care chaplaincy had its origins in the 1920s with the work of Reverend Anton Boisen, who worked with patients at Worcester State Hospital in Massachusetts.⁹ Chaplains are individuals—often members of the clergy—who usually have received advanced training in working with people in health care settings. Board certification, while not completed by all chaplains, especially in more underserved locations, requires completion of 1,600 hours of supervised clinical pastoral education training in an accredited hospital-based program. Chaplain trainees must demonstrate competence in twenty-nine different areas.

What Do Chaplains Do?

Research in many fields indicates that chaplains’ roles are highly varied.¹⁰ Some of their responsibilities include the following:

• When people experiencing pain, illness, or loss ask, “Why did this happen to me?” Chaplains may not have an answer for the question, but they can be present to help patients find their own answers.
• Chaplains may spend a lot of time focusing with patients on the “why,” ie questions related to meaning. For many clinicians, the task is to focus primarily on questions of “What is the medical explanation for what is happening?” or “What can be done to solve a problem?” Even when that is not the main focus, their work responsibilities may limit the time they can spend addressing suffering and spiritual needs. Chaplains can offer support as patients ask, “Why did this happen to me?”
• They can offer prayers or perform specific ceremonies or services, depending on a patient’s particular spiritual/religious background. They might lead meditation or reading of holy texts, assist with observance of holy days, anoint the sick, assist with memorial services, or facilitate holiday observances.
• Chaplains listen, and they help support decision-making and communication with other members of a person’s care team.
• They support patients’ family members.
• They offer support with end-of-life care and decision-making, including, in some locations, assisting with completion of Advance Directives.
• They address ethical concerns of staff and patients.
• They offer compassion and empathy.
• Chaplains add information about spiritual concerns and pastoral care interventions to the medical record.
• They share in positive experiences—recoveries, good news, celebrations—as well.
• They connect patients with appropriate clergy members, based on individual needs.
• Many chaplains provide all these services for health care colleagues as well as patients.

What Does the Research Tell Us About Involving Chaplains in Care?

Spiritual care unique to veterans includes forgiveness for war crimes or sin, working through guilt related to killing in war, reconnection to God, honor for what they have done for their country, and connection to religion through hospital chaplains because of the lack of their own churches or pastors.¹¹

Providing spiritual care improves patient outcomes. That idea is intuitive for most people, and it is supported by research. Chaplains fill an important niche on an interprofessional care team. Many clinicians are uncomfortable discussing spiritual issues or responding to patients’ responses on spiritual assessment tools.¹² Many clinicians do not have the time required to offer good spiritual care. Chaplains are comfortable working in these areas.

There is a need for more research related to chaplaincy, spiritual care, and patient outcomes, but there are some noteworthy study findings.

• A 2014 study of a group of primary care centers in England found that, even after controlling for numerous variables, there was a significantly positive relationship between well-being scale scores and having had a consultation with a chaplain.¹²
• A Canadian study concluded that “having a chaplain who supports the emotional and spiritual needs in the health care workplace makes good business sense” because one-third of the workers met with the chaplain at least once.¹³
• A 2017 mixed-methods study gathered data from 200 patients, as well as medical students and residents who had recently interacted with chaplains.¹⁴ 93% of patients felt that their interactions with chaplains changed their lives in a positive way. 88% of students and 93% of residents fully agreed chaplains were useful and important members of a care team, and fewer 1% of each group disagreed, versus feeling neutral.
• A 2013 survey of VA chaplains found that chaplains most commonly saw patients in the VA for anxiety, alcohol abuse, depression, guilt, spiritual struggle with understanding loss or trauma, anger, and PTSD.¹⁵
• There is room for greater integration of mental health professionals and chaplaincy services.¹⁵ There is also a need for more involvement of chaplains in interdisciplinary cancer care.¹⁶

When Should I Call a Chaplain?¹⁷

Here are some examples of when it might be helpful to call for a chaplaincy consult or otherwise request their services:

• A patient, family member, or care team member displays symptoms of spiritual distress, or spiritual pathologies, including the following:¹⁸
  • Expressing a lack of meaning and purpose, peace, love, self-forgiveness, courage, hope, or serenity
  • Feeling intense anger or guilt
  • Displaying poor coping strategies
  • Struggling with moral injury, as described earlier.¹⁵
• Someone requires additional assistance exploring the meaning of what is happening to them.
• Someone needs support with coping with the illness or death of a loved one.
• Ethical uncertainties or moral dilemmas have arisen around someone’s care.
• A patient (or family member, with the patient’s permission) wants to connect with clergy from their religion or wants have a particular ceremony, rite, or holiday observance performed.

Additional Resources

To learn more about chaplains, check out the following:

• Association of Professional Chaplains
  • National organization with resources explaining who chaplains are and what they do
• VA Chaplain Services
  • A video that explains a chaplain’s role to patients.
• Feldstein, BD. Bridging with the Sacred: Reflections of an MD Chaplain. J Pain Symptom Management. 2011;42(1):155-61.

Developing Your Own Spirit & Soul Skills

It is clear that Eric, our patient, has a number of spiritual concerns, and these are perhaps the highest priorities for his ongoing care, especially now that his acute physical issue—his pneumonia and shortness of breath—is resolving. He completed a spiritual assessment, based on the IAMSECURE mnemonic, and it is clear he feels disconnected from his religious community. He has certainly been subjected to moral injury related to watching helplessly, having been shot himself, as others were killed. Eric is struggling with guilt and loss. His spiritual life seems less rich for him, and it is likely he is experiencing some spiritual despair, including a sense of unworthiness. What are Eric’s next steps? How can his care team be most helpful to him? How might his Whole Health team support him? In addition to having Eric speak to the team chaplain, which would be a high priority, some of the following tools and guidelines might also prove useful:

1. Know yourself. What do you believe?

A physician needs to understand his or her own spiritual beliefs, values and biases in order to remain patient centered and nonjudgmental when dealing with the spiritual concerns of patients. This is especially true when the beliefs of the patient differ from those of the physician.¹

First and foremost, it is vital that you, as a clinician, have a strong sense of your own spiritual beliefs and struggles as you approach the care of Eric and others like him. If you want to focus on “Spirit & Soul” as an essential part of your patients’’ self-care, you will inevitably encounter situations where knowing your own perspectives will be vital. For example, with Eric, it will likely help if you have a sense of the following:

• What your personal faith, tradition, beliefs, and practices are (or are not)
• Whether or not you believe in a Higher Power
• What you think about prayer
• Your perspectives on sin and punishment
• How you relate to guilt yourself
• Your comfort with the concept of forgiveness and your view of its relevance to medical settings
• Your comfort with discussing these topics with others (which will increase as you give greater attention to all these areas).

See “Assessing Your Beliefs about Whole Health” for additional guidance with exploring these issues. To explore working more effectively with clashes between your beliefs and those of others, go to “How Do You Know That? Epistemology and Health.”

2. Know about coping.

In a 2006 essay on spiritual growth and illness, Tu describes three stages that people experience during the coping process:

The first stage occurs during an acute, serious illness and characterizes the patient and family as withdrawn, shocked, passive, compliant, and unquestioningly dependent on the care-providers. The second stage is one of struggle, and is characterized by refusing to take pills and trying to regain control, in addition, to re-examining the cause of the illness so as to prevent its recurrence. Finally, the third stage, which does not always occur, may depend on the patient’s and family’s life experiences and on the seriousness of the illness. The third stage of the coping process involves a far-reaching assessment into the meaning of suffering and life. Thus, the third stage is regarded as the spiritual stage, which originates from inner self-reflection and the reorganization of one’s value system with respect to existence in the universe. Because of this, growth may change and enrich a patient’s life after illness…¹⁹

Many patients are most in need of additional support when they are at Stage 2 and potentially moving into Stage 3. This is the case for Eric, and it is the case for many people going through some form of loss. As Tu goes on to elaborate,

However, growth in spirituality is not limited to illness or death. Any severe loss in life may lead to the reordering of one’s value system, such as the loss associated with physical disability, bereavement, or bankruptcy. Moreover, any severe disappointment or maladjustment may also provide an opportunity for spiritual growth. In the face of the threat of death, the fear and anxiety of “becoming nothing” tend to pool all the patient’s past, present, and future anger and pain together, resulting in an even stronger motivation for a spiritual solution.¹⁹

What you, as a clinician, can do to help someone move through these stages will vary based on your personal beliefs, training, scope of practice, and comfort level. Of course, it will also vary based on the unique needs of any given patient. Exploring options is much less daunting if you remember that it is a collaborative process. The patient’s entire team ideally will participate, and the patient is the captain of that team.

Keep asking what you can do to help, in whatever your role is. Van Leeuwen and Cusveller, suggest that nurses can do much to help people meet needs such as performing everyday spiritual rituals (e.g. giving them opportunity to pray, honoring diet requests, helping them with Sabbath observations).²⁰ Similarly, all the members of a patient’s team can help to console anyone who is experiencing general stress. When true spiritual distress arises, though, it is important to involve others with additional expertise. These others may include chaplains, clergy, spiritual directors, shamans, medicine men and women, or others, depending on the patient’s background and preferences.

3. Listen

An important aspect of working with “Spirit & Soul” is asking the right questions. Spiritual care is about recognizing and responding to the “multifaceted expressions of spirituality” clinicians encounter.²¹ Simply listening, with compassionate and nonjudgmental presence, promotes better health. “The Power of Your Therapeutic Presence” explores this important topic in more detail.

4. Discuss forgiveness, when appropriate

“Forgiveness: The Gift We Give Ourselves” explores the importance of forgiveness, outlines how forgiveness might unfold, and discusses forgiveness research. Studies indicate that people who are more inclined to forgive have lower blood pressure, muscle tension, and heart rate and fewer overall chronic conditions.^22,23 Of course, how forgiveness fits into a person’s overall perspectives and life experiences will determine whether or not a clinician raises the topic. Forgiveness is given different emphasis in different spiritual and religious traditions.

5. Encourage a patient to start a spiritual practice of his/her choice

What starting a spiritual practice looks like will vary from person to person. Some people may choose to join a particular spiritual group or community, be it a church, a scripture study group, or even a 12-step program. Others may wish to find a teacher who will work with them individually, or they may choose a solo practice, such as praying or meditating quietly on their own on a regular basis. It may be helpful for you to briefly describe a variety of spiritual practices that others find helpful. Regularly spending time in nature can be a useful spiritual practice, as can various creative pursuits. Some people gravitate toward doing a regular loving-kindness meditation. Trust that patients will have insights into what works best if you help them explore their options.

6. Work with spiritual anchors

At the end of the Healer’s Art medical student course, participants are given a small object, such as a palm-sized stuffed heart, to carry with them in their white coat pockets. This heart is their anchor, a reminder to them of their purpose in going into medicine, of their truest nature. To learn more, refer to “Whole Health Tool: Spiritual Anchors” in the Passport to Whole Health.

7. Broaden your familiarity with other belief systems

Doing so can be useful in terms of offering care that displays cultural humility as well. A useful online guide entitled “Religious Diversity: Practical Points for Health Care Providers” can be found at the Penn Medicine website.

8. Avoid pitfalls along the way

Take care not to proselytize. It is not helpful to try to impose your perspectives on others. Do not try to resolve unanswerable questions. And do not say any of the following, if at all possible:²⁴

• “It could be worse.”
• “We are all out of options.”
• “It’s God’s will.”
• “I understand how you feel.”
• “We all die.”

Back to Eric

Eric had two additional important visitors before he left the hospital. One was the pastor of his church, with whom he agreed to visit. The other was the hospital chaplain. Over a few days, both spent a several hours sitting with Eric and discussing his concerns in greater depth.

No one, at any point, told Eric that what he was experiencing was “wrong.” On the contrary, he was encouraged to voice his concerns and talk about what happened to him during the shooting and how it affected his beliefs. Topics such as moral injury and ways to work with pain and suffering were raised.

When the team sees Eric on his day of discharge, he informs them that he plans to meet with a psychologist who is comfortable with incorporating Eric’s spiritual perspectives. Eric also has agreed—tentatively—to try doing some work with forgiveness. He understands that forgiveness is, first and foremost, about freeing himself from what happened in the past, and while he is not sure he can ever forgive the person who shot him and many others, he is willing to explore this.

Eric made an agreement with the chaplain, as a “homework assignment,” to take 10 minutes every day to pray, or—if praying just doesn’t feel right—to quietly reflect or read scripture. He isn’t ready to go back to church, but he is hoping that eventually the time will come. He also agrees to carry a photo of his wife and children with him as a spiritual anchor, a reminder of what really matters to him.

As the team says good-bye to Eric on his last day at the hospital, he says, “Thanks for taking the extra time to help me. I feel a lot better, and I don’t just mean my lungs. We’ll see how it goes.” His wife, Julie, calls the team later and expresses her gratitude as well.

Integrative Health Tools

• Assessing Your Beliefs about Whole Health: Considerations for Clinicians
• How Do You Know That? Epistemology and Health
• The Healing Benefits of Humor and Laughter

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

References

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