Home > Chronic and Serious Illness > Mind-Body-Spirit

Spirituality and Healing in Medicine

By Marcia London Albert, Ph.D.

Marcia London Albert, Ph.D., breast cancer survivor and education counselor presented this paper to a monthly discussion forum at the University of California at Irvine School of Medicine in September 1998. Her talk was part of their effort to teach new doctors to understand the way in which patient's faith and spirituality may affect recovery.

Introduction

There has been a prevailing tradition of omitting spiritual issues in clinical care and research in the practice of Western medicine. Spirituality is frequently omitted in medical training (Maugans, 1996). Often, spirituality is expressed through formalized religions. Recently, literature has begun to address the importance of religious and spiritual factors on the incidence, experiences, and outcomes of chronic and acute physical illnesses and mental health disorders (Maugans, 1996). Belief systems can influence patients' perceptions of health and illness, and help to support cognitions that affect stress appraisal and physiology (e.g., McKee & Chappel, 1992).

This handout will examine the neglect of spirituality in the practice of Western medicine, the role of religion in medical practice, the impact of religious beliefs on health maintenance, and the close mind-body connection in treating medical illness.

Historical Background and Context

During this past century modern medicine has been influenced by medical technology, and part of the change in medical practice includes the acceptance of a mechanistic-reductionist model with an emphasis on technology (McKee & Chappel, 1992). This biomedical model has led to patients feeling alienated from their physicians' humanity, and viewing their treatment as unrelated to other aspects of themselves, which include the mental, social, and spiritual areas.

In spite of this trend, it is important to consider that medicine originally developed in religious contexts (McKee & Chappel, 1992), and that medicine and religion have worked in a collaborative relationship to promote healing for thousands of years. Medical and religious practitioners have generally enjoyed an important and respected role in various cultures. From the time of the Byzantine Empire through the Reformation, both Jews and Christians believed in the linkage between medicine and religion. By the 17th century, rifts between medicine and religion became apparent, as a consequence of the challenges to church authority, and the rise of empirical science.

In 1980, Engel (Schenker & Rabenou, 1993) attempted to expand the biomedical model to include the psychosocial factors when providing medical care. Since that time there has been an explosion of interest in psychosocial issues in medicine, and the biopsychosocial model has been widely taught in medical schools. In 1986, Hiatt proposed expanding the model to biopsychosocial-spiritual, as did Kuhn (1988).

In 1996 six medical schools received $10,000 from the National Institute for Healthcare Research to develop courses in spirituality. In December, a conference on Spirituality and Healing" at Harvard Medical School attracted nearly 1,000 health-care professionals, including many faculty members from public medical colleges ("Spirituality & Healing," 1996). Participants discussed a survey conducted by the American Academy of Family Physicians, which found that 99% of family physicians believe that religious beliefs can help the healing process. Eighty per cent of those surveyed said that medical students should learn relaxation and meditation techniques as part of their formal training ("Spirituality & Healing," 1996).

According to Herbert Benson, president of the Mind/Body Medical Institute at Beth Israel Deaconess Medical Center and an associate professor at Harvard Medical School, reports, " Given such an overwhelming consensus, it would be irresponsible for medical schools not to address these issues," ("Spirituality & Healing," 1996).

These findings are not surprising when reviewing the surveys of the general United States population over the past decades concerning a belief in God. That is, surveys have consistently shown that 95% of the population espouses a belief in God (Gallup, 1988). In addition, nearly three-quarters of the population claim that their view of life is determined by their religious beliefs (Bergin & Payne, 1990). Interestingly, health professionals are less religious than the general public. In one study of 146 family physicians and 135 family practice patients in Vermont, patients were more likely than physicians to believe in God (91% vs. 45%, p<01), and the afterlife (60% vs. 45%%, p=.02), to use prayer (85% vs. 60%, p<.01), and to feel close to God (74% vs. 43%, p<.01) (Maugans & Wadland, 1991). Given the prevalence of religious beliefs in the general population, as well as the potential importance of religious beliefs in the clinical process, it may be appropriate for physicians to view spirituality as a critical part of health care.

Definitions of Religion and Spirituality

At this point it is necessary to define the concepts of religion and spirituality. First, published research has begun to establish that the concept of religion can differ in meaningful ways from the concept of spirituality (Aldridge, 1993). In the literature (Larson & Larson, 1992; Lukoff et al, 1994) religion has been most frequently assessed as issues pertaining to the practices, beliefs, and attitudes that an individual has towards a higher power or supernatural force according to a set of institutional or congregational codes or traditions. For many religions there are beliefs concerning the value of life, a belief in immortality, and a higher power. Organized religion is one way of expressing one's spirituality.

Spirituality, on the other had, has been found to be most frequently assessed as the practices, beliefs, and attitudes that an individual might have towards a higher power or supernatural force in the universe (Chappel, 1990). Thus, spiritual people can either be religious or non-religious and, similarly, religious people can be either spiritual or non-spiritual. The wide variety of religions attests to the importance of religion and/or spirituality for many people. For this reason, it is important that the physician provide medical skills that incorporate spirituality to both atheists and devoutly religious persons, no matter how different their beliefs are from those of the physician (McKee & Chappel, 1992).

Incorporating Spirituality Into Medical Practice

There is a growing body of medical literature suggesting that spirituality is of interest and beneficial to the practice of primary care medicine (McKee & Chappel, 1992). Spiritual practices can complement medical treatments in cases of both acute and chronic health problems (Hanadeh, 1987). Groups such as Alcoholics Anonymous (AA) and "12-step programs" incorporate belief in a higher power. Some innovative teaching program such as California's Loma Linda University, have integrated a spiritual dimension into medical training by pairing the hospital clergy with residents during medical rounds.

McKee and Chappel (1992) support and recommend the guidelines adopted by the American Psychiatric Association (1990):

1. Physicians should maintain respect for their patients' beliefs. It is useful for physicians to obtain information on the religious or ideologic orientation and beliefs of their patients so that they may properly attend to them in the course of treatment. If an unexpected conflict arises in relation to such beliefs, it should be handled with a concern for the patient's vulnerability to the attitudes of the physician. Empathy for the patient's sensibilities and particular beliefs is essential.

2. Physicians should not impose their own religious, antireligious, or ideologic systems of beliefs on their patients, nor should they substitute such beliefs or rituals for accepted diagnostic concepts or therapeutic practice.

There is some evidence that spiritual healing and prayer are beneficial for patients. Cohen (1989) referred 44 patients to spiritual healers and found that 35 (80%) felt better after the experience. This researcher found that these healers spent up to eight times longer with patients than the average family physician. The experience of touch in a safe environment, combined with the increased time with the healer, counteracts fear, stress, and loneliness, all of which retard healing. Vaillant (1983), in three prospective studies, reported that participation in Alcoholics Anonymous was significantly more effective than medical or psychological treatment in helping alcoholics achieve long-term sobriety. Studies on faith healing suggest that this practice does not need to be in competition with medical treatment (Cohen, 1989; Pattison, Lapins & Doerr, 1973). The results are often enhancements of the patient's subjective well-being and changes in the patient's lifestyle rather than changes in the disease process. That is, this treatment may of benefit to the patient. Prayer, a spiritual activity found in every religion, has been studied since the 19th century. A recent study ((Byrd, 1988) randomly assigned 393 patients admitted to a coronary care unit either to a group that received daily prayer, or a group that did not. At admission there were no significant differences between the two groups with respect to cardiac and noncardiac diagnoses. At discharge the prayer group differed significantly on 6 of 26 treatment and outcome variables. They required less ventilation assistance, fewer antibiotics, had fewer cardiopulmonary arrests, fewer episodes of congestive heart failure, and pneumonia, and required fewer diuretics.

Beliefs and Prescriptions for Health; Strongly Prescribed Health Behaviors

Research has documented a direct association between religious beliefs and health as a consequence of strongly prescribed health behaviors. The Mormons and Seventh-Day Adventists, for example, incorporate specific attitudes toward health maintenance behaviors that seen to promote a positive general health status (Levin & Vanderpool, 1991; Schiller & Levin, 1988). In addition, other researchers have discussed psychological connections between religious beliefs and health outcomes (McFadden, 1995). As mentioned earlier physicians are beginning to acknowledge the high stature that religion may have in their patients' lives (Mathews, 1994), and that some patients perceive prayer as a type of "alternative" therapy treatment (Eisenberg, Kessler et al., 1993).

In addition to religious prescriptions about how to remain healthy, results from the literature on the subject seem to suggest a facilitative relationship between religious identity and health (Levin, 1994). For example, a 1995 study by the Dartmouth Medical School found that patients who took comfort from religion were three times as likely to be alive six months after heart surgery than their non-religious counterparts. Other studies have found that people who believe in a higher power tend to live longer, have a higher quality of life, fewer drug and alcohol problems, and fewer mental and physical problems.

There is a general consensus among physicians (Hecht et al., 1993; Hopper & Seeman, 1994; Klatsky, Friedman, & Siegelaub, 1981; Sandvik et al., 1993) that good health practices and screening visits can have a positive impact on longevity and health . Studies have shown that religious beliefs can influence such health practices such as birth control, diet, smoking, sexual practices, and alcohol consumption (Gorsuch, 1995). These prescriptions for lifestyle may affect long-term health, such as extremely low rates of lung cancer because smoking is practically nonexistent among Seventh-Day Adventists, Amish, Hutterites, and Mormons (Troyer, 1988).

Cognition and Health: The Mind-Body Connection

Is it possible that psychological and social factors might influence the course of an illness such as cancer? In other words, what evidence do we have that psychological and social variables influence cancer incidence or progression? In order to systematically examine the interaction of mind and body in a physical illness such as cancer, we must knowledgeably account for the profound biological effects of the disease itself. There is much more variance in outcome if psychological and social variables such as social support, stress, and emotional expression are considered. The literature from 1990 through 1996 was reviewed examining the relationship between psychosocial variables and the occurrence of cancer. The literature was also reviewed to examine the relationship between psychosocial variables and disease progression.

There is little support for a link between psychosocial variables and the occurrence of cancer (e.g., Jensen, 1991; Greer & Morris, 1975; Antoni & Goodkin, 1988). The literature provides more support for an association between psychosocial variables (i.e., emotional expression, social support, and stress) and disease progression (Levenson & Bemis, 1991; Spiegel & Sands, 1989).

Several researchers have examined the effects of two constructs, "fighting spirit" and type C personality, on cancer progression. People with a type C personality are characterized as conforming and acquiescent; they tend to respond to stress with depression, helplessness, and hopelessness. On the other hand, people with a fighting spirit demonstrate characteristics such as optimism, assertiveness, and determination to fight their cancer (Spiegel, 1996). Patients with cancer who demonstrate a fighting spirit tend to live longer than patients with the so-called type C personality profile (e.g., Stavraky, Donner, Kincade, & Stewart, 1988; Stein, Linn, & Stein, 1989).

Some studies suggest that emotional distress is a predictor of decreased survival time with cancer (e.g., Kreitler, Chaitchik, & Kreitler, 1993). However, such emotional distress may be a result of more severe initial disease rather than a cause of more-rapid disease progression (Spiegel, 1996). Although these investigations do not demonstrate a clear relationship between intrapsychic variables and cancer progression, they do suggest that high distress, especially about somatic symptoms, predicts proximate mortality. What is even more compelling, difficulty in expressing distress has been shown in several studies to predict longer-term poor outcome (e.g., Dean and Surtees, 1989).

There is much evidence to support a positive relationship between social support and cancer survival (e.g., Spiegel, 1993), although the association is still unclear and deserves further investigation. Spiegel organized self-help groups as an intervention program with women with cancer and found that participants in a weekly discussion group lived longer on average than a control group. Spiegel concluded, "Modern medicine has suffered from an artificial distinction between mind and body. We have assumed that only physical interventions can influence physical problems. Yet... mind and body are connected and must work together, and this should be a powerful asset in treating medical illness" (pp. 97-98).

Cognition and Stress

Psychological research in cognitive control seems to indicate that control beliefs can also affect physical experiences. In these studies cognitive strategies for reducing pain have included imagery (Spanos, Horton, & Chaves, 1975), distraction (Kanfer & Goldfoot, 1966; Kanfer & Seider, 1973), calming self-talk, and selective attention (Langer, Janis, & Wolfer, 1975). Such cognitive strategies for reducing pain are somewhat analogous to certain religious practices, such as praying, chanting, or meditating. Individuals practiced in these strategies report being able to clear their minds, problem solve, and reduce physical discomfort (Ramaswami & Sheikh, 1989).

Few empirical studies have been done on positive cognitions. It is unclear whether it would be appropriate to assume that emotions (e.g., euphoria, calmness, transcendence, and joy) which are often associated with religious experience , would lead to long-term improved health conditions (Edwards & Cooper, 1988). Yet, there is some early evidence that certain types of cognitions have an association with at least temporary physiological states.

Psychoneuroimmunology

Preliminary evidence from scientific studies on the complex subject of the mind-body connection target two physical systems that control possible mediation pathways: the nervous and immune systems. For this reason, this area of research is called psychoneuroimmunology (PNI). Research in PNI appear to indicate that cognitions may interact with physiological states, which may then have a direct or indirect influence on health (Cohen, 1980). The idea that self-beliefs and "attitude patterns" might influence physical outcomes is not a new concept (Higgins, Vookles, & Tykocinski, 1992). Researchers have long noted how people with greater predispositions to display anger and corresponding stress are at far greater risk for heart disease (Jenkins, 1971, 1973).

Studies of stress highlight the relationship between immune changes and psychological factors. The primary dependent measure in most studies of this type are the number of "natural killer" (NK) cells in blood drawn from subjects compared at baseline time points and at various times after some stressful event. NK cells are thought to play an important role in the prevention of both infectious diseases and spread of tumors (Kiecolt-Glaser et al., 1985). Decremental changes to baseline levels of NK cells are show after stress produced from feelings of loneliness (e.g., Kiecolt et al., 1987), bereavement (Bartrop et. al., 1977), marital strain (Kiecolt et al., 1987) and even medical school final exams (Kiecolt-Glaser, Garner et. Al., 1984). These findings seem to indicate that stress from many types of life events and from different domains can lead to changes in physiology affecting immunological effectiveness. Religious beliefs are often used by people in coping with many of these stressful situations (e.g., Dull & Skokan, 1995).

There are methodological shortcomings when reviewing studies that used cognitive interventions, and use of cognitive interventions for specific illnesses have not consistently shown a facilitative pattern. The methodologically sound studies with cognitive interventions such as biofeedback, meditation, relaxation, stress management, or any combination of these were shown to be superior to no therapy (Dull & Skokan, 1995). However, the intervention programs were no better than self-monitoring techniques or even "sham" techniques that changed patients expectations about their ability to improve their blood pressure levels.

Conclusions

Evidence in support of a mind-body connection is sketchy perhaps because the topic presents a methodological challenge to researchers, and because it violates several traditional boundaries of specialists. Medical researchers or physiologists may be reluctant to "crossover" into domains of study that include religion, while social scientists may be uncomfortable incorporating blood draws as dependent measures. However, the need for interdisciplinary collaboration may increase as the substantial pressures to stay healthy in our society increases.

In addition to the need for further research in the relationship of spirituality and health, it will be increasingly important for primary care providers trained to consider the whole family and person, to include the patient's spiritual health (Maugans, 1996). Physicians should be able to identify the spiritual resources available in their hospitals and communities. Most hospitals provide pastoral care services. These clergy often have specialized training in the provision of spiritual support to the sick and injured patient. Involvement of pastoral clergy should be a part of the treatment plan. In summary, physicians and medical students should continue to explore and dialogue with other health care professionals and pastoral care staff concerning the interplay of spirituality and medicine.

© Copyright 1998, Marcia London Albert, Ph.D., Reprinted with permission