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 by James L. Risk, BCC
 Association of Professional Chaplains ~ Healing Spirit ~ Fall 2008

Religion and spirituality can be very positive influences in a person's life, and chaplains often help patients access those positive elements through ritual, prayer and empathic listening. In contrast, there are times when a patient's spirituality presents challenges, sometimes even ones that are life threatening, and a professional chaplain must help in those times as well.

According to James Griffith, a psychiatrist at George Washington University; "Spirituality is centered on the essential quality of relationships and refers to the relationship between people and their environment, people and other people, people and their heritage, and people and the numitious [holy]."

Spiritual struggle is about the struggle a person experiences when those relationships are fundamentally challenged or broken during times of great stress and disequilibrium; times when the self is embattled by illness or loss. In those times, a chaplain can listen for the clues or context in a person's story that tell of spiritual struggle.

"Any core dimension of human existence has the power to yield both joy and sorrow, and the spiritual side of life is no exception. Religion and spirituality provide potent sources of comfort, direction and meaning for many people, but they can also be sources of strain and struggle," says Julie Exline, a psychologist at Case Western Reserve University.

When persons are at spiritual risk, they have high spiritual needs and low spiritual resources with which to meet them. They may feel angry at God or not forgiven by God. They may struggle to make meaning of the unfairness of life and suffering. They may even wonder whether their illness is a punishment for something they did.

Patients at spiritual risk: case studies

At Rush University Medical Center, a tertiary critical care hospital in Chicago, a psychiatric nurse liaison requested the chaplain visit a patient on an acute rehabilitation unit. Mary (name changed) had been admitted with bone cancer that resulted in the radical amputation of her right leg. Following the surgery, she was treated for depression along with the physical issues associated with the surgery, but the psychiatric nurse thought a chaplain visit might address Mary's spiritual struggle.

The 42-year-old mother of three young children, she was the primary source of financial support for her family. Mary's husband was legally blind and dependent upon her for mobility. As the family chauffeur, she went to the supermarket to buy groceries and took the children to medical appointments. Now, Mary was deeply disturbed, even terrified. Her sense of self all the core relationships Griffith described in his definition of spirituality were changed, and she wasn't sure that she could "keep the family going."

"Why has God done this?" she asked the chaplain. She went on in tears, "I've been a good person ... What did I do to deserve so much suffering? I'm so confused. I'm angry at God. Why did I have to lose my leg? And thankful, too. I'm alive ... Oh ... I don't know..."

Mary was dealing with several critical health issues cancer, amputation of her leg, depression... and spiritual struggle. She thought she had been "a good person" but, angry at God, she was questioning the moral underpinnings of her world and asking what she had done to deserve such suffering.

Spiritual struggle is, in some ways, like a disease; it has "markers" or symptomatic qualities. According to Christina Puchalski, a palliative care physician and director of the George Washington University Institute for Spirituality and Health, spiritual struggle is recognizable by a loss of meaning and purpose, despair, anger at God, grief or loss, hopelessness, feeling punished or abandoned by God, guilt, or need for reconciliation.

Spiritual struggle takes on many voices:

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


A 40-year-old man who had been hospitalized for several months began to lose confidence and said, "I have asked 'Why me' many times in the past year. Why is God doing this?... I know he doesn't give us more than we can handle ... If you just fix the problem with my incontinence, I'll take all the pain that recovery dishes out."

Alice (name changed), a 63-year-old woman, had been admitted to the emergency department one Friday night with difficulty breathing. She lived alone in a comfortable house paid for over a successful and rewarding career. Following a CT scan, she received the devastating news that she had lung cancer. She asked the chaplain, "What's my life all about? I have my condo, my two cats and my job. Nothing else."

Each of these patients, revealing something important about themselves and their relationships, exhibited some of the indicators of spiritual struggle identified by Puchalski. Chaplains are very familiar with these issues and encounter them frequently in patient visits.

Mary, angry at God and terrified about the future, had found strength in her relationship with God prior to her illness. She even brought several books about spirituality and CDs of religious songs with her to the hospital, and they lay on the bedside table when the chaplain first introduced himself. As their visits continued, he asked her what those books and CDs represented to her. He explored her feelings and perceptions about her relationship with herself, with others and with God. She shared her fears about cancer being a punishment for something.

Mary cried out in lamentation about her losses of her leg, her future and being able to find strength in her faith. The chaplain listened. lie let her name her fears and doubts, and then he explored the positive images of faith she had learned as a child. He gently drew on those memories and images of a loving Presence and helped her reframe her future story. Over several weeks and many visits, lie prayed with her and helped her to reclaim a sense of self sufficiency as she faced an uncertain future. She left the hospital with strengthened coping strategies with which to meet the challenges of a new life that would include raising her three children and resumption of her work with a prosthesis.

When Alice arrived at the emergency department that Friday night, she had no books or CDs with her. She had little except the clothes on her back, but she carried a great deal in her heart. At age 63 and afraid of being alone, she had begun to reexamine her life. She told the chaplain about her lonely childhood with German parents who were judgmental and distant, her sister who had a wonderful family and beautiful daughters, her cats that were her only companionship, her sorrows, her coping strategy of keeping emotion out of her life, her spiritual crisis, and her search for faith in a halting return to the church of her childhood.

In those visits with her chaplain, Alice shared her struggle to trust God. Faced with a grave diagnosis, she cried as she opened her heart to accepting life her life on its terms. She confronted the loneliness of her childhood. Accompanying this interior work of confronting her own feelings, long bottled up, was a growing sense of communion with a chaplain, with God, with others. She felt a deepening sense of shared lives as she lay in her bed in the isolation of a reverse-pressure hospital room.

Six months after her discharge from the hospital, Alice wrote a letter, to the chaplain thanking him for helping her "sail through it all," words that she used to describe "sailing through the chemotherapy and all the rest with God's help." Her spiritual struggle had not continued. In fact, much of her struggle seemed to have been forgotten as Alice looked back on her hospitalization. Through this difficult period in her life, through conversation with a chaplain, she found a positive reconnection with the Holy.

Impact of spiritual struggle on healing

A body of research has developed in recent years about spiritual struggle. It offers clear indications about the impact of spiritual struggle on healing.

One study of 96 medical rehabilitation patients reported that higher levels of religious struggle were associated with less recovery of independence in activities of daily living (Fitchett, 1999). 'The patients who were angry at God, one marker of spiritual struggle, didn't do as well in their rehabilitation as patients who found strength and comfort in their faith.

Another study of 577 hospitalized, medically-ill, older patients found that spiritual struggle was associated with poorer physical health, greater depressive symptoms and lower quality of life (Koenig, 1998). In a two-year followup of this sample, patients with chronic spiritual struggle were found to have poorer quality of life, greater depression and increased disability (Pargament, 2001). This same study also found that spiritual struggle was a significant predictor of increased mortality even after controlling for other factors. An earlier mortality study of 232 elderly cardiac surgery patients identified risk factors for death after surgery, such as greater impairment in activities of daily living and a history of prior cardiac surgery One factor was surprising: Patients with greater isolation and who reported they received no strength or comfort from their faith had a threefold increase of postoperative morbidity (Oxman, 1995).

Chaplains address unique spiritual dimension

This growing body of research demonstrates how important it is to identify patients who may be experiencing spiritual struggle, and, clearly, all disciplines involved in patient care need to pay attention to the potential presence of spiritual struggle.

The research about spiritual struggle offers a broader perspective within which to place Alice's story, emphasizing why it is important to identify her spiritual struggle and engage her spirituality through empathic spiritual care. Alice's prognosis remained difficult; the lung cancer and, ultimately, a rare infection left her with chronic issues. Nonetheless, she was able to face her future with positive spiritual coping strategies. She regained a sense of purpose and reconciliation in her life, no longer despairing or feeling hopeless.

Identifying spiritual risk and developing a strategy for intervening in spiritual struggle needs to be a part of the clinical assessment of a patient when they are hospitalized. Chaplains can address those unique dimensions of a person's life, which can be described as spiritual, and the research about spiritual struggle tells us that patients like Mary, Alice and others will be served best when chaplains are a part of a patient, health care team.

The Rev. James L. Risk BCC is a staff chaplain at Rush University Medical Center in Chicago and executive director of Bishop Anderson House in the Illinois Medical District He may be contacted at James_L_Risk@rush.edu.

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