Medicine and Faith in 1910: Immeasurable

1
Medicine and Faith in 1910 Immeasurable?

• Nothing in life is more wonderful than faith --
  the one great moving force which we can neither
  weigh in the balance nor test in the
  cruciblemysterious, indefinable, known only by
  its effects, faith pours out an unfailing stream
  of energy while abating neither jot nor tittle of
  its potency.
• Sir William Osler (1910). The faith that heals,
  British Medical Journal, 11470-72.

2
The Forgotten Factor
3
Are Religion and Science Mutually Exclusive?

• Religion and science are mutually exclusive
  realms of thought whose presentation in the same
  context leads to misunderstanding of BOTH
  scientific theory and religious belief.
• National Academy of Science (1984). Science and
  creationism A view from the National Academy of
  Science.

4
Are Religion and Science Mutually Exclusive?

• Religion and science seem to be mutually
  exclusive perspectives.
• Stark (1963). Journal for the
• Scientific Study of Religion, 33-20.

5
Scientist and Clinician Beliefs Rates of
Atheism and Agnosticism

• U.S. Population 6
• American Men and Women
• of Science 1916 and 1996 55
• Vermont Family Practitioners 36
• Psychologists 28
• Psychiatrists 21
• Bergin and Jensen, Psychotherapy, 1990, 273-7.
• Maugans and Wadland, Journal of Family Practice,
  
• 1991, 32210-213.

6
Religion Has Been Labeled

• A universal obsessional neurosis...infantile
  helplessness...a regression to primary
  narcissism.
• Freud, S. Civilizations and its Discontents,
  1959.

7
Religion Has Been Labeled

• Borderline psychosis . . . a regression, an
  escape, a projection upon the world of a
  primitive infantile state.
• Group for the Advancement of Psychiatry.
• Mysticism Spiritual Quest or Mental Disorder,
  1976.

8
Religion Has Been Labeled

• A psychotic episode.
• Horton, PC. American Psychoanalytic
• Association Journal 22(1-2) 364-380, 1974.
• Temporal lobe dysfunction.
• Mandel, AJ. In The Psychobiology
• of Consciousness. Ed. by RJ Davidson, 1980.

9
DSM-III-R Misrepresentation of Religion

• Of 45 case examples used to illustrate
  psychopathology in the DSM-III-R Glossary of
  Technical Terms
• 10 (22.2) had religious content.
• 2 (4.4) had occupational content.
• 1 (2.2) had family content.
• NONE had sexual, ethnic, racial, age, gender,
  educational, or cultural content.
• Larson DB, et al. (1993). American Journal of
  Psychiatry 15012.

10
Unresolved Religion Dynamics

• In their training our generation of analysts
  have not received the detailed understanding I
  think is necessary to appreciate the specific
  contribution of the God representation to psychic
  balanceAs in many other areas, if the analysts
  personal analysis has not helped them to come to
  terms with their religious beliefs, or lack of
  them, there is a risk of unchecked,
  countertransference in this realm.
• Rizzuto, A. The Birth of the Living God.
  University of Chicago Press, 1979.

11

• A national survey of psychologists found that
• Only 5 had received training on handling
  religious issues during their education.
• Yet
• More than one-half of psychologists believed that
  religion was a relevant topic for training, and
• Nearly two-thirds believed that such supervision
  and training was desirable.
• Shafranske, EP, Malony HN. Psychotherapy 1990
  27(1)72-78.

12

• A recent survey of members of the American
  Association of Directors of Psychiatric Residency
  Training found that while religion was viewed as
  an issue of significant clinical importance,
  religious issues were infrequently addressed in
  training.
• Sansone, RA, et al. Academic Psychiatry 1990
  434-38.

13
The Art and Practice of Medicine

• Medicine is the art and practice of understanding
  and treating physical and emotional illnesses so
  as to
• 1) Prolong life
• 2) Restore health
• 3) Fend off death
• Levin Vanderpool (1990). Journal of
• Religion and Health, 299-20.

14
Religion and spirituality are among the most
important factors that structure human
experience, beliefs, values, behavior, and
illness patterns.

• Lukoff D, et al. Journal of Nervous
• and Mental Disease 180673-682, 1992.

15
The R Word
16
The R Word

• Religion is a comprehensive picturing and
  ordering of human existence in nature and the
  cosmos.
• Levin Vanderpool (1990). Journal
• of Religion and Health, 299-20.

17
Perspectives Concerning The R Word

• Abraham Joshua Heschel
• Religious thinking, then, is an intellectual
  endeavor out of the depths of reason. It is a
  source of cognitive insight into the ultimate
  issues of human existence.
• Heschel, AJ. The abiding challenge of religion.
  The Center Magazine. March/April 1998, pp. 43-51.

18
Perspectives Concerning The R Word

• Clifford Geertz religion and stress
• The force of religion in supporting beneficial
  social values rests, then, on the ability of its
  symbols to formulate a world in which those
  values, as well as the forces (e.g., stressful
  events) opposing their realization are
  fundamental ingredients.
• Geertz C, 1973. The Integration of Cultures.
  Basic Books.

19
Religious and Spiritual Measures

• Duke University Religion Index (DUREL)
• How often do you attend church or other religious
  meetings?
• How often do you spend time in private religious
  activities, such as prayer, meditation or Bible
  study?
• In my life, I experience the presence of the
  Divine (i.e. God).
• Koenig HG, et al. Religion index for psychiatric
  research (DUREL).
• Am J Psychiatry 1997154885-6.

20
Religious and Spiritual Measures

• Duke University Religion Index (DUREL)
• My religious beliefs are what really lie behind
  my whole approach to life.
• I try hard to carry my religion over into all
  other dealings in life.
• Koenig HG, et al. Religion index for psychiatric
  research (DUREL). Am J Psychiatry 1997154885-6.

21
The S Word
22
The S Word

• Spirituality is a belief system focusing on
  intangible elements that impact vitality and
  meaning to lifes events.
• Maugans (1995). The SPIRITual history.
• Archives of Family Medicine, 511-16.

23

• Spirituality Self-transcendence which gives
  integrity and meaning to life by situating the
  person within the horizon of ultimacy
• The religious meaning of spirituality is based on
  the conception of what constitutes the proper and
  highest actualization of the human capacity for
  self-transcendence in personal relationships,
  namely, relationship with God.
• Conn JW, 1987. In The New Dictionary of
  Theology. The Liturgical Press Collegeville,
  MN.

24
Questions That Can Be Used to Facilitate Clinical
Discussions About Patient Spirituality

• From SPIRITual History
• What does your spirituality/religion mean to you?
• What aspects of your religion/spirituality would
  you like me to keep in mind as I care for you?
• Would you like to discuss the religious or
  spiritual implications of your health care?
• As we plan for your care near the end of life,
  how does your faith impact on your decisions?
• Maugans TA. The SPIRITual history.
• Arch Fam Med 1996 511-6.

25
Questions That Can Be Used to Facilitate Clinical
Discussions About Patient Spirituality

• From Inspirit
• How close do you feel to God or a higher power?
• Have you ever had an experience that convinced
  you that God or a higher power exists?
• How strongly religious (or spiritually oriented)
  do you consider yourself to be?
• McBride JL, et al. The relationship between a
  patients spirituality and health experiences.
  Fam Med 1998 30(2)122-6.
• Kass JD, et al. Health outcomes and a new index
  of spiritual experience. J Scientific Study of
  Religion 1991 30203-11.

26
Questions That Can Be Used to Facilitate Clinical
Discussions About Patient Spirituality

• From McBride, et al.
• How has your religious or spiritual history been
  helpful in coping with your illness?
• How has your belief system been affected by your
  illness?
• McBride JL, et al. The relationship between a
  patients spirituality and health experiences.
  Fam Med 1998 30(2)122-6.
• Hatch RL, et al. The spiritual involvement and
  beliefs scale development and testing of a new
  instrument. J Fam Pract 1998 46476-486.

27
Religious and Spiritual Measures

• For further reading
• Hill, Peter C., Wood, Ralph W., eds. (1999).
  Measures of Religiosity, Birmingham, AL
  Religious Education Press.

28
Measures of Spirituality and Religion

• Pargament, Kenneth I. (1997) The Psychology of
  Religion and Coping Theory, Research, Practice.
  New York The Guilford Press.
• Also Pargament KI, et al. Patterns of positive
  and negative religious coping with major life
  stressors. J Scientific Study of Religion
  199837(4)710-724.

29
Why Is This Clinically Important?

• Patient Need
• The Forgotten Factor
• Clinical Relevance

30
Patient NeedU.S. Religious Beliefs and Attitudes

• Item U.S. Population
• Feel God loves you 90
• Belief in power of prayer 88
• God performs miracles today 85
• Mind over matter -
• God not involved 11
• Emerging Trends, Princeton Religious Research
  Center, 1996.

31
Patient NeedPersonal Priorities in the U.S.

• Very strongly committed to
• 90 Family
• 79 Relationship and friends
• 54 Job
• 52 Religion
• 18 Ones political party
• USA Today survey of US adults, February 10, 1997.

32
Patient NeedU.S. Beliefs Faith, Prayer, and
Health

• 82 Believe in healing power of
• personal prayer
• 77 Believe that God can intervene
• to cure those with a serious
• illness
• 73 Believe that praying for another
• can help cure their illness
• Time, June 24, 1996.

33
Patient NeedU.S. Beliefs Faith and Health

• 79 Believe spiritual faith can help one
• recover from illness, injury, or disease
• 56 Believe their faith helped them recover
• from illness, injury, or disease
• 63 Believe doctors should talk to patients
• about their spiritual faith
• Only 10 of doctors have done so
• USA Weekend, April 5-7, 1996.

34
Patient NeedU.S. Beliefs Faith, Prayer, and
Health

• 64 Believe physicians should pray
• with their patients if asked
• 28 Believe faith healers can make
• people well
• Time, June 24, 1996.

35
Patient NeedSpirituality and Religion

• Psychiatry Medical/Surgical
• Inpatients Inpatients
• Consider self
• Spiritual or religious 80 86
• Deeply religious 48 38
• Need for prayer 80 88
• Religion important source
• of strength and comfort 68 72
• Fitchett, et al. J Nerv Ment Dis 1997185(5).

36
Patient NeedCoping with Illness

• Hospitalized
• Most Important Factor Patients
  Physicians
• The Patients Faith 44 9
• Koenig HG, et al. Religious perspectives of
  doctors, nurses, patients, and families. J
  Pastoral Care 1991 45(3)254-67.

37
Patient NeedPatient Views Regarding
Spirituality When Seriously Ill

• Pulmonary
• Patients
• Consider self religious 51
• Welcome religious questions in medical history
  66
• Not welcome religious questions
  16
• Ehman JW, Ott BB, Short TH. Do patients want
  physicians to inquire about their spiritual or
  religious beliefs if they become gravely ill?
  Arch Intern Med 1999 159 (15) 1803-1806.

38
Patient NeedPatient Views Regarding
Spirituality When Seriously Ill

• Pulmonary
• Patients
• Believe prayer can aid in recovery from illness
  90
• Agree physicians should ask religious questions
• if they became gravely ill
  94
• Ehman JW, Ott BB, Short TH. Do patients want
  physicians to inquire about their spiritual or
  religious beliefs if they become gravely ill?
  Arch Intern Med 1999159 (15) 1803-1806.

39
Patient NeedTeaching Spirituality in Medical
Schools

• Study sample More than one half of U.S. medical
  schools have courses in spirituality and
  medicine, many are required.
• Medical school curricula include
• Teaching students to make a spiritual assessment.
• Viewing and collaborating with chaplains as
  relevant part of the health care team.
• Puchalski CM, Larson DB. Developing
• curricula in spirituality and medicine. Acad
• Med. 1998 73(9)970-74.

40
Patient NeedTeaching Spirituality in Medical
Schools

• Medical school curricula include
• Showing students how to care for dying patients
  even when disease specific treatment no longer
  available.
• Exploring major religions to identify aspects
  that might affect health care choices, illness
  coping or social support value.
• Puchalski CM, Larson DB. Developing
• curricula in spirituality and medicine. Acad
• Med. 1998 73(9)970-74.

41
Patient NeedProvider and Patient Views-When to
Include Spirituality

• Physicians Patients
• Counseling terminal illness 69 61
• Handling death 68 60
• Major illness 45 36
• Intake history 31 ------
• Birth of a child 23 48
• Major surgery 7 47
• Maughans and Woodland (1991).
• Journal of Family Practice 32210-213.

42
Patient ReligiousnessWhen Should Physicians
Include In Care

• Attend church
• weekly or more
• Doctors should refer to chaplain or clergy 90
• Doctors should discuss religious issues 59
• A religious evaluation should
• be part of medical record 68
• Doctors should ask patients about their religion
  63
• Daaleman and Neare. J Fam Pract
• 199439564-568.

43
Patient NeedClergy Referral by Physicians

• Study sample survey of Am Acad of Fam Med
• Study results Family Physicians
• 80 had recommended clergy referral
• 30 had referred 10 or more times per year
• 40 clergy referrals depression mood disorder
• 20 clergy referrals alcohol drug abuse
• Daaleman TP, Frey B. Prevalence and patterns of
  physician referral to clergy and pastoral care
  providers. Arch Fam Med 1998 7548-53.

44
Patient NeedPhysicians Addressing Patient
Spiritual Needs

• Study sample 170 Missouri family physicians
• Result
• 1. Considered spiritual well-being an 96
• important health component
• 2. Supported referral of patients with 86
• spiritual questions to chaplains
• 3. Physicians should address their 58
• patients spiritual concerns
• Ellis MR, et al. Addressing spiritual concerns of
  patients family
• physicians attitudes and practices. J Fam Pract
  199948(2)105-9.

45
Patient NeedPhysicians Addressing Patient
Spiritual Needs

• Physicians view of top 5 barriers to addressing
  patient spiritual concerns
• Lack of time 71
• Lack of training to take spiritual history 59
• Uncertainty about how to identify
• patients w/spiritual needs 56
• Concern about projecting own beliefs onto
  patients 53
• Uncertainty about how to manage patients
• spiritual issues 49
• Ellis MR, et al. Addressing spiritual concerns of
  
• patients family physicians attitudes and
  practices.
• J Fam Pract 199948(2)105-9.

46
Patient NeedFamily Physicians View of
Spirituality

• National survey of family physicians
• Felt somewhat close to God 77
• Attend religious services monthly 74
• Daaleman TP, Frey B. Spiritual and religious
  beliefs and practices of family physicians a
  national survey. J Fam Pract 1999 48(2)98-104.

47
Patient NeedFamily Physicians View of
Spirituality

• National survey of family physicians
• 35 pray, spend time in spiritual practice daily
  
• 5 did not believe in God, higher power, force
• Daaleman TP, Frey B. Spiritual and religious
  beliefs and practices of family physicians a
  national survey. J Fam Pract 1999 48(2)98-104.

48

• Why Is This Clinically Important?
• Patient Need
• The Forgotten Factor
• Clinical Relevance

49
Finding the Forgotten FactorSystematic Reviews

50
The Forgotten FactorSystematic Reviews

• Assess the quantity as well as the quality of
  analyzing a factor in a field or body of research

51

• For many people religion forms a basis of
  meaning and purpose in life. The profoundly
  disturbing effects of illness can call into
  question a persons purpose in life and work,
  responsibilities to spouse, children, and
  parents, and motivations and fidelity priorities.
  Healing, the restoration of wholeness (as
  opposed to merely technical healing), requires
  answers to these questions.
• Foglio Brody. Journal of Family Practice 1988.

52
A systematic review of 2,348 studies published in
the four leading psychiatry journals from
1978-1982 found that

• 2.5 of the studies included a quantified
  religious or spiritual variable.
• Less than 1 assessed religion or spirituality
  with minimal standards of acceptability.
• Only 1 study employed a state-of-the-art approach
  to measuring religion or spirituality.
• The majority of studies measured religion with
  denomination -- a much less useful measure of
  religiousness.
• Larson et al. (1986). American Journal
• of Psychiatry, 143329-334.

53
Systematic ReviewsPsychiatrys Handling of
Religion - A Second Look

• Study sample 1991-95 systematic review of
  leading journals of psychiatry 2,766
  quantitative studies
• Study results 32 of 2,766 studies (1.2)
  included a religious or spiritual variable.
• This result was one-half (2.5) of a previous
  1978-82 psychiatry systematic review.
• Weaver AJ, et al. A systematic review of research
  on religion in four major psychiatric journals
  1991-1995. J Nerv Ment Dis 1998186(3)187-190.

54
The Forgotten FactorFrequency of Study

• Systematic Reviews of Clinical Fields
• Fields with Religion
• Psychiatry I 2.5
• Geriatrics 3.6
• 4 Fields Psychology 2.7
• Family Medicine 1.9
• Psychiatry II 1.2
• Primary Care 1.1
• Mean 2.3

55
Systematic ReviewsPsychology Research
Concerning the Clergy

• Study sample 1991-94 systematic review of eight
  leading psychology journals.
• 2,400 studies reviewed
• four assessed the role of clergy -- OR
• one in 600 studies
• In contrast, when in personal distress, at least
  4 in 10 Americans seek help from clergy.
• Weaver AJ, et al. What do psychologists know
  about working with the clergy? An analysis of
  eight APA journals 1991-94. Professional
  Psychology Research and Practice
  199428(5)471-74.

56
Systematic ReviewsSpirituality in Mental Health
Nursing

• Study sample 1991-95 systematic review of all
  research published in Archives of Psychiatric
  Nursing, Journal of Psychosocial Nursing and
  Issues in Mental Health Nursing
• Study results
• Of 311 quantitative studies, 31 (i.e. 10)
  included a spiritual or religious variable.
• Like other fields, most studies (61) assessed
  with a single item.
• Weaver WJ, et al. An analysis of research on
  religious
• and spiritual variables in three major mental
  health
• nursing journals. Issues Ment Health Nurs
  199819263-76.

57
The Forgotten FactorExamining Denomination

• Findings of the Penn Psychotherapy Project
• Christian Jewish None
• Penn Study 37 34 29
• National Surveys 87 3 6
• No Other Category
• Luborsky et al. Archives of General Psychiatry
  1990 37471-481.

58
Systematic ReviewsAssessing Religious
Affiliation

• Could not be determined 12.5
• By cemetery type w/reliability 12.5
• Pre-death subject interview 25
• By cemetery type w/out reliability 50
• McCullough ME, et al. The mismeasurement of
  religion in mortality research. Mortality
  19994(2)183-194.

59
Systematic ReviewsAssessing Religious
Affiliation

• Five Class Taxonomy 12
• Four Class Taxonomy 19
• Three Class Taxonomy 63
• Two Class Taxonomy 6
• Total 100
• McCullough ME, et al. The mismeasurement of
  religion in mortality research. Mortality
  19994(2)183-194.

60
The Forgotten FactorSystematic Reviews -
Quality of Study

• Research Studies
• Method Number With The
• Deficiency of SRs
  Deficiency
• Single item measure 5 79
• Denomination only 6 46
• No research citation 6 77

61
The Forgotten FactorSystematic Reviews
Clinical Findings

• Clinical Harm?
• or
• Clinical Benefit?

62
The Forgotten Factor

• Of those studies examining religion in the
  leading psychiatry journals
• 83 found a positive relationship
• 14 found a neutral relationship
• 3 found a negative relationship
• ...between religion and mental health
• Larson DB, et al. American Journal
• of Psychiatry 1992 149557-559.

63
The Forgotten FactorPhysical Health

• Craigie (1990) evaluating 10 years of the Journal
  of Family Practice where measures of religious
  commitment were measured demonstrated
• - 81 showed positive association
• - 15 were neutral
• - 4 were negative
• Craigie et al. References to religion in the
  Journal of Family Practice dimensions and
  valence of spirituality. Journal of Family
  Practice 1990 4477-480.

64
The Forgotten FactorPhysical Health

• Levin and Vanderpool (1987) when examining the
  epidemiological research which used a measure of
  frequency of religious attendance found results
  strikingly similar in proportions
• - 81 showed benefit
• - 15 were neutral
• - 4 showed harm
• Levin JS, Vanderpool HY. Is frequent religious
  attendance really conducive to better health?
  toward an epidemiology of religion. Social
  Science and Medicine 1987 24589-600.

65
The Forgotten FactorSystematic Reviews of the
Findings

• Of studies examining religious commitment
• variables in clinical research
• Family Frequency
• Psychiatry Medicine of Worship
• Clinical harm --ALL less than 5--
• Clinical benefit -- ALL greater than
  80--