Screening for Spiritual Struggle

Transcription

1 Screening for Spiritual Struggle Association of Professional Chaplains September 23, 2009 Rev. James L. Risk III BCC George Fitchett DMin PhD BCC

2 Screening for Spiritual Struggle Rev. James L. Risk III BCC Executive Director Bishop Anderson House and Assistant Professor Department of Religion, Health, and Human Values Rush University Medical Center, Chicago, IL George Fitchett DMin PhD BCC Associate Professor and Director of Research, Department of Religion, Health, and Human Values Rush University Medical Center, Chicago, IL

3 Workshop Outline Challenges for Chaplains Vignettes about Spiritual Struggle Research about Spiritual Struggle Your Questions about the Research Spiritual Struggle Screening Protocol Your Questions about Screening for Spiritual Struggle 3

4 (Only (Only one one answer answer allowed) allowed) In what type of institution do you work? (Please select one.) teaching hospital community hospital specialty hospital (e.g. peds, oncology, rehab, behavioral med) hospice long term care other 4

5 (Only (Only one one answer answer allowed) allowed) Where is your workplace located? (Please select one.) East South Midwest West 5

6 (Only (Only one one answer answer allowed) allowed) How many people are participating in this Webinar at your center? (Please select one.) 1-2 people 3-4 people 5 or more people 6

7 Challenges for Chaplains How did you decide which patients to see this week? How did the staff you work with determine who to refer and who not to refer? What evidence did you generate this week that your ministry made a difference in measurable patient outcomes? 7

8 Spiritual Struggle is recognizable as loss of meaning and purpose, despair, anger at God, grief or loss, hopelessness, feeling punished or abandoned by God, guilt or reconciliation 8

9 My sister died six months ago. Why did God take her and leave me? I m just taking up space (tearfully). I have done everything I m supposed to, but this disease 76-year-old patient with Parkinson s disease 9

10 Why has God done this? I ve been a good person What did I do to deserve so much suffering?.. (sobbing) Oh, I m so confused. I m angry at God. Why did I have to lose my leg? And thankful, too. I m alive. Oh, (muffled sobs) I don t know. 42-year-old mother with bone cancer 10

11 I have asked Why me many times in the past year. Why is God doing this?..i know He doesn t give us more than we can handle If you just fix the problem with my incontinence, I ll take all the pain that recovery dishes out. 40-year-old cancer patient after six-month hospitalization. 11

12 Anger with God and Rehabilitation Recovery Somatic Autonomy (ADL) Admission Follow-up Anger (n=6) 14.5 No anger (n=89) Fitchett et al,

13 Negative Religious Coping (Brief RCOPE) not at all somewhat quite a bit a great deal 8. I wondered whether God had abandoned me. 9. I felt punished by God for my lack of devotion. 10. I wondered what I did for God to punish me I questioned God s love for me I wondered whether my church had abandoned me. 13. I decided the devil made this happen I questioned the power of God Pargament et al,

14 (Only (Only one one answer answer allowed) allowed) Perceptions of Spiritual Struggle in Your Patients 1. Among the patients you visited in the past two weeks, in what proportion did you observe spiritual struggle? (Please select one.) None Between 1% and 9% Between 10% and 24% Between 25% and 49% 50% or more Not applicable (didn't visit patients) 14

15 (Only (Only one one answer answer allowed) allowed) 2. Among patients you visited in the past two weeks who expressed spiritual struggle, was it: (Please select one.) Spiritual struggle related to their illness/hospitalization. Spiritual struggle that pre-dated this illness and/or hospitalization Both Neither 15

16 (Multiple answers answers allowed) allowed) 3. Ken Pargament describes three types of spiritual struggle. If you heard patients express spiritual struggle in the past two weeks, which of these types did your patients express? (Please check all that apply.) Struggle with the Divine. (e.g. feeling abandoned by God, punished by God, angry with God) Spiritual struggle with other people (e.g. conflict with people with religious/spiritual authority, betrayal by people with religious authority) Intrapersonal spiritual stuggle (e.g. religious doubts, guilt) 16

17 Religious Coping and Health Status in Hospitalized Older Adults (N= 577) Negative Religious Coping Punishing reappraisal Depressed Mood.25*** Quality of Life -.17*** Self-Rated Health -.12** Demonic reappraisal.17*** -.10** -.12** Reappraisal of God's Power.15*** -.16*** Passive religious deferral.09* -.06 Self-directed religious coping.22*** -.19*** Spiritual discontent.22*** -.18*** Interpersonal religious discontent.27*** -.21*** -.12** Pleading for direct intercession.10* ** Values are standardized betas from regression models that included demographic variables, and for depressed mood and quality of life, severity of illness. *p<.05, **p<.01, ***p<.001 Koenig et al., 1998, Jnl of Nervous and Mental Disorders 17

18 Two Year Change in Religious Struggle and Its Effects on Outcomes Among Elderly Medically Ill Patients Group Any Religious Struggle At Baseline 2 Year Follow-Up Number Percent Outcome at Follow- Up* No Struggle No No 94 39% reference group Transitory Struggle Yes No 40 17% ns Acute Struggle No Yes 44 18% ns Chronic Struggle Yes Yes 61 26% *Models adjusted for demographic factors and baseline values. > depression > functional limitations < quality of life Source: Pargament et al, Journal of Health Psychology,

19 Religious Struggle as a Predictor of Mortality (n=567) Model 1. Positive religious coping, religious struggle, demographic factors, physical health, mental health Adjusted RR = % CI = Model 2. Model 1, plus frequency of church attendance Adjusted RR = % CI = Pargament et al., 2001, Arch Intern Med 19

20 Religious Struggle among Stem Cell Transplant Patients Post-Transplant Outcome Predictors* β Anxiety Neg Relig Cope.21* Depression Neg Relig Cope.26* Emotional WB Neg Relig Cope -.22* *Models adjusted for baseline value of outcome N=94 myeloma patients who received autologous stem cell transplant Average time between pre and post-transplant was 3.4 months (SD 2.9). Sherman et al, J Behav Med,

21 Increases in Religious Struggle and Post-Transplant Outcomes Outcome β a Model Adj R 2 for Depression.21*.31 Functional WB -.23**.29 Emotional WB -.20*.20 Physical WB -.29*.12 a Regression coefficient for patients with increased negative religious coping (21%) compared with those whose negative religious coping decreased (23%) or was stable (56%). Models adjusted for baseline values of outcome. N=94 myeloma patients who received autologous stem cell transplant Sherman et al, J Behav Med,

22 Religious Struggle and Emotional Distress Diabetic Outpatients psychological distress (PAID).31* CHF Outpatients depressed mood (CMDI).35** emotional symptoms (LHFQ).30* Oncology Inpatients depression (POMS).42***.22* anxiety (POMS).32*.16 hostility (POMS).29*.16 emotional well-being (FACT-G) -.23* *p<.05, **p<.01, ***p<.001 Values are partial correlations, adjusted for age and gender. From Fitchett et al,

23 Prevalence of Religious Struggle None 7 items scored "not at all" % Low Moderate High 1 item scored "quite a bit" or "a great deal," or 1 or more items scored "somewhat" 80 34% 2 items scored "quite a bit" or "a great deal" 17 7% 3 or more items scored "quite a bit" or "a great deal" 18 8% From Fitchett et al,

24 Religious Struggle and Depression 7 Mean of Depression-Dejection (POMS) Religious Struggle recoded into 3 groups neg cope recode 3 gps 3+ None (56%) 1-2 points (11%) 3+ points (33%) N=100 oncology in-patients 24

25 Isn t Religious Struggle Really Just Depression? The size of the correlations between religious struggle and depression in our study (r from 0.22 to 0.42) suggest religious struggle is associated with but cannot be reduced to depression. Religious struggle predicts both poor recovery and mortality in models which adjust for depression. 25

26 Summary Religious/spiritual struggle compromises emotional adjustment to illness and quality of life may compromise recovery may increase risk of mortality 26

27 Discussion 27

28 Three Levels of Clinical Inquiry About Religion/Spirituality screening for religious struggle religious/spiritual history taking spiritual assessment Massey, Fitchett, and Roberts,

29 Screening for R/S Struggle Screening for R/S struggle is an attempt to identify patients who may be experiencing R/S struggle. Screening for R/S struggle employs a few simple questions that can be asked by health care colleagues. 29

30 Others Chaplain Models for Screening Older Models Stoddard, 1993 Derrickson, Berg, 1994, 1999 Hodges, 1999 Wakefield & Cox Fitchett Review, Chaplaincy Today, 1999 Newer Models Grossoehme, 2008 Ledbetter,

31 Spiritual Distress: NANDA Definition Disruption in the life principle that pervades a person's entire being and that integrates and transcends one's biological and psychosocial nature. Related factors [etiology] Separation from religious and cultural ties Challenged belief and value system (e.g., result of moral or ethical implications of therapy or result of intense suffering) Defining characteristics Expresses concern with meaning of life and death and/or belief system Anger toward God (as defined by the person) Questions meaning of suffering Verbalizes inner conflict about beliefs Unable to choose or chooses not to participate in usual religious practices Regards illness as punishment Does not experience that God is forgiving 31

32 Religious Struggle and DSM-IV Additional Conditions that May Be a Focus of Clinical Attention V62.89 Religious or Spiritual Problem This category can be used when the focus of clinical attention is a religious or spiritual problem. Examples include distressing experiences that involve loss or questioning of faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution (emphasis added). 32

33 Screening Protocol 33

34 Results from Spiritual Struggle Screening Protocol Table 1. Results from Spiritual Struggle Screening Protocol Other Spiritual Care Requests Study Phase Screening Administered By Number (%) of New Admissions Screened Cases of Spiritual Struggle Identified by Screening Cases of Spiritual Struggle Confirmed by Chaplain Assessment Request Chaplain Visit Request Communion Phase I (January- March) PCT 78/159 (49%) 4/78 (5%) 4/4 (100%) 51/78 (65%) 22/78 (28%) Phase II (July & August) Phase III (September- December) Medical Resident 10/46 (22%) 0/10 (0%) N/A 2/10 (20%) 0 Psychology Intern 85/108 (79%) 8/85(9%) 7/8 (88%) 52/85 (61%) 8/85 (9%) Fitchett and Risk, Journal of Pastoral Care and Counseling,

35 Patient/Family Satisfaction Scores Before and During Pilot Study Before Pilot Study (Jan 2004-Dec 2005) During and After Pilot Study (Jan 2006-Jan 2007) Percent of Survey Responses 'Good' or 'Very Good' 100% 75% 50% 25% 0% 87% 93% Staff addressed emotional needs 79% 96% Staff addressed spiritual needs* 93% 91% Chaplain (satisfaction with) Survey Items *Difference in Before vs During responses is marginally significant (2-sided Fisher s Exact Test, p=0.06). Fitchett and Risk, Journal of Pastoral Care and Counseling, forthcoming 35

36 Compare Rush Screening Protocol and Social Work Assessment Rush Screening Protocol Religious Struggle Social Work Assessment Interest in Chaplain Visit Religious Struggle Yes No Total 2 (8%) a 8 (31%) 16 (62%) 26 (26%) Interest in Yes 0 (0%) 27 (100%) 0 (0%) 27 (27%) Chaplain Visit No 0 (0%) 2 (4%) 45 (96%) 47 (47%) Total 2 (2%) 37 (37%) 61 (61%) 100 a Percents in the body of the table are row percents. That is, the percent of each Rush Screening Protocol group in each social work assessment category. N=100 HSCT patients With appreciation to Chaplain Stephen King, Seattle Cancer Care Alliance. Watch for his workshop on this project at 2010 APC annual meeting. 36

37 Two-Tier Model for Spiritual Care A two tier process of screening and, if indicated, spiritual assessment Responsible screening and intervention 37

38 38

39 The 7 x 7 Model for Spiritual Assessment Holistic Assessment Spiritual Assessment Medical Belief and Meaning Psychological Vocation and Obligations Family Systems Experience and Emotions PsychoSocial Courage and Growth Ethnic, Racial, or Cultural Ritual and Practice Social Issues Community Spiritual Authority and Guidance Published in 2002 Available from Academic Renewal Press, Lima, Ohio

40 Discipline for Pastoral Care Giving Arthur Lucas, 2001 Profile Concept of Holy Meaning Hope Community 40

41 Pastoral Responses to Religious Struggle Assess source of struggle duration: new, transient, leading to growth, chronic available resources Giving Voice, Being Heard muteness, lament, companionship Finding Meaning creating a new narrative, a new future story Including pt s positive coping strategies, increased awareness of effect on internal and external environment, and capacity for living in tension with new reality posed by diagnosis, illness, and loss. 41

42 Conclusions The screening protocol had a high level of accuracy (specificity) for identifying patients in the midst of Spiritual Struggle. The screening protocol had a high level of effectiveness in identifying patients who were interested in receiving pastoral care. PCTs and Resident Physicians appeared not to be the appropriate staff to administer the protocol in this institution. Screening questions can be simplified to reduce protocol non-compliance. Screening Protocol subject to false negatives when patient has underdeveloped spirituality. 42

43 This screening protocol was highly effective in directing limited pastoral care resources to patients who could most benefit from pastoral care during hospitalization. 43

44 Screening for Spiritual Struggle and Aims for Quality Improvement Aim Aim #2: Care is Effective (evidence based) Aim #3: Care is Patient-Centered Aim #4: Care is Timely Aim #5: Care is Efficient Screening Protocol A) The protocol is based on research indicating the harmful effects of spiritual struggle. B) A pilot study has tested the effectiveness of the protocol. Use of the protocol increases the likelihood that patient's preferences for spiritual care services are respected. The protocol reduces the time between admission and referral for spiritual care or assessment. The protocol makes efficient use of nonchaplain healthcare staff to reduce the time chaplains spend in case finding Aims for quality improvement from the Institute of Medicine 2001 report, Crossing the Quality Chasm. The protocol does not explicitly address Aim #1: Care is Safe, or Aim #6: Care is Equitable. A summary of the report is available at 44

45 (Only (Only one one answer answer allowed) allowed) Describe screening at your center. 1. Does your workplace have any process for screening and referrals to chaplains? (Please select one.) No Yes 45

46 (Multiple answers answers allowed) allowed) 2. If yes, who does the screening? (Please select one.) RN Social Worker Other staff Volunteer Patient self-assessment 46

47 (Only (Only one one answer answer allowed) allowed) 3. If yes, what is the process for screening and referral? (Please select one.) Automatic referral from data entered in computer. Staff records data (paper or electronic) and notify chaplain (electronic or phone). Staff records data (paper or electronic) and chaplain checks records on units. 47

48 Discussion 2 Questions about the Screening Protocol 48

49 Implications for Health Professionals Clinicians should be alert to indicators of religious struggle, and inquire about it in their initial assessments. Is religion or faith important to you? If no, Has that always been the case? Where patients responses indicate possible religious struggle, consider referral to a chaplain. 49

50 Further Research on Spiritual Struggle Descriptive Conceptualization and measurement Screening Prevalence in specific populations Correlates Trajectory Spiritual Care Intervention What, if anything, helps people resolve R/S struggle? 50

51 Challenges for Chaplains How did you decide which patients to see this week? How did the staff you work with determine who to refer and who not to refer? What evidence did you generate this week that your ministry made a difference in measurable patient outcomes? 51

52 Further Information about Religious Struggle at the 2010 APC Annual Meeting Plenary Speaker Kenneth Pargament Pre-Conference Workshop Introduction to Pastoral Research - G Fitchett & P Murphy 90 Minute Workshop Screening for Religious/Spiritual Struggle in Stem Cell Transplant Patients - S King & G Fitchett 52

53 Questions and Answers Discussion Participant Questions Other definitions of Spiritual Struggle? Spiritual Struggle - effective interventions? 53

54 Screening for Spiritual Struggle Thank you for participating in today s Professional Chaplaincy Webinar. You will be ed a link to a brief evaluation form within the next two days, along with a link to the downloadable audio recording and presentation materials. 54

55 References Spiritual Struggle September, 2009 Ano GG, Vascolcelles EB. Religious coping and psychological adjustment to stress: A meta-analysis. Journal of Clinical Psychology 2005;61(4): Boscaglia N, Clarke DM, Jobling TW, Quinn MA. The contribution of spirituality and spiritual coping to anxiety and depression in women with a recent diagnosis of gynecological cancer. Int J Gynecol Cancer 2005;15(5): Balboni TA, Vanderwerker LC, Block SD, et al. Religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. J Clin Oncol. 2007;25(5): Berg, Gary E. (1994). The Use of the Computer as a Tool for Assessment and Research in Pastoral Care. Journal of Health Care Chaplaincy 6(1): Berg GE (1999). A Statement on Clinical Assessment for Pastoral Care. Chaplaincy Today 14(2): Bradshaw, A and Fitchett, G. "God, Why Did This Happen to Me?": Three Perspectives on Theodicy. Journal of Pastoral Care and Counseling 2003;57(2): Derrickson, Paul E. ( ). Screening Patients for Pastoral Care: A Preliminary Report. The Caregiver Journal 11(2): Exline JJ, Rose E. Religious and Spiritual Struggles. In RF Paloutzian and CL Parks (Eds.) Handbook of the Psychology of Religion and Spirituality (New York: The Guilford Press, 2005, pp ).

56 Exline, Julie J., Yali, Ann M., and Lobel, Marci. When God Disappoints: Difficulty Forgiving God and its Role in Negative Emotion. Journal of Health Psychology 1999;4(3): Exline, Julie J., Yali, Ann M, and Sanderson, William C. Guilt, Discord, and Alienation: The Role of Religious Strain in Depression and Suicidality. Journal of Clinical Psychology 2000;56(12): Fitchett, G. (1993) Assessing spiritual needs: A guide for caregivers (Minneapolis: Augsburg; reprint edition Lima, Ohio: Academic Renewal Press, 2002). Fitchett G. Screening for Spiritual Risk. Chaplaincy Today 1999;15(1): Fitchett G. Selected Resources for Screening for Spiritual Risk. Chaplaincy Today 1999;15(1): Fitchett G, Meyer P, and Burton LA. Spiritual Care: Who Requests It? Who Needs It? Journal of Pastoral Care 2000;54(2): Fitchett, G., Murphy, PE, Kim, J, Gibbons, JL, Cameron, JR, and Davis JA. Religious Struggle: Prevalence, Correlates and Mental Health Risks in Diabetic, Congestive Heart Failure, and Oncology Patients. International Journal of Psychiatry in Medicine 2004;34(2): Fitchett, G., and Risk, J. (2009). Screening for Spiritual Struggle. Journal Of Pastoral Care & Counseling, 63(1,2). Retrieved from Fitchett, G., Rybarczyk, BD, DeMarco, GA, Nicholas, JJ. The Role of Religion in Medical Rehabilitation Outcomes: A Longitudinal Study. Rehabilitation Psychology 1999;44(4):

57 Grossoehme DH. Development of a spiritual screening tool for children and adolescents. Journal of Pastoral Care & Counseling. 2008;62(1-2): Hodges, S (1999). Spiritual Screening: The Starting Place for Intentional Pastoral Care. Chaplaincy Today 15(1): Jacobson CJ, Luckhaupt SE, Delaney S, Tsevat J (2006). Religio-biography, Coping, and Meaning-Making Among Persons with HIV/AIDS. Journal for the Scientific Study of Religion 45(1): Koenig, HG, Pargament, KI, and Nielsen, J. Religious Coping and Health Status in Medically III Hospitalized Older Adults. Journal of Nervous and Mental Disease 1998;186: Ledbetter, Timothy J. (2008). Screening for pastoral visitations using the Clinical+Coping Score. Journal of Pastoral Care & Counseling, 62(4): Lucas, Arthur M. (2001). Introduction to the Discipline for Pastoral Care Giving. In Larry VandeCreek and Arthur M. Lucas (Eds.) The Discipline for Pastoral Care Giving (Binghamton, NY: Haworth Press, Inc.), pp Mako C, Galek M, Poppito SR. Spiritual pain among patients with advanced cancer in palliative care. J Palliat Med. 2006;9(5): Manning-Walsh, J. Spiritual struggle: effect on quality of life and life satisfaction in women with breast cancer. Journal of Holistic Nursing 2005;23(2): , with discussion on pp Massey, K, Fitchett, G, and Roberts, PA. (2004). Assessment and diagnosis in spiritual care. In Mauk, K.L. and Schmidt N.K. (Eds.) Spiritual care in nursing practice, Philadelphia, PA: Lippincott, Williams and Wilkins, pp

58 NANDA International. NANDA-I Nursing Diagnoses: Definitions and Classification, Philadelphia: NANDA International; Oxman TE, Freeman DH Jr., Manheimer ED. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. Psychosomatic Medicine 1995; 57:5-15. Pargament, KI. The Psychology of Religion and Coping: Theory, Research, Practice. (New York: The Guilford Press, 1997). Pargament, KI, Koenig, HG, Tarakeshwar, N, and Hahn, J. Religious Struggle as a Predictor of Mortality among Medically Ill Elderly Patients: A Two-Year Longitudinal Study. Archives of Internal Medicine 2001;161: Pargament, K. I., Koenig, H. G., Tarakeshwar, N. and Hahn, J. Religious coping methods as predictors of psychological, physical and spiritual outcomes among medically ill elderly patients: a two-year longitudinal study. Journal of Health Psychology 2004;9(6): Pargament, KI, Smith, BW, Koenig, HG, Perez, L. Patterns of Positive and Negative Religious Coping with Major Life Stressors. Journal for the Scientific Study of Religion 1998;37: Pargament, KI, Zinnbauer, BJ, Scott, AB, Butter, E.M., Zerowin J, and Stanik, P. Red Flags and Religious Coping: Identifying Some Religious Warning Signs Among People in Crisis. Journal of Clinical Psychology 1998;54: Sherman AC, Plante TG, Simonton S, Latif U, Anaissie EJ. Prospective study of religious coping among patients undergoing autologous stem cell transplantation. J Behav Med 2009;32:

59 Sherman AC, Simonton S, Latif U, Spohn R, Tricot G. Religious struggle and religious comfort in response to illness: Health outcomes among stem cell transplant patients. J Behavioral Med 2005;28: Stoddard, Gregory A. (1993). Chaplaincy By Referral: An Effective Model for Evaluating Staffing Needs. The Caregiver Journal 10(1): Taylor EJ, Outlaw FH, Bernardo TR, Roy A (1999). Spiritual conflicts associated with praying about cancer. Psycho-Oncology, 8: Wakefield JL, Cox D, Forrest JS (2001). Seeds of Change: The Development of a Spiritual Assessment Model. Chaplaincy Today 15(1): Additional References Bay PS, Beckman D, Trippi J, Gunderman R, Terry C. (2008). The Effect of Pastoral Care Services on Anxiety, Depression, Hope, Religious Coping, and Religious Problem Solving Styles: A Randomized Controlled Study. Journal of Religion and Health, 47: Iler WL, Obenshain D, Camac M. (2001). The Impact of Daily Visits from Chaplains on Patients with Chronic Obstructive Pulmonary Disease (COPD): A Pilot Study. Chaplaincy Today 17(1):5-11.