Ann Fam Med 2008;6: DOI: /afm.864. INTRODUCTION

Transcription

1 The 3 H nd BMSEST Models for ulity in Multiulturl Whole-Person Mediine Gowri Anndrjh, MD Deprtment of Fmily Mediine, The Wrren Alpert Medil Shool of Brown University, Memoril Hospitl of Rhode Islnd, Pwtuket ABSTRACT PURPOSE The explosion of evidene in the lst dede supporting the role of spiritulity in whole-person ptient re hs prompted proposls for move to iopsyhosoil-spiritul model for helth. Mking this prdigm shift in tody s multiulturl soieties poses mny hllenges, however. This rtile presents 2 theoretil models tht provide ommon ground for further explortion of the role of spiritulity in mediine. METHODS The 3 H model (hed, hert, hnds) nd the BMSEST models (ody, mind, spirit, environment, soil, trnsendent) evolved from the uthor s 12- yer experiene with urriul development regrding spiritulity nd mediine, 16-yer experiene s n ttending fmily physiin nd edutor, lived experiene with oth Hinduism nd Christinity sine hildhood, nd lifetime study of the world s gret spiritul trditions. The models were developed, tested with lerners, nd refined. RESULTS The 3 H model offers multidimensionl definition of spiritulity, pplile ross ultures nd elief systems, tht provides opportunities for ommon voulry for spiritulity. Therpeuti options, from generl spiritul re (ompssion, presene, nd the heling reltionship), to speilized spiritul re (eg, y linil hplins), to spiritul self-re re disussed. The BMSEST model provides oneptul frmework for the role of spiritulity in the lrger helth re ontext, useful for ptient re, edution, nd reserh. Intertions mong the 6 BMSEST omponents, with referenes to ongoing reserh, re proposed. CONCLUSIONS Inluding spiritulity in whole-person re is wy of furthering our understnding of the omplexities of humn helth nd well-eing. The 3 H nd BMSEST models suggest multidimensionl nd multidisiplinry pproh sed on universl onepts nd foundtion in oth the rt nd siene of mediine. Ann Fm Med 2008;6: DOI: /fm.864. Confl its of interest: none reported CORRESPONDING AUTHOR Gowri Anndrjh, MD Deprtment of Fmily Mediine The Wrren Alpert Medil Shool of Brown University Memoril Hospitl of Rhode Islnd 111 Brewster St Pwtuket, RI Gowri_Anndrjh@rown.edu INTRODUCTION To ure sometimes, To relieve often, To omfort lwys. Anonymous, 16th entury, Frne The idel of whole-person re hs long een espoused y physiins. Mny hve written out the role of physiin s sientist nd heler, who uses oth ojetive nd sujetive methods to ring ure, relief, nd omfort to those fing suffering, illness, nd deth. 1,2 Sine the time of this 16th entury quottion, we hve mde tremendous dvnes in the ility to ure. Yet, experiened physiins relize tht s we egin the 21st entury, with the glol urden of disese shifting to hroni illness, 3 we still live in n er in whih most of wht we n offer onsists of providing relief nd omfort. 448

2 Growing evidene for the enefi il role of spiritulity in helth nd well-eing suggests promising opportunities for innovtion in providing relief nd omfort The Assoition of Amerin Medil Colleges (AAMC), the World Helth Orgniztion (WHO), nd the Joint Commission on Aredittion of Helthre Orgniztions (JCAHO) now inlude spiritulity in medil prtie nd edution. 22,23 In ddition, mny hve lled for n expnsion of Engel s iopsyhosoil model 24,25 for helth re to iopsyhosoil-spiritul model, in whih relief requires understnding physil, mentl, nd spiritul suffering, nd spiritul re plys ruil role in providing omfort lwys. Yet there still remin mny hllenges to inorporting spiritulity into mediine. Identified rriers inlude the lk of ommon lnguge for spiritulity, s well s onern regrding oundries, ethis, nd ulturl nd religious differenes. 12,30 Few omprehensive models exist tht expliitly ddress how spiritulity fi ts into whole-person helth re. Reviewing the medil literture, Sulmsy 26 onludes tht speifi models for ptient re re lking nd proposes iopsyhosoil-spiritul model for improving qulity of life for dying ptients. Fithett s 7 7 model 31 for spiritul ssessment, tilored for those providing pstorl re, inludes 7 dimensions of holisti ssessment nd 7 elements of spiritul ssessment in 2-olumn tle. Wiler s 4-qudrnt integrl model orgnizes ll humn phenomen into 4 domins (interiors of individuls, exteriors of individuls, interior olletive, nd exterior olletive) nd n e pplied to mediine. 34 Benson nd Strk 13 inlude spiritulity in the self-re leg of their 3-legged therpeuti stool (phrmeutils, surgery, self-re). A few models for whole-person re re lso desried in the nursing nd soil work literture. 29,35 Some models lso exist regrding speifi spets of spiritulity/religion nd mediine. These models inlude effets of religion on helth 36 ; links etween mind nd spirit 33 ; frmeworks for spiritulity 37,38 ; nd models for nurse edution 39 nd ounselor trining. 40 Although these models re helpful, few re speifilly tilored to the dily ptient re needs of physiins. There is lso need for models tht expliitly ddress the prolem of ulturl nd religious diversity regrding spiritulity, the role of spiritulity in the therpeuti reltionship, nd the spiritul needs of helth re professionls themselves. This rtile provides theoretil frmework for the inlusion of spiritulity in whole-person re in modern multiulturl soieties, for liniins, edutors, nd reserhers, through use of 2 models: the 3 H dimensions of of spiritulity model (hed, hert, hnds) nd the BMSEST model (ody, mind, spirit, environment, soil, trnsendent). Speifi gols for these models re (1) omprehensiveness, (2) ppliility ross elief systems (religious or seulr), (3) essiility to liniins nd lerners, nd (4) provision of theoretil home for reserh on spiritulity nd helth. MODEL DEVELOPMENT The 3 H nd BMSEST models evolved from the uthor s 12-yer experiene with urriul development regrding spiritulity nd mediine. This experiene inluded extensive literture review; implementtion of 4 different urriul (3 required nd 1 eletive) for medil students, residents, fulty, nd stff t Brown University, eh running 4 to 7 yers ; nd ntionl presenttions. The models were developed, tested with lerners, nd refi ned over 12 yers. Other infl uenes on model development inlude 16 yers s n ttending fmily physiin nd edutor, inluding 13 yers s ore fmily mediine resideny fulty; lived experiene with oth Hinduism nd Christinity sine hildhood, in Sri Lnk, Englnd, the United Sttes, nd Indi; nd lifetime study of the world s gret spiritul trditions, inluding forml study of Hinduism nd Christinity, nd informl study of Judism, Buddhism, Islm, Ntive Amerin spiritulity, Jinism, Sikhism, Zorostrinism, nd the writings of mystis nd seulr philosophers. The 3 H nd BMSEST models represent synthesis of these experienes. The effets of these experienes on model development inlude emphsis on the prtil needs of physiins, lerners, nd ptients; ttention to ulturl nd religious diversity; nd quest for ommon ground. WHOLE-PERSON CARE The fi rst step in inorporting spiritulity into mediine is estlishing model of the humn eing, omposed of ody (B), mind (M), nd spirit (S). Figure 1, sed on Mslow s tringle 44 for hierrhy of needs, illustrtes this onept. Mslow s lesser known, lter work desries stte, eyond the ommonly epted pinnle of self-tuliztion, termed self-trnsendene, whih is onsistent with the inlusion of the spirit s prt of the whole person. 45 Dshed lines etween ody, mind, nd spirit indite tht these re losely relted rther thn distint entities. Arrows (,, ) represent the omplex mehnisms through whih these 3 fets intert. Ongoing reserh regrding these mehnisms inludes ntomi, physiologi, iohemil, immunologi, energeti, nd psyhologil explortion. 17,32,33,46-61 l (E) nd soil (S) infl uenes on physil, mentl, nd spiritul helth re lso depited in this fi g- 449

3 Figure 1. BMSEST model t the individul level: the whole person plus externl ftors. Tle 1. The 3 H Dimensions of ulity, With Exmples of Eh Dimension Cognitive (Hed) Experientil (Hert) Behviorl (Hnds) d ure nd re onsidered seprte ftors, onsistent with the WHO Qulity of Life pproh. 62 In order for this model to e prtil, defi nition of humn spiritulity must e developed tht is pplile to ll humn eings, regrdless of kground, just s defi nitions of the humn ody nd mind re universl. BMSEST = ody, mind, spirit, environment, soil, nd trnsendent. Note: = ells, orgns, iohemistry, genetis, physiology, possily energy systems, et.; mind = thoughts, emotions, ognitive funtion, et.; spirit = see Tle 1; environment = physil environment, ouptionl exposure, helth re system, et.; soil = fmily, ulture, religious orgniztion, edution, eonomi ftors, et. Arrow = intertions etween ody nd mind. Arrow = intertions etween mind nd spirit. Arrow = intertions etween ody nd spirit. Arrow d = intertions etween environmentl ftors nd the individul. Arrow e = intertions etween soil ftors nd the individul. DEFINITION OF SPIRITUALITY (THE 3 H MODEL) Defi ning spiritulity hs een hllenge for the medil profession. Yet, in order to hve meningful dilog, ommon understnding of spiritulity is essentil. ulity is omplex onstrut. Responses from t lest 800 medil students, residents, fulty, nd stff in smll-group tehing sessions to the question, Wht does this word spiritulity men? ; qulittive study of fmily mediine residents (unpulished dt); nd review of the literture 37,38,63-67 led to formultion of the multidimensionl 3 H model of spiritulity shown in Tle 1. The 3 H s enompss ognitive (hed), experientil (hert), nd ehviorl (hnds) spets of the humn spiritul experiene. The phrse hed, hert, nd hnds The Individul e Beliefs Vlues Idels Mening Purpose Truth Wisdom Fith (elief) Love Compssion, ltruism, forgiveness Connetion, reltionship with: Self Others, ommunity, nture The trnsendent Inner energy Strength, resiliene Inner pee, omfort, support Hope Fith (trust) Trnsendene Duties Dily ehvior Morl oligtions Choies Life hoies Medil hoies Speifi prties: Pryer, medittion, yog, hnting, rituls, diet, nture wlks, et Prtiiption in religious ommunity is used widely in other ontexts ut is pplile here. The ognitive, or existentil, (hed) spets inlude serh for mening nd purpose, nd vlues nd eliefs most importnt in one s life. The experientil (hert) spets enompss the humn need for love, inner pee, resiliene, nd onnetion. Finlly, the ehviorl (hnds) spets pertin to the outwrd expression of spiritul eliefs nd needs, suh s life hoies, ehvior towrd others, rituls, nd prties. These dimensions of spiritulity re pplile to ll humn eings irrespetive of ulture or elief system, whether seulr or religious. In the medil ontext, spiritul issues pertining to the hed inlude suh questions s why is this hppening to me (or my loved one), wht will hppen fter I die, re these tretments onsistent with my eliefs, nd if God exists, where is God now? ul issues relted to the hert inlude the experienes of feeling onneted vs lone when ill; feeling pee vs turmoil when fing deth; or feeling hope vs despir when deling with hroni illness. Finlly, hnds spets n mnifest in the medil ontext in vriety of wys inluding spiritully sed tretment deisions y ptients or fmilies; ptients requests for speifi rituls, pryers, or diets; or physiins own needs for spiritul rituls or pryer when deling with stressful situtions. RELATION BETWEEN SPIRITUALITY AND RELIGION People differ widely in the wy they view the reltionship etween spiritulity nd religion. For some, these terms refer to the sme thing; for others, they re overlpping onepts; nd for yet others, they re vstly different ,72 450

4 One prtil pproh is to envision spiritulity s ddressing universl humn questions nd needs, nd religion s providing speifi (nd often differing) nswers to those questions, nd wys of meeting those needs. Humn spiritulity, therefore, is often expressed in the speifi lnguge of religions or other world views. For exmple, to the question of wht hppens fter deth, Christinity might disuss heven nd hell, wheres Buddhism will refer to krm nd reirth. To the question of how to feel more onneted nd t pee, Islm might suggest speifi pryers nd the reding of the Korn, wheres Hinduism might reommend speifi Vedi hnts nd mntrs. Regrding how to led good life nd mke good hoies, Judism might point to the Ten Commndments nd Tlmudi disussions, wheres n theist might point to ertin si humn soietl vlues to guide life s mny deisions. The questions nd needs re universl, ut the nswers nd pprohes vry. In Figure 1, orgnized religion is listed under soil ftors (S) tht infl uene the individul. Beuse the omintion of religious kground, ulture, fmily, nd pst experiene shpe the individul s spiritulity, memers of similr religious kgrounds my hve different spiritul eliefs nd needs. Huston Smith sserts tht in every religious ommunity, vriety of spiritul personlity types exist, rnging from theists, to polytheists, to monotheists, to mystis. 73 In Jewish fmily, for exmple, one rother my e orthodox in his prties, wheres nother rother my desrie himself s seulr Jew; eh will hve different needs relted to helth re. Personl religiosity, therefore, is n spet of person s spirit in Figure 1 (the 3 H s) nd interts to vrying degrees with orgnized religion. SPIRITUAL SUFFERING ul suffering n our in ny of the 3 dimensions outlined in Tle 1 (hed, hert, hnds). A mother whose hild hs just died my wonder whether this is divine punishment for something she did erlier in life, thus experiening spiritul suffering in the hed dimension. A ptient who is dying of ner nd hs notied fmily nd helth professionls withdrwing from him my e suffering in the hert dimension. Finlly, reent immigrnt, without ess to fmily or religious ommunity, my e unle to perform importnt rituls tht sustin him, thus suffering in the hnds dimension. It is importnt to note tht these 3 dimensions re losely relted; thus, suffering my our in ll 3 dimensions simultneously. The mother who is struggling with mening (hed), in the exmple ove, my lso feel disonneted from God (hert) nd find herself unle to pry for help (hnds). She needs ssistne from someone speifi lly trined to ddress ll of these issues. Beuse suffering hs physil, mentl, nd spiritul spets, therpeuti options should e ville t ll of these levels. Relief from spiritul suffering n e provided y spiritul self-re nd 2 levels of therpeuti options: speilized nd generl spiritul re (desried elow). Figure 2 illustrtes therpeuti pprohes t the ody, mind, nd spirit levels (rrows f, g, h, i). Given the omplexity of humn suffering, multidisiplinry tems re inresingly needed to provide pproprite therpeuti interventions. SPIRITUAL CARE ul Self-Cre Self-re of the ody nd mind, suh s y helthy diet, exerise, nd soil support, hs long een enourged. ul self-re n tke the form of self-understnding nd inquiry regrding eliefs nd vlues, or methods for ringing pee nd trnquility, suh s pryer, medittion, nture wlks, hurh ttendne, or yog. With the growing interest in the effi y of self-mngement in the tretment of hroni illness, the role of spiritul self-re in helth is fertile ground for explortion. Speilized ul Cre For speifi struggles with hed issues or hnd needs, suh s speifi pryers or rituls, the most pproprite pproh involves onsulting professionl trined in spiritul re, suh s hplin with linil pstorl edution (CPE) trining or ommunity religious leder In muh the sme wy s soil workers or psyhologists provide the mentl helth omponents of whole-person re, hplins re lso integrl to the helth re tem. To mintin high-qulity ptient re, it is ritil to ttend to the oundries of role nd trining etween physiin nd speilist in providing this speilized spiritul re Physiins n identify the need nd provide simple modifitions in the tretment pln to ommodte speifi eliefs. Chplins, however, re trined to provide in-depth ounseling nd ess to religious rituls nd pryers (intertion h in Figure 2). In ddition, it is essentil for ll professionls to ultivte self-wreness to void interferene of personl eliefs nd ises in ethil, ptient-entered re. 76 Generl ul Cre Being Heler ul re lso ttends to the hert needs (intertion i in Figure 2). The helth re setting n e impersonl, leving ptients feeling vulnerle nd disonneted from their usul soures of strength. This stte of spiritul distress is esily overlooked euse no ler religious struggle or need is rtiulted. The therpeuti intervention t this hert level is t one oth simple nd extremely diffi ult. It requires tht helth re profes- 451

5 Figure 2. Seulr version of the BMSEST model for whole-person re: the physiin-ptient reltionship. Medittion, pryer Compssion, presene, onnetion, et i ul ounseling, et h Counseling, ognitive therpy, et g Medittion, pryer Medition, surgery, PT, et f The Individul (Physiin) BMSEST = ody, mind, spirit, environment, soil, nd trnsendent; PT = physil therpy. Arrow = intertions etween ody nd mind. Arrow = intertions etween mind nd spirit. Arrow = intertions etween ody nd spirit. Arrow d = intertions etween environmentl ftors nd the individul. The Individul (Ptient) Arrow e = intertions etween soil ftors nd the individul. Arrow f = therpeuti pprohes t the ody level. Arrow g = therpeuti pprohes t the mind level. Arrow h = therpeuti pprohes t the spirit level (speilized spiritul re). Arrow i = therpeuti effets t the spirit level (generl spiritul re). sionls ring their humnness to the medil enounter. Elements inlude ompssion, presene, true listening, nd the enourgement of relisti hope, whih hve een rtiulted s ritil elements of spiritul re. 77 Unlike hed nd hnd issues, these elements do not require doing, ut rther eing. These interventions do not require inquiring out speifi eliefs nd tke no more time thn liniin s usul duties. Rther, they require tht helth re professionls ugment their everydy tivities with presene, ompssion, nd positive intention. This definition of spiritul re overlps onsiderly with the onept of physiin s heler, 1,2,78-81 who ures, relieves, nd omforts lwys. Blint 82 refers to the dotor s potent medition, nd Hipportes 2 sid, Some ptients, though onsious tht their ondition is perilous, reover their helth simply through their ontentment with the goodness of the physiin. Some of these onepts re lso ddressed in the literture on mindfulness 83 nd professionlism 79 in mediine, nd in the reserh eing done on listening, 84 ltruism nd ompssion, 85 nd the pleo effet. 13 Importntly, generl spiritul re does not involve emotionl entnglement. There re ler distintions etween eing engged vs enmeshed. Osler, in his fmous speeh Aequnimits, 86 desries the vlue of linil dethment, the mentl equilirium of the physiin, ut dvises striving for this without t the sme time hrdening the humn hert y whih we live. More reently, Frihione 87 desries the middle ground etween seprtion nd tthment in his neuroiologi modeling of humn development nd spiritulity. To hieve this ritil lne, physiins need to ttend to their own helth nd well-eing, inluding their spiritul helth. Doing so is hllenging in tody s helth re environment, yet is essentil in the quest to e heler nd sientist. Figure 2 reminds us tht every physiin is lso whole person produt of his or her own ulture, fmily, nd soil institutions (inluding the medil industry). It lso reminds us tht t the level of generl spiritul re, the therpeuti ssoition (rrow i) is idiretionl physiins hve the potentil to hel nd e heled through their linil intertions, s lerly illustrted y numerous physiin stories BMSEST MODELS CULTURAL AND RELIGIOUS VARIATIONS Figure 2 illustrtes the physiin-ptient reltionship with therpeuti options t ody (B), mind (M), nd spirit (S) levels within the ontext of environmentl (E) nd soil (S) ftors; however, mny who exmine this figure will rgue tht no disussion regrding spiritulity is omplete without disussion of the trnsendent (T). The figure displys seulr version of the BMSEST model, whih my resonte most redily with seulr humnists or theists. In this model, spiritul ftors 452

6 re entirely ontined within the humn eing, nd pryer nd medittion re likewise humn phenomen. The trnsendent, in this model, my refer to the set of soietl vlues nd needs tht trnsend the individul s needs, thus guiding omplex ethil deision mking. When one studies the world s religions, 73, mjor oneptul models of divine trnsendent emerge, giving rise to 2 BMSEST vritions the dulity model (Figure 3) nd the unity model (Figure 4). Both models exist to some degree in ll the mjor religions; however, the dulity model predomintes in western religion, nd the unity model predomintes in estern thought nd the mysti trditions of mny religions. In the dulity model (Figure 3), God is seen s seprte from humn eings ut le to ffet us on ll levels. God is seen s fther or mother, nd our reltionship with other people is tht of rothers nd sisters. Pryer nd medittion re methods of ommuniting with nd ttuning oneself to God, nd ll heling nd morl guidne ultimtely ome from God. A vrition of this model is pplile to polytheisti religions. In the unity model (Figure 4), Mslow s tringles re turned upside down. Here, the ody is just the tip of the ieerg, nd on spiritul level, we re ll one. In this model, we re prt of God, s wve is prt of the oen, nd our reltionship with other people is kin to lims on the sme ody. Pryer nd medittion re methods to onnet with God within or the Oneness of the universe, nd heling nd ethil deisions rise from onneting with tht oneness. These 3 BMSEST models provide insight into the vrious wys people view spiritulity nd the trnsendent, thus pving the wy for more meningful ommunition. They lso emphsize tht, in the linil ren, the pprohes to ptient re (rrows f, g, h, i) re the sme, regrdless of the model vrition most resonnt with physiin or ptient. The hoie of the most pproprite speifi therpeuti intervention for the ptient vries depending on the ptient s elief kground. SPIRITUALITY, SERVICE, AND ADVOCACY The individul s role in the helth re system does not stop t the physiin-ptient reltionship. The Figure 3. Dulity version of the BMSEST model for whole-person re. Medittion, pryer j Trnsendent God Compssion, presene, e, onnetion, et i ul ounseling, ng et h Medittion, pryer j Counseling, ognitive therpy, et g Medition, surgery, PT, et f The Individul (Physiin) The Individul (Ptient) BMSEST = ody, mind, spirit, environment, soil, nd trnsendent; PT = physil therpy. Arrow = intertions etween ody nd mind. Arrow = intertions etween mind nd spirit. Arrow = intertions etween ody nd spirit. Arrow d = intertions etween environmentl ftors nd the individul. Arrow e = intertions etween soil ftors nd the individul. Arrow f = therpeuti pprohes t the ody level. Arrow g = therpeuti pprohes t the mind level. Arrow h = therpeuti pprohes t the spirit level (speilized spiritul re). Arrow i = therpeuti effets t the spirit level (generl spiritul re). Arrow j = intertions etween the individul nd the Trnsendent. 453

7 Figure 4. Unity version of the BMSEST model for whole-person re. Medittion, pryer j Trnsendent Universl Consiousness God Medittion, pryer j Compssion, presene, onnetion, et i ul ounseling, et h Counseling, ognitive therpy, et g Medition, surgery, PT, et f The Individul (Physiin) BMSEST = ody, mind, spirit, environment, soil, nd trnsendent; PT = physil therpy. Arrow = intertions etween ody nd mind. Arrow = intertions etween mind nd spirit. Arrow = intertions etween ody nd spirit. Arrow d = intertions etween environmentl ftors nd the individul. The Individul (Ptient) Arrow e = intertions etween soil ftors nd the individul. Arrow f = therpeuti pprohes t the ody level. Arrow g = therpeuti pprohes t the mind level. Arrow h = therpeuti pprohes t the spirit level (speilized spiritul re). Arrow i = therpeuti effets t the spirit level (generl spiritul re). Arrow j = intertions etween the individul nd the Trnsendent. BMSEST models lso illustrte the 2-wy intertion etween the individul nd soil nd environmentl ftors (rrows d nd e). Idels nd vlues (hed), energized y inner strength nd resiliene (hert), n led to profound tion on systems level (hnds) to enefi t the helth of others. History ounds with exmples of individuls, suh s Mhtm Gndhi, Mother Teres, nd Mrtin Luther King, who hrnessed spiritulity to improve the soil environment, with effets on mny people s helth nd qulity of life. Reserh on ltruism is eginning to eluidte some of the ftors tht infl uene this spet of humn experiene. 85 FINDING COMMON GROUND For ptient re, edution, nd reserh to suessfully inorporte spiritulity into whole-person re, it is essentil tht humn spiritulity e understood in universl terms, just s the humn ody nd mind re onsidered universl. From the universl, we n ppreite norml vritions, nd from there, identify ftors tht ffet helth nd well-eing. The 3 H s (Tle 1) provides frmework for understnding ommon spiritul themes. These themes re oth expliitly nd impliitly present in ptients nrrtives nd tions. By reognizing nd responding to ptients ues, we n llow ptients to provide us with the lnguge of spiritulity tht est suits them whether religious or seulr. The BMSEST models (Figure 2, 3, 4) provide theoretil frmework for understnding the role of spiritulity in whole-person re, pplile to ll people. They lso remind us of the existene of onsiderle vritions in world views nd imges of God, while 454

8 emphsizing the ommon therpeuti pprohes ville t the ody, mind, nd spirit levels. Optiml ptient re requires multidisiplinry tem pproh to nvigte this omplex system. However, the true ommon ground nd foundtion for integrting spiritulity into mediine lie in the heling ttitude nd self-wreness of the professionl. Adopting ptient-entered pproh, refleting spiritul humility, kin to ulturl humility, 97 together with n ttitude of servie nd dvoy, will likely yield etter understnding nd thus etter therpeuti options thn simply following estlished spiritul history protools. 98,99 In ddition, unlike questions in other res of mediine, mny spiritul questions re unnswerle. Thus, it is often in the ppreition of the questions, rther thn the provision of nswers, tht heling ours. CLINICAL AND EDUCATIONAL APPLICATIONS The BMSEST models nd the 3 H s hve mny prtil linil nd edutionl pplitions. The former remind liniins of the lyers of omplexity in their ptients experiene of illness, nd the ltter provide mens for ridging ulturl differenes in spiritul eliefs nd prties. Exmple 1. Medil students n use the BMSEST frmework (Figure 2) to develop holisti dignosis nd tretment pln. For exmple, when lerning out domesti violene, rpe, nd inest, they n visulize potentil effets on ptients physil helth (eg, ruises, sexully trnsmitted diseses, hroni pin); mentl helth (eg, posttrumti stress disorder, depression); spiritul helth (eg, serh for mening, onfl its etween eliefs nd tretment options); soil reltionships (eg, disruption of fmily ties, ontriution of lohol nd drugs, polie nd legl issues); nd environment (eg, sfety/emergeny housing). Therpeuti options my inlude meditions for sexully trnsmitted diseses (rrow f) or posttrumti stress disorder (rrows f nd ); ounseling y psyhologist for nxiety (rrow g); prourement of housing in homeless shelter y soil worker (rrow d); ounseling y linil hplin regrding tretment options for pregnny resulting from rpe or inest (rrow h); nd sfe, ompssionte, therpeuti reltionship (rrow i). The 3 H model proves useful tool for spiritul ssessment during medil enounter, s n lterntive to existing tools. 98,99 It helps liniins reognize spiritul themes in their ptients nrrtives nd offers ommon voulry for open-ended questions tht n revel the speifi lnguge of spiritulity tht ptient uses (religious or seulr). Exmple 2. A 59-yer old hospitlized ptient with metstti lung ner is struggling with the deision etween hospie vs more hemotherpy. Her physiin is struggling to ontrol her severe pin euse the ptient is relutnt to inrese the mount of pin medition. A piture of Jesus on her tle ues her physiin to lern more out her eliefs. The 3 H s remind him to strt with generl spiritul questions. He lerns tht lthough the ptient elieves in God s Jesus, her speifi lnguge of spiritulity is from the 12-Step reovery ommunity. Beuse the physiin hs ompssionte, respetful ttitude (BMSEST rrow i), she tells him more. She elieves in the fterlife nd tht things hppen for reson (hed), nd she feels loved y God nd does not fer deth (hert); however, she is struggling with the hospie deision nd pin mngement (hnds) euse of onfl it etween her fer of pin nd symptoms vs her fer tht tking nrotis is ginst the eliefs of her spiritul ommunity. She worries tht she will lose her ommunity nd die lone, ddited to pin meditions. These onerns needed to e ddressed diretly, with the help of her 12-Step ommunity, in order for her to peefully trnsition to hospie re. At the end of her life, her physiin relizes tht ttention to his own spiritul 3 H s gve him the strength to visit her edside, when nothing ws left to do exept provide his presene. Medil students nd residents in the United Sttes hve diverse spiritul eliefs, rnging from devoutly religious (in different religions), to theist, to undeided. The 3 H s offer the opportunity for ll lerners to sit t the tle when disussing spiritulity nd mediine. Exmple 3. Edutors ( physiin nd hplin tem) hve suessfully used the following smll group exerise s n introdution to spiritulity nd mediine in required medil shool lerkship sessions 41 nd resident edution 43 : (1) sk lerners to defi ne spiritulity, (2) orgnize their nswers using the 3 H model, (3) using smll group filittion skills, provide sfe nd respetful environment for students nd residents to lern from eh other out the vriety of world views present in their own lerning ommunity, (4) expnd the onverstion to stories from lerners out ptient enounters in whih spiritul issues plyed role, nd (5) filitte onverstion regrding hllenges nd pprohes. This tehnique introdues the onept of spiritulity s universl humn experiene nd promotes ross-ulturl disussion. The 3 H nd BMSEST models n lso e used to nurture helth re professionls self-understnding. These models help professionls lrify their own world view nd provide tools for trversing ulturl differenes in spiritul eliefs nd prties. Exmple 4. A medil student, visily shken, tells her dvisor out n upsetting experiene in her ommunity mentor s offi e. Her mentor, whom she respets, 455

9 strted prying with ptient while the student ws present. She ws tken y surprise nd felt trpped, onfused, nd sred. Her dvisor n use the 3 H nd BMSEST models s tools to derief her experiene y enourging self-understnding regrding her response (she is undeided out her eliefs, nd her fmily hs experiened religious disrimintion); filitting her understnding of the positive experienes of the ptient nd her mentor in this sitution; nd exploring strtegies for responding to pryer in the linil setting. In ddition, the dvisor ould use the BMSEST models s trining tools in ross-ulturl ommunition for liniins interested in inluding spiritulity in their work. The 3 H nd BMSEST models n lso help promote physiin self-re y ting s springords for physiins to disover (nd redisover) their idels, vlues, nd purpose, nd to explore methods to rejuvente nd sustin themselves during hllenging reer. These methods, imed t reenergizing the spiritul hert, n vry widely, depending on the individul physiin, from religion-sed tivities, to seulr tivities, suh s nture wlks, dning, nd lughing with their hildren. Workshops regrding spiritul self-re hve een vlule dditions to medil edution. 42,43 RESEARCH APPLICATIONS The 3 H nd BMSEST models lso hve reserh pplitions. Elements of these models n e tested. A vriety of methods might e used to evlute the universlity of the 3 H dimensions of spiritulity nd the extent to whih urrent res of reserh/study hve home within the BMSEST model. BMSEST homes for pulished studies inlude the following: medittion nd helth (rrow,,, or j) 4,5,13,17,52,56 ; religion nd helth (rrow,, or e) 8,11,12,14,16,36 ; ompssion nd ltruism (rrow i, d, or e) 85 ; iologi meditors of spiritulity (rrows nd ) 17,46-55 ; onsiousness studies, in the res of mind nd spirit (rrow ) 32,33,45 ; nd humn energy systems (ody, rrows nd ) The BMSEST models n lso help identify whih of the 6 omponents nd 10 reltionships ( to j) need further study. The vrious suthemes within eh of the 3 H dimensions of spiritulity n e used to develop sles for mesuring spiritul helth, well-eing, nd need (for use in iomedil reserh). The 3 H s n dd to existing sles (reviewed elsewhere 26,65 ) y providing frmework for ensuring tht mesures for eh dimension re inluded in omprehensive sles nd tht studies regrding the reltionships etween vrious suthemes (eg, effets of love, hope, forgiveness, mening) n e oneptulized in logil wy. Future reserh ould lso eluidte the ontriutions of physil, mentl, nd spiritul helth to overll qulity of life. Finlly, euse the BMSEST models inlude onsidertion of the trnsendent, whih is frequently defi ned s eing outside the relm of the physil world, they rise the question of whether effets diretly relted to the trnsendent (eg, rrow j) n e dequtely studied using methods typilly used in iomedil reserh. Mny hve deted this issue Perhps deeper understnding of these effets n e glened only through diret experiene nd indiretly through qulittive methods, the rts, nd the humnities. In onlusion, the 3 H nd BMSEST models provide oneptul sis for pprohing spiritulity s universl humn phenomenon, essentil to understnding whole-person mediine. Given the omplexities of the humn ondition, future study regrding whole-person re will require innovtive multimethod reserh nd multidisiplinry pproh, enompssing siene, soil siene, nd the humnities. Although hllenging, mny opportunities exist for fi nding ommon ground etween differing world views nd disovering etter wys to provide ure, relief, nd ove ll omfort to suffering ptients. To red or post ommentries in response to this rtile, see it online t Key words: ulity; theoretil models; whole-person re; edution; reserh Sumitted Ferury 27, 2007; sumitted, revised, July 15, 2007; epted Deemer 9, This work hs een previously presented in prt t the Soiety of Tehers of Fmily Mediine (STFM) 19th Conferene on Fmily nd Helth, Mrh 3-7, 1999, Kiwh Islnd, South Crolin; the STFM 20th Conferene on Fmilies nd Helth, Mrh 2000, Sn Diego, Cliforni; the 2000 Conferene on ulity in Helthre: Issues of Culture & End of Life, Septemer 2000, Dlls, Texs; the STFM Conferene on Fmilies nd Helth, Ferury 2001, Kiwh Islnd, South Crolin; the Assoition for Behviorl Siene nd Medil Edution 31st Annul Conferene, Otoer 2001, North Flmouth, Msshusetts; the World Orgniztion of Fmily Dotors (WONCA) World Conferene, Otoer 2004, Orlndo, Florid; nd the Siene nd ulity: Est nd West Conferene t the Center for Indi Studies, University of Msshusetts, June 26, 2004, Drtmouth, Msshusetts. Aknowledgments: I thnk the mny medil students, residents, nd ollegues who, over 11 yers, hve engged in frnk onverstions out spiritulity nd helth. I thnk Denise Lelir, MD, Roger Mennillo, MD, the Brown Fmily Mediine Sholrship Promotion Committee, Jeffrey Borkn, MD, PhD, nd Kohr Jones, MD, for reviewing this mnusript. Referenes 1. Lown B. The Lost Art of Heling. New York, NY: Bllntine Books; Dixon DM, Sweeney KG, Pereir Gry DJ. The physiin heler: nient mgi or modern siene? Br J Gen Prt. 1999;49(441):

10 3. Murry CJ, Lopez AD. Glol mortlity, disility nd the ontriution of risk ftors: glol urden of disese study. Lnet. 1997;349(9063): Benson H, Mlve BP, Grhm JR. Psysiologi orreltes of medittion nd their linil effets in hedhe: n ongoing investigtion. Hedhe. 1973;13(1): Kt-Zinn J. An outptient progrm in ehviorl mediine for hroni pin ptients sed on the prtie of mindfulness medittion. Gen Hosp Psyhitry. 1982;4(1): Millison MB. A review of the reserh on spiritul re nd hospie. Hosp J. 1995;10(4): Willims AL. Perspetives on spiritulity t end of life: met-summry. Pllit Support Cre. 2006;4(4): Mtthews DA, MCullough ME, Lrson DB, Koenig HG, Swyers JP, Milno MG. Religious ommitment nd helth sttus: review of the reserh nd implitions for fmily mediine. Arh Fm Med. 1998;7(2): Levin JS, Lrson DB, Puhlski CM. Religion nd spiritulity in mediine: reserh nd edution. JAMA. 1997;278(9): Lrimore WL, Prker M, Crowther M. Should liniins inorporte positive spiritulity into their prties? Wht does the evidene sy? Ann Behv Med. 2002;24(1): Mueller PS, Plevk DJ, Rummns TA. Religious involvement, spiritulity nd mediine: implitions for linil prtie. Myo Clin Pro. 2001;76(12): Koenig HG. Religion, spiritulity nd mediine: implitions for linil prtie. South Med J. 2004;97(12): Benson H, Strk M. Timeless Heling: The Power nd Biology of Belief. New York, NY: Sriner; Koenig HG, MCullough ME, Lrson DB. Hndook of Religion nd Helth. New York, NY: Oxford University Press; Wever AJ, Flnnelly KJ, Oppenheimer JE. Religion, spiritulity nd hplins in the iomedil literture Int J Psyhitry Med. 2003;33(2): Powell LH, Shhi L, Thoresen CE. Religion nd spiritulity: linkges to physil helth. Am Psyhol. 2003;58(1): Seemn TE, Dulin LF, Seemn M. Religion/spiritulity nd helth: ritil review of the evidene for iologi pthwys. Am Psyhol. 2003;58(1): Thoresen CE, Hrris AHS. ulity nd helth: wht s the evidene nd wht s needed? Ann Behv Med. 2002;24(1): Ehmn JW, Ott BB, Short TH, Cimp RC, Hnsen-Flshen J. Do ptients wnt physiins to inquire out their spiritul or religious eliefs if they eome grvely ill? Arh Intern Med. 1999;159(15): MCord G, Gilhrist VJ, Grossmn SD, et l. Disussing spiritulity with ptients: rtionl nd ethil pproh. Ann Fm Med. 2004;2(4): Oym O, Koenig HG. Religious eliefs nd prties in fmily mediine. Arh Fm Med. 1998;7(5): Lerning ojetives for medil student edution guidelines for medil shools: report I of the Medil Shool Ojetives Projet. Ad Med. 1999;74(1): WHOQOL SRPB Group. A ross-ulturl study of spiritulity, religion nd personl eliefs s omponents of qulity of life. So Si Med. 2006;62(6): Engel GL. The linil pplition of the iopsyhosoil model. Am J Psyhitry. 1980;137(5): Borrell-Crrio F, Suhmn AL, Epstein RM. The iopsyhosoil model 25 yers lter: priniples, prtie nd sientifi inquiry. Ann Fm Med. 2004;2(6): Sulmsy DP. A iopsyhosoil-spiritul model for the re of ptients t the end of life. Gerontologist. 2002;42(Spe No 3): MKee DD, Chppel JN. ulity nd medil prtie. J Fm Prt. 1992;35(2):201, Ben-Arye E, Br-Sel G, Frenkel M, Kuten A, Hermoni D. Is iopsyhosoil-spiritul pproh relevnt to ner tretment? A study of ptients nd onology stff memers on issues of omplementry mediine nd spiritulity. Support Cre Cner. 2006;14(2): Huthinson ED. A working model. In: Huthinson ED, Mtto HC, Hrrign MP, Chrlesworth LW, Viggini PA. Chllenges of Living: A Multidimensionl Working Model for Workers. Thousnd Oks, CA: Sge Pulitions, In; Ellis MR, Vinson DC, Ewigmn B. Addressing the spiritul onerns of ptients: fmily physiins ttitudes nd prties. J Fm Prt. 1999;48(2): Fithett G. Assessing ul Needs: A Guide for Cregivers. Lim, OH: Ademi Renewl Press; Wiler K. Integrl Psyhology: Consiousness,, Psyhology, Therpy. Boston, MA: Shmhl Pulitions; Wiler K. Wves, Strems, Sttes nd Self: A Summry of My Psyhologil Model. Boston, MA: Shmhl Pulitions; Astin JA, Astin AW. An integrl pproh to mediine. Altern Ther Helth Med. 2002;8(2): Friedmnn ML, Mouh J, Rey T. Nursing the spirit: the frmework of systemi orgniztion. J Adv Nurs. 2002;39(4): Koenig HG, Hys JC, George LK, Blzer DG, Lrson DB, Lndermn LR. Modeling the ross-setionl reltionship etween religion, physil helth, soil support nd depressive symptoms. Am J Geritr Psyhitry. 1997;5(2): Buk HG. ulity: onept nlysis nd model development. Holist Nurs Prt. 2006;20(6): Miner-Willims D. Putting the puzzle together: mking spiritulity meningful for nursing using n evolving theoretil frmework. J Clin Nurs. 2006;15(7): Nrynsmy A. ASSET: model for tioning spiritulity nd spiritul re edution nd trining in nursing. Nurse Edu Tody. 1999;19(4): Purdy M, Dupey PA. Holisti flow model of spiritul wellness. Couns Vlues. 2005;49(2): Anndrjh G, Mithell M, Stumpff J. Evlution of required spiritulity nd mediine tehing session in the fmily mediine lerkship. Fm Med. 2007;39(5): Anndrjh G, Mithell M. A spiritulity nd mediine eletive for senior medil students: 4 yers experiene, evlution nd expnsion to the fmily mediine resideny. Fm Med. 2007;39(5): Anndrjh G, Long R, Smith M. Integrting spiritulity nd mediine into the resideny urriulum. Ad Med. 2001;76(5): Mslow AH. Motivtion nd Personlity. 2nd ed. New York, NY: Hrper nd Row; Koltko-River ME. Redisovering the lter version of Mslow s hierrhy of needs: self-trnsendene nd opportunities for theory, reserh, nd unifition. Rev Gen Psyhol. 2006;10(4): Borg J, Andree B, Soderstrom H, Frde L. The serotonin system nd spiritul experiene. Am J Psyhitry. 2004;160(11): Kurup RK, Kurup PA. Hypothlmi digoxin, hemispheri hemil dominne nd spiritulity. Int J Neurosi. 2003;113(3): MCin NL. Psyhoneuroimmunology, spiritulity nd ner. Gyneol Onol. 2005;99(3 Suppl 1):S Sephton SE, Koopmn C, Shl M, Thoresen C, Spiegel D. ul expression nd immune sttus in women with metstti rest ner: n explortory study. Brest J. 2001;7(5): Austin J. Zen nd the Brin. Cmridge, MA: MIT Press; Newerg A, D Aquili E, Ruse V. Why God Won t Go Awy: Brin Siene nd the Biology of Belief. New York, NY: Bllntine Books;

11 52. Lzr SW, Bush G, Gollu RL, Frihione GL, Khels G, Benson H. Funtionl rin mpping of the relxtion response nd medittion. Neuroreport. 2000;11(7): Frihione G, Dly R, Rogers MP, Stefno GB. Neuroimmunologi influenes in neuropsyhitri nd psyhophysiologi disorders. At Phrmol Sin. 2001;22(7): Frihione G, Stefno GB. Pleo neurl systems: nitri oxide, morphine nd dopmine rin rewrd nd motivtion iruitries. Med Si Monit. 2005;11(5):MS54-MS Koenig HG, Cohen HJ. The Link Between Religion nd Helth: Psyhoneuroimmunology nd the Fith Ftor. New York, NY: Oxford University Press; Stefno GB, Esh T. Integrtive medil therpy: exmintion of medittion s therpeuti nd glol medil outomes vi nitri oxide [review]. Int J Mol Med. 2005;16(4): Ruik B. The iofield hypothesis: its iophysil sis nd role in mediine. J Altern Complement Med. 2002;8(6): Rein G. Bioinformtion within the iofield: eyond ioeletromgnetis. J Altern Complement Med. 2004;10(1): Bell IR, Bldwin CM, Shwrtz GE. Trnslting nonliner systems theory model for homeopthy into empiril tests. Altern Ther Helth Med. 2002;8(3): Jung CG. Psyhology nd Religion. New Hven, CT: Yle University Press; Fowler JW. Stges of Fith: The Psyhology of Humn Development nd the Quest for Mening. Sn Frniso, CA: HrperCollins; Division of Mentl Helth nd Prevention of Sustne Ause. World Helth Orgniztion. WHOQOL. Mesuring Qulity of Life. Aessed Aug 20, MBrien B. A onept nlysis of spiritulity. Br J Nurs. 2006;15(1): Miller WR, Thoresen CE. ulity, religion nd helth: n emerging reserh field. Am Psyhol. 2003;58(1): Hill PC, Prgment KI. Advnes in the oneptuliztion nd mesurement of religion nd spiritulity: implitions for physil nd mentl helth reserh. Am Psyhol. 2003;58(1): Zinnuer BJ, Prgment KI, Cole B, et l. Religion nd spiritulity: unfuzzing the fuzzy. J Si Study Relig. 1997;36(4): She J. ulity nd Helth Cre: Rehing Towrds Holisti Future. Chigo, IL: Prk Ridge Center; Sthy Si. Edution in Humn Vlues. Philosophy of SSEHV. Aessed Aug 20, Hed, Hert, Hnds Diversity Ledership [We site]. Hedherthnds.om/min.phtml. Aessed Aug 20, Hed, Hert, Hnds Frmework. Singpore Ministry of Edution. Ntionl Edution Brnh. htm. Aessed Aug 20, Hed, Hert & Hnd Art Studio [We site]. Aessed Aug 20, Hll DE, Koenig HG, Medor KG. Coneptulizing religion : how lnguge shpes nd onstrins knowledge in the study of religions nd helth. Perspet Biol Med. 2004;47(3): Smith H. Why Religion Mtters: The Fte of the Humn in n Age of Diselief. Sn Frniso, CA: HrperSnFrniso; Hndzo G, Koenig HG. ul re: whose jo is it nywy? South Med J. 2004;97(12): Puhlski CM, Lunsford B, Hrris MH, Miller RT. Interdisiplinry spiritul re for seriously ill nd dying ptients: ollortive model. Cner J. 2006;12(5): Post SG, Puhlski CM, Lrson DB. Physiin nd ptient spiritulity: professionl oundries, ompeteny, nd ethis. Ann Intern Med. 2000;132(7): O Connor PM. ul elements of hospie re. Hosp J. 1986; 2(2): Cssel CK. The ptient-physiin ovennt: n ffirmtion of Asklepios. Conn Med. 1996;60(5): Cruess RL, Cruess SR. Tehing mediine s profession in the servie of heling. Ad Med. 1997;72(11): Novk DH, Epstein RM, Pulsen RH. Towrds reting physiin-helers: fostering medil students self-wreness, personl growth nd well-eing. Ad Med. 1999;74(5): Miller WL, Crtree BF. Heling lndspes: ptients, reltionships, nd reting optiml heling ples. J Altern Complement Med. 2005;11(Suppl 1):S41-S Blint M. The Dotor, His Ptient nd the Illness. London, Englnd: Pitmn Medil; Epstein RM. ful prtie. JAMA. 1999;282(9): Frnk AW. Asking the right questions out pin: nrrtives nd phronesis. Lit Med. 2004;23(2): Post SG, Underwood LG, Shloss JP, Hurlut WB, eds. Altruism nd Altruisti Love: Siene, Philosophy, nd Religion in Dilogue. New York, NY: Oxford University Press; The Aln Mson Chesney Medil Arhives of the Johns Hopkins Medil Institutions. Osler W. Aequnimits. Aessed Aug 20, Frihione GL. Seprtion, tthment nd ltruisti love: the evolutionry sis for medil ring. In: Altruism nd Altruisti Love. New York, NY: Oxford University Press; Remen RN. Kithen Tle Wisdom: Stories Tht Hel. New York, NY: Riverhed Books; Snnell K. Writing for our lives: physiin nrrtives nd medil prtie. Ann Intern Med. 2002;137(9): Borkn JM, Reis S, Medlie JH, Steinmetz D. Ptients nd Dotors: Life-Chnging Stories From Primry Cre. Mdison, WI: University of Wisonsin Press; Smith H. The World s Religions: Our Gret Wisdom Trditions. Sn Frniso, CA: HrperCollins; Jung CG. Psyhology nd the Est. Prineton, NJ: Prineton University Press; Jung CG. Psyhology nd Western Religion. Prineton, NJ: Prineton University Press; Jmes W. The Vrieties of Religious Experiene. New York, NY: New Amerin Lirry; Cmpell J. The Hero With Thousnd Fes. Prineton, NJ: Prineton University Press; Elide M. The Sred nd Profne: The Nture of Religion. Orlndo, FL: Hrourt, In; Tervlon M, Murry-Cri J. Culturl humility vs. ulturl ompetene: ritil distintion in defining physiin trining outomes in multiulturl edution. J Helth Cre Poor Underserved. 1998;9(2): Anndrjh G, Hight E. ulity nd medil prtie: using the HOPE questions s prtil tool for spiritul ssessment. Am Fm Physiin. 2001;63(1): Puhlski C, Romer AL. Tking spiritul history llows liniins to understnd ptients more fully. J Pllit Med. 2003;3(1): Turner DD. Just nother drug? A philosophil ssessment of rndomized ontrolled studies on interessory pryer. J Med Ethis. 2006;32(8): Hlperin EC. Should demi medil enters ondut linil trils of the effiy of interessory pryer? Ad Med. 2001;76(8): Olshnsky B, Dossey L. Retrotive pryer: preposterous hypothesis? BMJ. 2003;327(7429):