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Erin L. Moss and Keith S. Dobson, PhD

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.

SPIRITUALITY AND RELIGION AS AN ASPECT OF CULTURAL DIVERSITY

It can be argued that incorporating religion or spirituality into psychological end of life care is an important demonstration of cultural inclusiveness (Shafranske & Malony, 1996), since faith and religion are dominant forces in American society. However, there is evidence that psychologists are, on average, less religious than the general population (Shafranske, 1996). The disparity between society’s and psychology’s degree of religiosity can have negative consequences for health care. If a lack of concern for religious or spiritual issues is conveyed, palliative patients may be reluctant to consult a psychologist out of concern for how that professional will respond to such issues. Moreover, even if the individual does seek psychological services, he or she may feel reticent to share religious or spiritual concerns for fear that an unsympathetic psychologist might either minimize the value of these beliefs or construe them as pathological. Religious biases, which would include a bias against including spiritual/religious matters into the therapeutic process, may ultimately jeopardize the benefits of therapy.

Principle E of the American Psychological Association’s (APA) Code of Ethics (APA, 2002) enjoins psychologists to acknowledge that all persons have innate worth as human beings and to respect differences, including religious differences. In an effort to eliminate biases from their work, psychologists are trained in areas of diversity such as gender, ethnic and cultural differences. Spirituality/religion ought to be treated in the same manner. Though religion often tends to be given less importance in graduate schools for psychologists (Hertzsprung & Dobson, 2000), it is an important diversity variable that can contribute to recognizing and understanding substantial differences in internalized values and beliefs of patients. For the palliative individual, respect for his/her unique identity, affiliations and values is essential for maintaining a sense of dignity (Chochinov et al., 2002).

SPIRITUAL/RELIGIOUS ASSESSMENT

Having established the importance of including spirituality and religion into end of life treatment, the next question is how to ethically provide these services in the context of contemporary health care. As with most health care, assessment is the first step in sound psychological practice. Similar to other areas of functioning, psychologists should accurately assess an individual’s spiritual/religious functioning, and discern whether these beliefs/ behaviors are related to the other issues that the patient presents. An objective assessment involves not labeling spiritual beliefs as pathological, per se, nor dismissing potentially pathological beliefs as normative spiritual/religious concerns. Moreover, knowledge of a patient’s belief system can help guide clinicians in sensitively and appropriately responding to patient needs and the dying process.
There are various components of spiritual/religious involvement and beliefs that need to be assessed (see Table 1 for a summary of assessment recommendations). Typically, these components can be addressed in open-ended interview or with questionnaires. First, it is important to assess religiosity, which relates to religious orientation/ affiliation, beliefs, practices and commitment (Richards & Bergin, 2005; Sulmasy, 2001). Assessment of this area includes examining the importance of organized religion in the person’s life, private religious or spiritual practices, and nontraditional spiritual practices. It is helpful to also distinguish whether the patient’s orientation to spirituality/religion is intrinsic or extrinsic.

Second, it is important to investigate an individual’s spiritual identity (Richards & Bergin, 2005). Spiritual identity refers to one’s sense of divine worth and potential, and this sense of identity is particularly important for the palliative care population. Richards and Bergin (2005) note that people with a positive sense of their spiritual identity “believe that their inner spirit, or core identity, is eternal and that their identity and consciousness persist beyond the death of the physical body” (p. 227).

The third aspect of assessment involves investigating the individual’s current spiritual/religious coping and support (Gall et al., 2005; Sulmasy, 2001). Spiritual coping involves examination of the patient’s inner resources, and how spiritual/ religious beliefs, attitudes and practices influence one’s reactions to and coping with dying. For example, the clinician should assess whether the individual currently employs various rituals or practices, such as prayer, contemplation/meditation, or reading sacred writings, as coping mechanisms (Richards & Bergin, 2005). It is also important to investigate the individual’s engagement with any particular faith community and the degree of perceived support received from this community (Sulmasy, 2001). Equally important is the assessment of perceived support from a Transcendent Other (Gall et al., 2005). Thus, the clinician needs to examine the patient’s relationship with God/Transcendent Other, and whether this relationship is positive (i.e. God/Transcendent Other as loving, caring, nurturing) or negative (i.e. God/Transcendent Other as punitive, vindictive, and unjust) (Benson & Spilka, 1973).

A fourth area of assessment is the individual’s spiritual problemsolving style. Pargament (1997) has outlined three different types of spiritual problem solving: (1) self-directing, where the individual acts of his/her own accord, independent of God; (2) deferring, where the individual is entirely reliant upon God; and (3) collaborative, where the individual perceives himself/herself in partnership with God and working together to arrive at a solution.

The fifth area of assessment considers the patient’s spiritual well-being as an aspect of quality of life (Sulmasy, 2001). One measure for this area is the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (Brady et al., 1999). This measure is composed of two subscales: meaning/peace and faith. The meaning/peace subscale addresses the extent to which the individual feels inner serenity and peace within himself or herself, and thus addresses the overarching dimension of spirituality. The faith subscale measures the extent to which individuals find comfort and strength in their beliefs.

The next domain of assessment is that of spiritual needs. Kellehear (2000) has presented a useful clinical interview framework of the three different needs that palliative patients may have: situational, moral/biographical, and religious. Situational needs relate to finding purpose, hope and meaning during this last phase of life. Individuals with these needs may desire support and affirmation. Moral and biographical needs include reconciliation in relationships, prayer, moral and social analysis, forgiveness and closure. Finally, religious needs encompass reconciliation, divine forgiveness and support, religious rites/sacraments, visits by the clergy, religious literature, and discussion about God, eternal life and hope.

The final domain of assessment consists of spiritual appraisals, which pertains to the causal attributions assigned to a particular life event. Individuals faced with life-threatening illnesses may attribute the disease to chance, karma, a higher power, God, or other spirits (Pargament & Hahn, 1986). Including this component in assessment is important as the attributions an individual gives to the cause of the illness may indicate whether beneficial spiritual/religious coping strategies and activities are available.

An overarching goal of spiritual/religious assessment is to avoid preconceived notions, and instead to ask relevant questions in order to have a comprehensive spiritual history. By incorporating a spiritual component into assessment, the psychologist gains valuable insight about the patient and helps to fulfill the duty of responsibly caring for the “whole” person. As well, by allowing individuals to indicate where they fall in various domains of spirituality/religion, the psychologist can respect patients’ dignity and right for self-determination and autonomy.

INTEGRATING SPIRITUALITY/RELIGION INTO PSYCHOTHERAPY

Tan (1996) has described two major models of integrating religion into the therapeutic process: implicit integration and explicit integration. Each of these types of integration implicates different ethical concerns. A clinician who adopts an implicit approach tends to rarely initiate conversation about spiritual matters, or does so indirectly. Spiritual resources, such as prayer, the use of scriptures or sacred texts, and referral to a religious support group within the belief system of the patient are initially avoided. Spiritual/religious issues are dealt with in this model only if they are identified by the patient. An emphasis of implicit integration is focusing on the words the patient uses to describe his or her beliefs and practices in order to comprehend how that patient experiences spirituality or religion (Griffith & Griffith, 1992). Ideally, the clinician allows the patient to discuss his/her particular conceptualization of God, the transcendent, religion, or spirituality in therapy, without the therapist stepping in (Kahle & Robbins, 2004).

While the implicit approach supports the autonomy of the patient to broach spiritual issues in therapy or not, one must consider whether this approach compromises responsible caring. Research indicates that while many patients wish their medical practitioner to address spiritual/religious matters (Post, Puchalski, & Larson, 2000), the patients themselves are reluctant to take the initiative in this domain (Murray et al., 2004). Given the evidence that patients may not bring up issues related to spirituality, even if they would appreciate such discussion, holistic responsible caring may dictate that the clinician explore whether the patient wishes to address the concept of spirituality in therapy.

Explicit integration overtly incorporates spiritual/religious issues into therapy. This model posits that both the clinician’s and the patient’s openness to spirituality are essential components for effective therapy. Clinicians working within this framework may even provide some degree of spiritual guidance and direction. The clinician must carefully assess the appropriateness of using an explicit approach when first conducting the assessment of the patient’s spirituality and spiritual needs (Tan, 1996). It has been suggested that the defining features of explicit integration include the use of prayer, spiritual scriptures/ texts and referral to religious groups (Tan, 1996). Prayer may be used throughout the session in the aims of anxiety reduction, desensitization and spiritual development (Finney & Malony, 1985). Scripture and spiritual texts may be used in positive cognitive restructuring and referral to religious groups may provide the patient with fellowship of like-minded individuals (Tan, 1996).

Richards and Bergin (2005) have highlighted some additional explicit spiritual practices that may be incorporated into psychotherapy. First, contemplation and meditation may be appropriate for individuals from both Eastern and Western religious traditions. Therapists may recommend or practice spiritual/religious relaxation and imagery with their patients. Also, repentance and forgiveness, with both the divine and significant others, may be particularly relevant for the palliative population (Kellehear, 2000; Richards & Bergin, 2005).

Psychologists may have significant ethical reservations about explicit integration, specifically in relation to issues of competency and integrity in relationship (Richards & Bergin, 2005). Clinicians may lack competency in the use of prayer, particularly with regards to how it is used differently in various religious groups. The clinician may risk offending the patient and consequently jeopardizing the therapeutic relationship if prayer is used inappropriately or ineffectively. Richards and Bergin (2005) also note the possibility of negative transference emerging from the use of prayer during therapy, as they suggest that patients may project negative perceptions towards religious leaders or God to the therapist, thereby compromising the therapeutic relationship. In addition, while the use of inspirational scriptural messages or promotion of religious rituals may appear to have benefit, there is a potential for them to be misused as well (Tan, 1996). If the clinician is not from a particular religious background, he or she may misinterpret the meaning of scriptures or rituals, and inadvertently use them in an inappropriate manner. Unskilled psychologists run the risk of appearing “phony” or contrived to patients, if their practices are not fluent with the religious or spiritual approach being employed.

The second significant concern about employing explicit techniques with a patient from a different religious background relates to whether or not the psychologist can maintain integrity in the therapeutic relationship (Richards & Potts, 1995). The question is, can one be truly objective and unbiased while using strategies from different religious faiths? Of particular concern is the potential of manipulating and potentially proselytizing patients (Chappelle, 2000). Psychologists need to be acutely aware that a bias and resulting lack of objectivity can increase the risk of abusing power differentials. The palliative individual is already in a particularly vulnerable position. The explicit incorporation of religious practices can potentially be construed as disrespectful, exploitive and paternalistic. Certainly, such practices must avoid all perceived and real conflicts of interest.

Although employing explicit techniques such as prayer, ritual, and scripture use with patients in therapy may pose some potential ethical dilemmas, it may be appropriate to encourage the patient to engage in these activities outside of the therapy setting (Richards & Bergin, 2005). Moreover, incorporating repentance and forgiveness into therapy as well as referring the patient to spiritual/religious organizations within his or her belief system are explicit strategies that may be more ethically sound (Tan, 1996). First, the inclusion of forgiveness is common within secular psychotherapy and need not be directly related to spirituality/religion (Richards & Bergin, 2005). Second, through referral to spiritual/religious organizations, the individual may find fellowship, as well as a sounding board for discussing spiritual matters. Other spiritual resources, such as meditation, contemplation, or yoga classes, may also be useful adjuncts to psychotherapy (Richards & Bergin, 2005).

It is becoming increasingly common for palliative individuals to have access to institutionally-based chaplains or spiritual care workers, whose roles are to offer support and work with patients to understand their values and beliefs. The role of these spiritual health care workers may include praying for or with patients, leading them in various rites of worship, and reading scriptures. Thus, these professionals are in a prime position to address the more explicit techniques that are outside the ethical bounds of a psychologist’s competency and training. The psychologist may also refer the patient to a priest, pastor, imam, rabbi, shaman or other religious leader within the community for counseling directly related to spiritual concerns. Collaboration and consultation with these various leaders can be a fruitful union, as they may be an invaluable source of information for psychologists (Chappelle, 2000). If referral is seen as a responsible course of action, the psychologist should maintain contact with the religious leader (with the patient’s consent, of course), to optimize the consistency of care being provided.

Every clinician must decide for himself or herself whether to adopt an implicit or an explicit approach to integration, and whether or not to vary that perspective from case to case. That said, the ethical appropriateness of pure explicit integration into secular psychology is questionable and may ultimately be detrimental to the therapeutic process. Explicit integration likely will work best when the patient and psychologist have similar belief systems (Chappelle, 2000). It thus appears that the needs of a pluralistic, multi-religious culture will typically be best served with an implicit integration, but with an added degree of directiveness to provide the most responsible degree of attention to the patient’s spiritual health. Patients should be permitted to express their spiritual/religious needs, if they so desire, in a respectful and supportive therapy environment (Richards & Bergin, 2005). The primary roles of the psychologist in this regard are to listen nonjudgmentally, and to assist the patient in determining what actions are needed to fulfill these needs. The initiation of spiritual or religious therapy goals should occur only when the patient has directly indicated his or her wish to do so (Richards & Bergin, 2005). Thus, once the clinician has raised the issue, control is passed back to the patient, to allow him or her to direct the conversation. When using an implicit approach for integration, the particular beliefs and spiritual/religious practices of the psychologist and patient need not be isomorphic (Richards & Bergin, 1997). A clinician must approach an individual of a different religious background in the same manner that he or she would approach a patient from any different gender, age, or ethnic background: being open about these issues, being honest about his or her knowledge within that particular tradition (or lack thereof), and asking the patient to clarify any uncertainties. Crucially, the psychologist should not attempt to indoctrinate the patient in a specific belief system, label certain actions or choices as spiritually wrong, or use spiritual/ religious interventions without the patient’s consent (Chappelle, 2000; Richards & Bergin, 2005).

The integration of spirituality/religion into psychological practice may not be pertinent for all patients. It is imperative to undertake a risk-benefit analysis prior to assessing and discussing these matters. If a patient indicates that this is not an area of interest, it should not be further pursued. On the other hand, if the patient wishes to address these issues, the psychologist must be open and willing to engage in such a discussion. Above all, prior to any integration of spirituality into clinical work, the competency of psychologists in this area must be ensured.

RECOMMENDATIONS FOR TRAINING

Whether psychologists can truly practice from a biopsychosocial-spiritual perspective depends heavily upon their competency in the area of spirituality. Thus, to justify the ethical integration of spirituality into psychological end of life care, clinicians need to possess adequate knowledge and skill in this area (Richards & Bergin, 2005). Competency in an area requires formal training, and not simply layman knowledge or personal experience.

Graduate students in professional psychology would benefit from formal instruction on topics related to spirituality and religion. Instructional goals would be to: (1) address the relationship between mental health and spirituality, (2) explore spiritual issues that may be especially salient for the palliative population; (3) examine comparative religions and spiritual beliefs. It is argued that spiritual/religious differences should be addressed in the same manner as other diversity variables such as gender, culture, or ethnicity.

Second, psychologists need to be taught how to properly assess spirituality and underlying worldviews. As with any other assessment domain, gaining knowledge surrounding measures in this area and how to competently administer them is crucial. Introducing students to spirituality instruments in assessment classes and teaching them to incorporate spiritual questions into psychological interviews will help to realize this training goal. Application of these skills should be further refined within practicum settings, where supervision could provide guidance for students in how to sensitively and competently approach these matters.

Students also need to be aware of how various treatment approaches fit within the patient’s belief system. The student’s knowledge of comparative religion, in addition to his or her skills in spiritual assessment, will assist in the selection of the most appropriate intervention. Training should also focus on using background knowledge of different faiths to identify appropriate referral avenues for the patient and when consultation with clergy is necessary.

This self-knowledge is an important component of competency and a critical component for training students in spiritual awareness (Wasner, Longaker, & Borasio, 2005). Psychologists need to explore their own beliefs, as well as their attitudes and responses to different spiritual and religious values associated with death and dying. The “Wisdom and Compassion in Care for the Dying” program, for example, involves health care workers in non-denominational spiritual exercises such as contemplation and meditation, with the goals of assisting them to explore their spirituality and spiritual health (Wasner et al., 2005). Such programs could be especially beneficial for psychologists working with palliative patients, as frequent confrontation with death involves continually being faced with one’s own mortality.

Despite a fairly substantial research base in specialized journals, as well as the Division of Psychology of Religion in APA, the psychological study of religion has remained largely neglected by the discipline of psychology as a whole (Hill et al., 2000). In fact, some psychologists’ relationship with religious and spiritual matters has bordered between complete disregard to perceiving these areas as potentially maladaptive and detrimental to mental health. Is it possible to find a middle ground, whereby spirituality/religion and psychology are mutually appreciated and respected? If psychology is to progress and grow as a discipline, as well as adapt to the changing perspectives and demands of the healthcare system, spiritual care needs to be incorporated into practice, particularly within the palliative context (see Table 2 for recommendations). If the empirical literature continues to implicate religion as an important variable in mental health, psychologists would provide a disservice to their patients by failing to consider these needs. Seeking ways to integrate these concepts into psychology training and practice is an essential endeavor in a multicultural and diverse society.

Table 1: Suggested Recommendations for Areas of Spiritual/Religious Assessment

  1. Religiosity: Examine spiritual/religious affiliation, beliefs, practices and commitment. Distinguish whether spiritual/religious orientation is extrinsic or intrinsic.
  2. Spiritual Identity: Examine individual’s sense of divine worth and potential.
  3. Spiritual/Religious Coping and Support: Investigate patient’s inner resources and whether spiritual/religious beliefs, attitudes, or practices influence reactions to and coping with dying. Assess whether individual uses prayer, contemplation/meditation, reading sacred writings, or is involved with spiritual/religious community. Determine individual’s perceived support from: (1) spiritual/ religious community and (2) Transcendent Other.
  4. Spiritual Problem-Solving Style: Consider patient’s spiritual problem-solving style with respect to Transcendent Other (e.g., self-directing, deferring, or collaborative).
  5. Spiritual Well-Being: Assess patient’s spiritual well-being as an aspect of quality of life.
  6. Spiritual Needs: Examine patient’s spiritual needs in terms of: situational (e.g., finding purpose/hope/meaning), moral/ biographical (reconciliation in relationships, prayer, moral and social analysis, forgiveness and closure), and religious (reconciliation, divine forgiveness and support, religious rites/sacraments, visits by clergy, religious literature, and discussion about God, eternal life and hope).
  7. Spiritual Appraisals: Determine patient’s attributions for cause of illness.

Table 2 : Suggested Recommendations for Integrating Spirituality/Religion into Clinical Practice

  1. In order to competently integrate spiritual issues within the psychological assessment and treatment process, clinicians should receive training related to: 1) spiritual issues that are salient for the palliative population; 2) comparative religious and spiritual beliefs; and 3) ways of properly assessing and discuss spirituality and underlying worldviews with patients.
  2. Inquiry about patient spirituality should become a routine part of psychological assessment for palliative patients. Psychologists should address these issues in open-ended interviews, or screening tools that designed for this purpose (e.g., FACIT-SP, Brady, et al, 1999; Daily Spiritual Experience, Underwood & Teresi, 2002; or the RCOPE, Pargament, Koenig, & Perez, 2000). Psychologists should assist patients in identifying their spiritual needs and determining how best to fulfill these needs.
  3. In order to initiate appropriate spiritual referrals, clinicians need to become aware of spiritual/religious organizations and resources (e.g. meditation, contemplation, yoga).
  4. In dealing with spiritual issues within palliative care that require explicit spiritual/religious intervention techniques, psychologists are advised to seek support from chaplains and spiritual care workers. Psychologists should collaborate and consult with religious leaders in the community (i.e. priest, pastor, imam, rabbi, shaman), as appropriate, to enhance the spiritual care of the patient.
  5. Psychologists should engage in self-reflection regarding their religious beliefs, values, and faith commitments. Participation in programs aimed at helping mental health care professionals explore their own spirituality would be particularly advantageous.

Authors

Erin L. Moss is a doctoral student in Clinical Psychology at the University of Calgary, with interests in the area of eating disorders and professional issues in psychology. Her doctoral research will address the efficacy of motivational interviewing in weight loss programs for obesity.

Keith Dobson, Ph.D. is a Professor of Clinical Psychology and Head of Psychology at the University of Calgary. His interests include cognitive-behavioral therapies and professional issues in psychology.

Correspondence concerning this article should be addressed to Keith S. Dobson, Department of Psychology, University of Calgary, Calgary, Alberta, Canada T2N 1N4
(ksdobson@ucalgary.ca).

This is an abstracted version of Moss, E. L., & Dobson, K. S. (2006). Psychology, spirituality, and end-of-life care: An ethical integration? Canadian Psychology, 47, 284-299. Copyright 2006. Canadian Psychological Association. Reprinted with permission.