Spirituality and Pain Allen R. Dyer, MD, PhD Professor of Psychiatry and Behavioral Sciences East Tennessee State University.

Spirituality and Pain

Allen R. Dyer, MD, PhD

Professor of Psychiatry and Behavioral Sciences

East Tennessee State University

Religion - Spirituality

• Religiousness manifests itself in external rituals of devotion or worship, while spirituality focuses upon an inner state of being.

Ethics

Boundaries

Fowler’s Stages of Faith• Stage 0 – "Primal or Undifferentiated" faith (birth to 2 years), is characterized by an early learning of the safety of their environment (ie. warm, safe and secure vs. hurt, neglect and abuse).

• Stage 1 – "Intuitive-Projective" faith (ages of three to seven), is characterized by the psyche's unprotected exposure to the Unconscious.

• Stage 2 – "Mythic-Literal" faith (mostly in school children), stage two persons have a strong belief in the justice and reciprocity of the universe, and their deities are almost always anthropomorphic.

• Stage 3 – "Synthetic-Conventional" faith (arising in adolescence) characterized by conformity

• Stage 4 – "Individuative-Reflective" faith (usually mid-twenties to late thirties) a stage of angst and struggle. The individual takes personal responsibility for their beliefs and feelings.

• Stage 5 – "Conjunctive" faith (mid-life crisis) acknowledges paradox and transcendence relating reality behind the symbols of inherited systems

• Stage 6 – "Universalizing" faith, or what some might call "enlightenment".

Stage 1 - Intuitive - Projective Faith

• is the fantasy-filled, imitative phase in which the child can be powerfully and permanently influenced by examples, moods, actions and stories of the visible faith of primally related adults.

Stage 2 Mythic-Literal Faith

• the stage in which the person begins to take on for him- or herself the stories, beliefs and observances that symbolize belonging to his or her community. Beliefs are appropriated with literal interpretations, as are moral rules and attitudes. Symbols are taken as one-dimensional and literal in meaning. In this stage the rise of concrete operations leads to the curbing and ordering of the previous stage's imaginative composing of the world. The episodic quality of Intuitive-Projective faith gives way to a more linear, narrative construction of coherence and meaning. Story becomes the major way of giving unity and value to experience.

Stage 3 - Synthetic-Conventional Faith

• a person's experience of the world now extends beyond the family. A number of spheres demand attention: family, school or work, peers, street society and media, and perhaps religion. Faith must provide a coherent orientation in the midst of that more complex and diverse range of involvements. Faith must synthesize values and information; it must provide a basis for identity and outlook.

Stage 4 Individuative-Reflective Faith

• it is in this transition that the late adolescent or adult must begin to take seriously the burden of responsibility for his or her own commitments, lifestyle, beliefs and attitudes. Where genuine movement toward stage 4 is underway the person must face certain unavoidable tensions: individuality versus being defined by a group or group membership; subjectivity and the power of one's strongly felt but unexamined feelings versus objectivity and the requirement of critical reflection; self-fulfillment or self-actualization as a primary concern versus service to and being for others; the question of being committed to the relative versus struggle with the possibility of an absolute.

Stage 5 Conjunctive Faith

• involves the integration into self and outlook of much that was suppressed or unrecognized in the interest of Stage 4's self-certainty and conscious cognitive and affective adaptation to reality. This stage develops a "second naivete'' (Ricoeur) in which symbolic power is reunited with conceptual meanings. Here there must also be a new reclaiming and reworking of one's past. There must be an opening to the voices of one's "deeper self." Importantly, this involves a critical recognition of one's social unconscious-the myths, ideal images and prejudices built deeply into the self-system by virtue of one's nurture within a particular social class, religious tradition, ethnic group or the like.

Stage 6 - Universalizing Faith The persons best described by it have a sense of an ultimate

environment that is inclusive of all being.

• They are "contagious" in the sense that they create zones of liberation from the social, political, economic and ideological shackles. They are often experienced as subversive. Many persons in this stage die at the hands of those whom they hope to change. Universalizers are often more honored and revered after death than during their lives. They have a special grace that makes them seem more lucid, more simple, and yet somehow more fully human than the rest of us. Life is both loved and held to loosely. Such persons are ready for fellowship with persons at any of the other stages and from any other faith tradition.

SPIRITual history

• S-spiritual belief system

• P-personal spirituality

• I-integration with a spiritual community

• R-ritualized practices and restrictions

• I-implications for medical care

• T-terminal events planning

S-spiritual belief system

• Do you have a formal religious affiliation? Can you describe this?

• Do you have a spiritual life that is important to you?

• What is your clearest sense of the meaning of your life at this time?

P-personal spirituality

• Describe the beliefs and practices of your religion that you personally accept. Describe those beliefs and practices that you do not accept or follow.

• In what ways is your spirituality/religion meaningful for you?

• How is your spirituality/religion important to you in daily life?

I-integration with a spiritual community

• Do you belong to any religious or spiritual groups or communities?

• How do you participate in this group/community? What is your role?

• What importance does this group have for you?

• In what ways is this group a source of support for you?

• What types of support and help does or could this group provide for you in dealing with health issues?

R-ritualized practices and restrictions

• What specific practices do you carry out as part of your religious and spiritual life (e.g. prayer, meditation, service, etc.)

• What lifestyle activities or practices does your religion encourage, discourage or forbid?

• What meaning do these practices and restrictions have for you?

• To what extent have you followed these guidelines?

I-implications for medical care

• Are there specific elements of medical care that your religion discourages or forbids? To what extent have you followed these guidelines?

• What aspects of your religion/spirituality would you like to keep in mind as I care for you?

• What knowledge or understanding would strengthen our relationship as physician and patient?

• Are there barriers to our relationship based upon religious or spiritual issues?

• Would you like to discuss religious or spiritual implications of health care?

T-terminal events planning• Are there particular aspects of medical care that you

wish to forgo or have withheld because of your religion/spirituality?• Are there religious or spiritual practices or rituals that

you would like to have available in the hospital or at home?• Are there religious or spiritual practices that you wish

to plan for at the time of death, or following death?• From what sources do you draw strength in order to

cope with this illness?• For what in your life do you still feel gratitude even

though ill?• When you are afraid or in pain, how do you find

comfort?• As we plan for your medical care near the end of life, in

what ways will your religion and spirituality influence your decisions?

F- Faith and Belief Do you consider yourself spiritual or religious?" or "Do you have spiritual beliefs that help you cope with stress?" If the patient responds "No," the health care provider might ask, "What gives your life meaning?" Sometimes patients respond with answers such as family, career, or nature.

I - Importance "What importance does your faith or belief have in our life? Have your beliefs influenced how you take care of yourself in this illness? What role do your beliefs play in regaining your health?"

C - Community "Are you part of a spiritual or religious community? Is this of support to you and how? Is there a group of people you really love or who are important to you?" Communities such as churches, temples, and mosques, or a group of like-minded friends can serve as strong support systems for some patients.

A - Address in Care "How would you like me, your healthcare provider, to address these issues in your healthcare?" “Do you consider yourself spiritual or religious?" or "Do you have spiritual beliefs that help you cope with stress?" If the patient responds "No," the health care provider might ask, "What gives your life meaning?" Sometimes patients respond with answers such as family, career, or nature.

Patient

• 1. adjective Capable of bearing affliction with calmness. 2. Tolerant; understanding. 3. Persevering; constant. 4. Capable of bearing delay and waiting for the right moment. –noun One under medical treatment. [from Latin patiens, to suffer]

"It is not nearly as important what disease the patient has

as what patient has the disease.”

Sir William Osler