Spirituality, Health, and Wholeness An Introductory Guide for

Health Care Professionals, 1st Edition

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 CONTENTS

About the Editors

Contributors

Acknowledgments

Introduction: The Resurgence of Interest in Spirituality and Health

Henry H. Lamberton

PART I: THEORY

Chapter 1. Toward a Theology of Wholeness: A Tentative Model of

Whole Person Care
Richard Rice

Objectives
Introduction
Ministryhealing in the Life of Jesus
Ministryhealing in Our Lives
Guided Questions

Chapter 2. Mind, Body, Spirit: Exploring the Mind, Body, and Spirit
Connection Through Research on Mirthful Laughter
Lee S. Berk

Objectives
Introduction
Background of the Studies
Humor and the Neuroendocrine and Immune Systems
Research Findings
Anticipation of Positive Humor/Mirthful Laughter Experiences: A
Metaphor for the Spirit of Hope
 Conclusion
Guided Questions

Chapter 3. Spirituality and Coping with Trauma

Brenda Cole
Ethan Benore
Kenneth Pargament

Objectives
Introduction
Definitions
The Spirituality and Coping Connection
Beyond Stereotypes
The Two Faces of Spiritual Coping: Negative and Positive
Assessing Spiritual Integration
Clinical Implications
Conclusion
Guided Questions

Chapter 4. Faith, Illness, and Meaning

Siroj Sorajjakool
Bryn Seyle

Objectives
Introduction
Meaning and Illness
Faith
Faith and Illness
Faith, Transformation, and Cancer Patients
Spiritual Care
Conclusion
Guided Questions

PART II: PRAXIS

Chapter 5. Spiritual Care: Basic Principles

James Greek
 Objectives
Introduction
Twelve Suggestions for a Spiritual Visit
Summary
Guided Questions

Chapter 6. Spiritual Care of the Dying and Bereaved

Carla Gober

Objectives
Introduction
Difficult News
The Bereavement Process
Religious, Spiritual, and Cultural Issues
Follow-Up Care
The Medical Professional
Guided Questions

Chapter 7. Health, Wholeness, and Diversity: Intercultural

Engagement in Health Care
Johnny Ramírez-Johnson

Objectives
Introduction
Diversity in America
Racial Discrimination and the American Health Care System
Case Studies
A Diverse Vision of Wholeness in Health Care

Chapter 8. Working with Difficult Patients: Spiritual Care Approaches

Leigh Aveling
Siroj Sorajjakool
Reginald Pulliam

Objectives
Introduction
Contexts
Spirituality and Difficult Patients
 Conclusion
Guided Questions

Index
 About the Editors

Siroj Sorajjakool, PhD, is Associate Professor of Religion and Program

Director for the MA in Clinical Ministry for the Faculty of Religion as well
as Research Associate for the Center for Spiritual Life and Wholeness for
Loma Linda University. He has served as Section Co-Chair of Religion and
Social Sciences for the American Academy of Religion, Western Region.
He has authored two books, both published by The Haworth Press: Wu Wei,
Negativity, and Depression: The Principle of Non-Trying in the Practice of
Pastoral Care and Child Prostitution in Thailand: Listening to Rahab. He
also has had articles published in the Journal of Pastoral Care, the Journal
of Religion and Health, Pastoral Psychology, Ministry Magazine, Dialogue,
and Spectrum Magazine.
Dr. Sorajjakool has pastored three churches in Thailand and served as
Director of Thailand Adventist Seminary, Academic Dean for Mission
College’s Muak Lek Campus, and Associate Director for the Adventist
Development and Relief Agency. He is currently a Fellow in the American
Association of Pastoral Counselors and is a member of the American
Academy of Religion, the Adventist Society for Religious Studies, the
Society for Pastoral Theology, and the Adventist Chaplaincy Ministry. He
received two awards from the Claremont School of Theology: The
President’s Award for Academic Excellence (1999) and the Willis &
Dorothy Fisher Scholarship (1998).
Henry H. Lamberton, PsyD, is Associate Dean for Student Affairs at the
Loma Linda School of Medicine. He is also Assistant Professor in the
Department of Psychiatry and Associate Professor in the Faculty of
Religion at Loma Linda University. He is a licensed clinical psychologist
and continues to carry on a part-time clinical practice. Dr. Lamberton has
worked as a hospital chaplain, a church pastor, and college and university
religion teacher. He has published articles about the influence of the
integration of cognition and emotion on physician-patient interaction; the
development of moral reasoning in medical students; and the process of
mentoring student physicians.
 Contributors

Leigh Aveling, DMin, received his doctorate from Claremont School of

Theology. His other academic training includes marriage and family
therapy. He currently serves as director of chaplaincy at Loma Linda
University Behavioral Medicine Center. He has served as a chaplain for
eighteen years during which time he has worked with a variety of patients.
Currently, he works with oncology and surgery patients along with their
family members. In addition, Dr. Aveling works in an addictions unit with a
focus on helping patients regain sobriety. Dr. Aveling also serves as Adjunct
Assistant Professor on the faculty of religion at Loma Linda University.

Ethan Benore, MA, is a doctoral candidate in clinical psychology at

Bowling Green State University. He is currently completing his internship
in pediatric psychology at The Kennedy Krieger Institute/The Johns
Hopkins University School of Medicine. His research interests include the
psychology of religion, coping in children and families, and pediatric
psychology.

Lee S. Berk, DrPH, is Adjunct Assistant Professor of Family Medicine,

Susan Samueli Center for Complementary and Alternative Medicine,
College of Medicine, University of California Irvine; Associate Clinical
Professor, Health Promotion and Education, School of Public Health, Loma
Linda University; and Adjunct Associate Research Professor of Pathology
and Human Anatomy, School of Medicine, Loma Linda University.

Brenda Cole, PhD, is a licensed clinical psychologist and Assistant

Professor at the University of Pittsburgh Cancer Institute (UPCI). For the
past nine years she has conducted research on the role of spirituality and
existential issues in the adjustment to chronic illnesses, including cancer
and heart disease. She has conducted quasi-experimental and experimental
studies of spiritually integrative interventions for these populations using
longitudinal designs and has obtained grant support through private
foundations to pursue this work. Dr. Cole has also written on related topics:
defining the concepts of spirituality and religion, spiritual surrender as a
paradoxical means to control, forgiveness, and the design of spiritually
integrative interventions. Most recently she has developed and tested two
scales to assess two aspects of spirituality within the process of coping with
illness. One scale assesses spiritual coping using subscales that differentiate
the emotion, problem, and meaning-focused aspects of coping. The other
scale assesses spiritual well-being in the form of positive and negative
affect experienced toward the sacred (God, Higher Power, etc.). Dr. Cole
currently has a National Institutes of Health (NIH) grant pending to study
the effects of a spiritually focused meditation program for people coping
with metastatic melanoma.

Carla Gober, MS, MPH, is Assistant Professor in religious studies and

associate director of the Center for Spiritual Life and Wholeness at Loma
Linda University. She is currently on study leave at Emory University to
pursue a PhD in religious studies with an emphasis in memory, illness, and
ethnography. She completed a master of science in marriage and family
counseling, and a master of arts in public health education from Loma
Linda University. Before joining the faculty of religion, she coordinated the
development of four hospital-based bereavement programs and functioned
as the program counselor for a hospital-based peer support program in her
role as spiritual nurse specialist.

James Greek, DMin, received his doctor of ministry from Fuller

Theological Seminary. He currently serves as the director of the Chaplain
Department at Loma Linda University Medical Center and Adjunct
Assistant Professor of religion at Loma Linda University. Dr. Greek plays
an active role in providing clinical training on spiritual care for medical
students and residents at Loma Linda University Medical Center.

Kenneth I. Pargament, PhD, is currently Professor of psychology at

Bowling Green State University in the clinical psychology PhD program.
He has published extensively on the psychology of religion, stress, and
coping. A fellow of the American Psychological Association and the
American Psychological Society, Dr. Pargament is author of the book, The
Psychology of Religion and Coping: Theory, Research, Practice and co-
editor of the book, Forgiveness: Theory, Research, and Practice. He is past
president of Division 36 (Psychology of Religion) of the American
Psychological Association. Dr. Pargament consults with national and
international health institutes, foundations, and universities.

Reginald A. Pulliam, MA, is a doctoral candidate in clinical psychology at

Loma Linda University. His research interests are in the area of psychology
and religion with an emphasis on the link between spirituality and
cognitive/emotional integration as predictors of behavior. He is currently
developing a God Schema Inventory to address cognitive/emotional
integration relative to spiritual, physical, and psychological health
outcomes.

Johnny Ramírez-Johnson, EdD, MA, graduated from Harvard University

where he majored in cultural psychology using ethnography as his main
research methodology for looking at the role religious ideology plays in a
Hispanic community. Dr. Ramírez-Johnson currently serves as Professor of
theology, psychology, and culture at Loma Linda University, Graduate
School, and the faculty of religion. He is actively involved in research on
the interplay of religion and health as well as cross-cultural aspects of
religion. He has published articles in various journals including American
Behavioral Scientist and Journal of Research on Christian Education; he
has published AVANCE: A Vision for a New Mañana with Loma Linda
University Press (2003). This book reports on the largest study ever
conducted of any U.S. group of Hispanic churches.

Richard Rice, PhD, graduated from the University of Chicago Divinity

School, with a dissertation on Charles Hartshorne’s Concept of Natural
Theology. His published writings include seven books, several chapters in
anthologies, and a number of scholarly articles. Dr. Rice’s distinctive
theological orientation is expressed in The Openness of God: A Biblical
Challenge to the Traditional Understanding of God.

Bryn Seyle, MA, is a graduate of Loma Linda University in clinical

ministry. She has been involved in a study on faith and illness and how
meaning is constructed among breast cancer patients.
 Acknowledgments

This project emerged from the teaching context itself. It derived from
attempts of various individuals to bring sharper focus and attention to the
concept of spiritual care. We wish, first of all, to thank students at Loma
Linda University in various departments and programs who helped to
clarify concepts and ideas through discussions and interactions on prayer,
spirituality, spiritual care, and other related issues. Gerald Winslow, dean of
the faculty of religion, has been most supportive in the pursuit of this
project. Gayle Foster spent numerous hours going through this manuscript,
engaging in conversations, contacting various individuals, and offering
wonderful editorial insights. Kelvin Thompson, our research assistant,
worked on formatting this manuscript.
We wish to thank various contributors for the time and wisdom shared;
Dr. Richard Rice for his theological and biblical perspective on the meaning
of wholeness; Dr. Lee Berk for his research on laughter as it relates to the
immune system; Drs. Brenda Cole, Ethan Benore, and Kenneth Pargament
for very thorough research on spirituality and coping with trauma; Bryn
Seyle for her research on ways cancer patients construct meaning based on
their struggles with illness; Dr. James Greek for his practical suggestions on
the principles of spiritual care; Dr. Carla Gober for wonderful insights on
ways we can provide spiritual care for the dying and bereaved; Dr. Johnny
Ramírez-Johnson for his multicultural perspectives on spiritual care; Dr.
Leigh Aveling for his clinical experience relating to the topic of difficult
patients; and Reginald Pulliam for researching the literature relating to
difficult patients.
 Introduction: The Resurgence of Interest in Spirituality and
Health
Henry H. Lamberton

Interest has grown among health care professionals and the public in the
relationship between spirituality and health. Literature searches show a
large increase, beginning in the late 1980s, in the number of research
articles that address this topic. In 1995, Harvard Medical School’s
Department of Continuing Education and the Mind/Body Institute of
Boston’s Deaconess Hospital sponsored their first national conference on
Spirituality and Healing in Medicine. The large attendance and interest
resulted in a series of follow-up conferences held throughout the United
States over several years. In 1997, the Association of American Medical
Colleges and the National Institute for Healthcare Research1 cosponsored
their first conference for medical school educators on spirituality in the
medical school curriculum. By 2001, over seventy of the 125 allopathic
schools of medicine in the United States offered required or elective courses
in spirituality and medicine compared with just one school in 1992
(Puchalski, 2001).
This resurgence of interest has, for understandable reasons, not been
without controversy. Religion and healing have been integrally linked
throughout most of recorded history. The role of healer, priest, shaman, or
other religious practitioners were one and the same. But, particularly in the
West, the separation of religion and science that came with the
Enlightenment and freed scientists from the constraints of the church,
helped to open the way for dramatic scientific advances in health care.
Partly because of this history, some are uncomfortable with calls for a
greater integration of the health sciences and religion. Others argue that the
epistemologies of science and religion are so fundamentally different (even
though both may be valid) that attempts to bring the two fields together
only invite confusion. Others point to the violations of the ethical principle
of patient autonomy that can occur if health care practitioners introduce
religious topics or methods into the patient care arena. Still others are
concerned that a tendency to “blame the sick for being ill” will develop if a
patient’s spiritual orientation is held up as a significant determinant of
health.
Although these are important concerns, a number of countervailing
influences have encouraged the renewed interest in spirituality and health.
One of these is the significant body of research that demonstrates a
relationship between religion, spirituality, and health.2 Another is the
increased emphasis on training professionals to develop an awareness of,
and respect for, cultural diversity. A third influence is the recognition of the
strength of religion and spirituality as cultural forces (Shafranske and
Malony, 1996).
Undoubtedly, spirituality and religion play a significant role in the lives
of many who seek care from health professionals. National poles show that
nearly 95 percent of the U.S. population answer yes to the question, “Do
you believe in God?” Eighty-eight percent report that they pray to God and
66 percent percent say they agree or mostly agree with the statement,
“prayer is an important part of my daily life.” About 75 percent say they
believe in an afterlife and 40 percent report weekly attendance at a church
or synagogue (Hodge, 1996). For many, religion provides a basis for
making value judgments and assigning meaning to life experiences.
Surveys indicate that a majority of patients would like their caregivers to
talk with them about their spiritual concerns related to their illnesses (Miller
and Thoresen, 2003).
Although few would disagree that religion and spirituality significantly
influence the values and practices of individuals and societies, there is
much less agreement about how to define religion and spirituality.
Consensus shows that religion is, to use the language of researchers, a
multidimensional construct, too diverse to be meaningfully reduced to a
single variable (Hood et al., 1996). The same can be said if we substitute
the word spirituality in place of religion. (More will be said about
distinctions between religion and spirituality as follows). If we were to
design a research project in which we surveyed a random sample from a
large population group to determine whether those who say they believe in
God have better health than those who say they do not, we would be
unlikely to find significant differences. This is because the vast majority of
our sample would say that do believe in God and our question would not
describe, for example, what they believe about God, the importance of their
beliefs, or how their beliefs influence their attitudes and behaviors. We
would need to look more closely at the phenomenon of belief and its
variations to find whether it was helpful or detrimental for an individual’s
mental or physical health.
One well-known investigation of variations in religious experience was
conducted by Gordon W. Allport. Allport (1950) was the first to distinguish
between “intrinsic” and “extrinsic” orientations among religious adherents.
Hood et al. (1996) summarize Allport’s definitions of these two concepts as
follows:

Extrinsic religion is described as “strictly utilitarian: useful for the

self in granting safety, social standing, solace and endorsement for
one’s chosen way of life.” Intrinsic religion “regards faith as a
supreme value in its own right. It is oriented toward a unification of
being, takes seriously the commandment of brotherhood, and strives
to transcend all self-centered needs…. A religious sentiment of this
sort floods the whole life with motivation and meaning.” (pp. 24, 25)

The intrinsic-extrinsic construct, which illustrates the approach of

focusing on a specific dimension of spirituality and religion, has fostered
considerable research. Koenig (1999), for example, studied the qualities of
well-being and life satisfaction as they were self-reported by 836 elderly
living in the Midwest. He found that intrinsic religiosity was a stronger
predictor of these qualities than financial security or social status.
Among the more recent examples of research that have focused on a
specific dimension of religion and spirituality is the work of Kenneth
Pargament (1997) who has been a leader in investigating how people use
spirituality to help cope with traumatic or stressful life events. He and his
associates have identified styles of spiritual coping that correlate with
positive, healthful outcomes and other spiritual coping styles that correlate
with negative outcomes.
Rice (2002) provides another example of the multidimensional nature of
religious experience in his description of three factors that support
membership in a religious community. These are believing, behaving, and
belonging. The first includes the beliefs individuals hold about God and/or
religion as well as the relative strength or importance (saliency) of these
beliefs in their experience. Behaving involves the way people express their
religion or spirituality through their actions, including actions they avoid
and those (e.g., prayer or a distinctive form of dress) they practice. The
third involves the way faith leads to involvement in a community, such as a
church or synagogue.
Many other examples could be given of the multidimensionality of
religion and spirituality and the perspectives from which their effect on
behavior and health can be studied (Hood et al., 1996; Koenig,
McCullough, and Larson, 2001; Pargament et al., 1995). An understanding
of this research is beneficial for health care professionals in a number of
ways. First, research that documents the potential health benefits (both
mental and physical) of religion and spirituality provides a rationale for
offering spiritual care to patients who want it. Second, an awareness of the
variety and complexity of religious experience helps the caregiver avoid
premature or simplistic judgments about a patient’s faith. Third, research
that develops and tests models to explain how spiritual beliefs, attitudes,
emotions, and behaviors interact and influence health can increase the
practitioner’s skill of observation in a clinical setting. Furthermore,
knowledge of such research can help overcome the natural tendency to limit
one’s view of spiritual phenomena to what can be seen from the viewpoint
of his or her own experience—whether that experience has been positive or
negative.
We have not tried to carefully define the meaning of the terms religion
and spirituality or to distinguish between them. One reason is the notable
lack of consensus regarding their definitions. This lack of consensus exists
whether one considers how these terms are used by psychologists or
sociologists of religion, spiritual care providers (including clergy), the
media, or the general public (Hodge, 1996; Pargament et al., 1995;
Zinnbauer et al., 1997; Zinnbauer, Pargament, and Scott, 1999). This does
not, however, mean that the definitions of religion and spirituality are
completely fluid or ambiguous. Hill and Pargament (2003) note that the
concept of the sacred is the defining characteristic of what religion and
spirituality have reference to:

Although any definition of a construct as religious and spiritual is

limited and therefore debatable, … the sacred is what distinguishes
religion and spirituality from other phenomena. It refers to those
special objects or events set apart from the ordinary and thus
deserving of veneration. The sacred includes concepts of God, the
 divine, Ultimate Reality, and the transcendent, as well as any aspect
of life that takes on extraordinary character by virtue of its
association with or representation of such concepts (Pargament,
1999). The sacred is the common denominator of religious and
spiritual life. It represents the most vital destination sought by the
religious/spiritual person, and it is interwoven into the pathways
many people take in life. (p. 65)

Another reason we have referred to religion and spirituality together is

that most of the empirical research that has identified significant
relationships between religion/spirituality and health has been conducted
using the more objective variables (such as church attendance), that are
traditionally associated with religion (Powel, Shahabi, and Thoresen, 2003).
The trend toward distinguishing spirituality from religion began in the
mid-twentieth century, during the same period of time that the membership
and influence of mainline denominations was declining and the influence of
secularism was increasing. Disenchantment with institutionalized religion
led many to view religion as an impediment to authentic personal
spirituality. Historically, conceptions of religion included elements of an
individual’s search for what was sacred or ultimately purposeful (Zinnbauer
et al., 1997). More recently, spirituality has become a term of reference for
an individual’s personal quest for, or subjective experience of, whatever is
sacred or of transcendent meaning. Zinnbauer et al. (1997) note that
assigning these personal elements to “spirituality” has resulted in a
narrowing of the concept of religion to refer to what is formally structured
or institutionally grounded. If we use this distinction3 we would
acknowledge that an individual could be (1) spiritual but not religious, (2)
religious but not spiritual, (3) both religious and spiritual, or (4) neither
religious or spiritual.
Zinnbauer et al. (1997) studied how the terms spirituality and religion
were used among persons representing a wide variety of geographical,
psychosocial, and religious and spiritual orientations. They found a
significant distinction between the way the two terms were used. These uses
were along the lines just noted. They also found that the terms were not
fully independent. Their Roman Catholic sample (taken from a conservative
church in a small community), nursing home patients, and students from a
conservative Christian college made little or no distinction in the way they
used these terms. Those making the greatest distinction between religion
and spirituality were “New Age” followers, mental health workers, and
nontraditional Episcopalians.
These considerations of definition highlight two practical points for
health care professionals. One is the importance of noting which definitions
and measures are used when evaluating studies of how religion and
spirituality affect health. The other is that the meanings of religiousness and
spirituality will vary significantly depending on who is using the terms.
We use the term spirituality in the book’s title to clarify that its primary
focus is on meeting spiritual needs of patients from a diversity of faith
traditions as well as those who do not identify themselves with an
established or organized faith tradition. Although spirituality and religion
are often positive influences with well-documented benefits for mental and
physical health, they frequently take on forms that are toxic or harmful.
Health care professionals will encounter individuals whose prior
experiences with religion/spirituality have been predominately negative.
For this and other reasons, not all patients want to have their caregivers
address religious or spiritual issues. The patient’s autonomy should always
be respected and a discussion of religious and spiritual issues should never
be imposed.
Knowing when and how to address spiritual issues is an art that is
developed through the application of knowledge, skill, perception, and an
attitude of respect for the patient. This book is intended to assist the health
care professional in learning this art. It is designed to be a practical guide
for health care professionals when they encounter patients for whom illness
creates a crisis of faith as well as those for whom it provides support. The
authors of the following chapters have had extensive experience in the areas
about which they write. Most of the authors come from the Judeo-Christian
or Judaic tradition. But they identify principles that they and others have
found to be important in working with patients from a wide diversity of
spiritual traditions.
Some of the chapters address the importance of “caring for the
caregiver,” or of the way a caregiver’s self-understanding influences his or
her work with patients. Richard Rice’s opening chapter provides a unique
perspective on the spiritual significance of caring for physical illness by
looking at the work of Jesus. This perspective becomes especially relevant
when one considers the far-reaching influence of this historical figure on
the establishment of hospitals and other health care institutions. Many of
the words and metaphors that are part of the health care vocabulary are
derived from the Christian tradition (Winslow, 1996).
Rice also outlines a theological/philosophical basis for spiritual care by
providing a wholistic view of persons. The various dimensions we ascribe
to personhood (physical, mental, emotional, social, spiritual, etc.) are
differentiations of convenience, but we must never forget that persons are
indivisible and that each dimension affects the others. Care for the whole
person requires attention to all of the dimensions that make us human,
including the spiritual dimension.
Throughout history, human experience has led people to understand that
the mind and body affect each other. But it is only recently that the
biological mechanisms of the mind-body connection have begun to be
understood. Two bidirectional linkages between the brain and the rest of the
body have been well established. These are the bio-chemical linkages
through the hypothalamic-pituitary-adrenal axis and the linkages through
the central nervous system. Lee Berk’s discussion in Chapter 2 of research
he and others have conducted on the affects of mirthful laughter on the
immune system will be of interest for its description of the physiology of
the mind-body connection as well as the benefits of humor.4 Equally
relevant and intriguing are the findings he and his colleagues have made
about specific physiological benefits of positive expectations. “We believe
that the ‘biology of hope’ that underlies recovery from many chronic
disorders includes, in part, the synonyms optimism, anticipation,
expectation of positive interventions and experiences” (p. 34). Surely one of
the benefits of spiritual care is the hope that it provides.
In Chapter 3, Brenda Cole, Ethan Benore, and Kenneth Pargament
summarize pertinent findings from the extensive research by Pargament and
his associates on spirituality and coping. The chapter provides an excellent
integration of research and practice that is of immediate relevance for health
care professionals. It also gives an important foundation for Chapter 4,
“Faith, Illness, and Meaning.”
We have referred to the close association between spirituality and hope.
However, serious illness or injury also bring loss, loss that will almost
inevitably create, to a lesser or greater degree, a crisis of meaning. This is
especially true when there is a loss of reliance or trust in a divine protector.
In Chapter 4 Siroj Sorajjakool and Bryn Seyle describe the development in