The Register Report, Spring 2007 The Place of Spirituality in Psychological End of Life Care by: Erin L. Moss and Keith S. Dobson, Ph.D. Return to Table of Contents

With an increased focus on multidisciplinary care in health care teams, psychologists are being called to work in palliative care. Spirituality is often a salient issue for individuals in such settings and has significant implications with respect to psychological functioning. This paper discusses the incorporation of spirituality/ religion into psychological end of life care, with a focus on the biopsychosocial-spiritual model of health and the consideration of spirituality/religion as an aspect of cultural diversity. We discuss the ethical integration of spirituality/religion into psychological assessment and treatment and provide recommendations for training. A theme of this article is that fulfilling one’s ethical responsibilities as a psychologist includes attending to the spiritual needs of palliative care individuals. Thus, seeking ways to ethically integrate these concepts into psychology training and practice remains an essential endeavor.

A recent survey on what constituted a “good death” for Americans found that 89% of respondents felt that it was important to be at peace with God, 85% endorsed the importance of praying, and 61% of respondents felt that discussing existential distress and the meaning of death was a critical aspect to a good dying process (Steinhauser et al., 2001). The role of health care providers in assisting a good quality of death experience has become progressively more important, as death has moved out of the home and into institutions. Multidisciplinary teams are becoming the standard of care for palliative patients, and psychologists may play a variety of different roles within this team context including: advocate, counselor, educator, evaluator, and researcher (Werth, Gordon, & Johnson, 2002). In particular, psychologists may play a key role on palliative care teams with respect to providing support and counsel for terminally ill patients and their family members. Psychologists also provide support to other health care providers on issues surrounding treatment decisions, adjustment difficulties, death anxiety, and general preparation for death (Kaut, 2002; Werth et al., 2002). However, Kaut (2002) has argued psychologists tend to be reluctant to address spiritual matters with their patients. Psychologists need to be able to broach this topic matter with patients, both to allow the use of their unique skills and knowledge towards addressing a palliative patient’s spiritual needs, and also to work effectively with other spiritual care workers on the palliative team (i.e. chaplains, clergy, and pastoral counselors).

THE BIOPSYCHOSOCIAL-SPIRITUAL MODEL OF HEALTH

The incorporation of religion and spirituality into psychological care is consistent with the biopsychosocial framework from which many psychologists operate. The biopsychosocial perspective involves the recognition that patients’ problems are multifaceted and have biological, psychological, and social aspects (Bakal, 1999). The biopsychosocial model has recently been expanded into the biopsychosocial-spiritual model (Sulmasy, 2002). This model does not take a dualistic approach to mind and body, but instead proposes that the biological, the psychological, the social and the spiritual cannot be disaggregated from the whole. Each factor interacts with and affects other aspects of the person. Thus, how one thinks, feels, and copes with an illness may impact bodily symptoms, illness progression and perhaps even ultimate prognosis. From this perspective, a palliative patient needs to be treated as a “whole person” by ad dressing unique life experiences, values, and beliefs in order to maintain a sense of personal dignity (Chochinov et al., 2002; Steinhauser et al., 2000). Holistic patient management requires that health professionals therefore consider the spiritual/religious dimension of the person, particularly when an individual is faced with death. Respect for the rights and dignity of persons suggests that each person has the right to have his or her innate worth as a human appreciated by others, and that this worth is not dependent upon any other factor or qualification. Respect for dignity involves understanding the patient within his or her life context, and taking into consideration the patient’s physical, psychological, social, and spiritual factors.

THE IMPACT OF SPIRITUALITY ON MENTAL HEALTH

Researchers have identified religion as a significant variable in mental health (Koenig & Larson, 2001). A comprehensive review by Koenig, McCullough, & Larson (2001) indicated that religious affiliation was linked to lower rates of suicide and more negative attitudes toward suicidal behavior (note, however, that some religions have prescriptions against suicide). Religious commitment was also negatively related to drug and alcohol abuse, but positively associated with greater life satisfaction, positive affect, hope, and optimism. The relationship between spirituality/religion and mental health appears especially important in palliative circumstances. For example, Brady, Peterman, Fitchett, Mo, and Cella (1999) investigated the quality of life in individuals with a life-threatening diagnosis of cancer or HIV and found that people with higher levels of spirituality were better equipped to tolerate increased pain and fatigue. This same study showed significant and positive associations between measures of quality of life and measures of spiritual well-being, meaning/peace, and faith. Similarly, Yates, Chalmer, St James, Follansbee, and McKegney (1981) found that terminally ill cancer patients who reported belief in a higher power, the presence of an afterlife, and the usefulness of prayer indicated lower pain intensity than those individuals who did not endorse these spiritual beliefs. This discrepancy occurred despite the fact that both groups had similar objective pain levels.

Spirituality and religion have also been found to be associated with lower levels of anxiety and distress. McClain, Rosenfeld, and Breitbart (2003) found that spiritual well-being was negatively correlated with end of life despair, as assessed by outcome variables such as hopelessness, desire for hastened death, and suicidal ideation. Another study (Dervic et al., 2004) demonstrated that religiously affiliated individuals had significantly fewer lifetime suicide attempts and more perceived reasons for living compared to religiously unaffiliated individuals. As patients near the end of life, some may become despondent or demoralized, indicate a desire to have a hastened death, and thus be at a heightened risk for suicide. While it can be argued that there may be rational grounds on which to commit suicide, particularly given the circumstances surrounding a terminal illness (Gailbraith & Dobson, 2000), clinicians must be cognizant of the fact that psychological symptoms and spiritual distress often trigger thoughts of a hastened death even when pain and physical symptoms have been treated (Breitbart et al., 2000). Clinicians working in this area need to be competent and to feel comfortable while asking the necessary questions to distinguish aspects of depression and spiritual despair from a more reasoned and rational desire for hastened death (Galbraith & Dobson, 2000). Thus, it appears that spirituality/religion may be an important contributing factor in positive mental health during the terminal stages of life.

Gall, Charbonneau, Grant, Joseph, and Shouldice (2005) reviewed the literature about the relations among perceptions of relationship with God, style of coping, methods of problem-solving, religious orientation, and various health-related outcomes. They reported that perceiving God as loving is linked with positive reinterpretations of an illness, while viewing God as punishing or withholding is related to increased distress in the face of an illness. In terms of coping styles, Pargament (1997) has also outlined differences between patterns of positive and negative spiritual/religious coping. Positive coping methods, which include spiritual support, collaborative religious coping, and religious reframing, appear to be linked to spiritual and psychological growth in the face of adversity. On the other hand, negative coping, which consists of religious pain, turmoil, and frustration, appears to be related to higher levels of emotional distress and depressive symptoms (Fitchett et al., 2004). Problem-solving styles are also related to how an individual responds to a life stressor. A collaborative style (i.e. in collaboration with God) may empower individuals in stressful circumstances, while a deferring approach to problems may be linked to diminished self-competency (Pargament et al., 1988). Finally, an intrinsic spiritual/religious orientation has been found to be of greater benefit in coping with challenging conditions than an extrinsic orientation (Park & Cohen, 1993). An intrinsic orientation is indicative of an individual who lives his or her beliefs in a personally relevant manner, while an extrinsic orientation involves the use of spirituality/religion for external means, such as gaining protection, social status, or acceptance (Allport, 1966). Overall, carefully assessing the various components of spirituality/religion will help to determine whether an individual’s beliefs will prove to be beneficial or detrimental with respect to his or her physical and mental health. continued

 

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