IRISC

International Research Institute into Spirituality and Change

Talk by Simon Robinson - on spirituality and health

Bangor 31/5/00

Spiritualities and Health Care.

Spirituality as we all know is a slippery customer. Long the province of the Christian church, and therefore seen as primarily about the Holy Spirit, spirituality has been claimed as essentially a human dimension, as something to do with the nature and quality of humanness. This has occurred nowhere more so than in the field of health care, and in this paper I will examine and critique two particular approaches to spirituality and health care and then begin to explore a more dynamic view which is person centered and dialogic. Finally I will suggest ways in which this might affect the practice of health care.

New Age Spirituality.

The New Age movement is really a loose connection of movements which assert many different spiritualities. Common themes are:

- reclaiming the spiritual dimension, wresting it from patriarchal institutions which impose it, such as churches, and the medical profession.

- spirituality as acceptable, whatever its form, unless it harms the other. Hence there is tolerance of a great range of spirituality.

- spirituality as essentially other worldly, stressing the mystical and even the magical.

- spirituality as largely anti-rational and anti-scientific. Feelings and experience are paramount.

This view of spirituality sees health as about getting in touch with the self and the environment. Healing is expressed through complementary medicine but also through encouraging similar insights within conventional nursing care. Such narratives of health and spirituality are not to be discounted, but they have problems. Firstly, the anti-scientific stance leads to a lack of critical rigour and to placing faith in approaches which do not merit such faith, such as crystals. (1) Secondly, the stress on the other worldly tends to stress spirituality in terms of difference, ignoring the pragmatic side of life and the spirituality that might be found in the ordinary. Thirdly, it reflects an individualistic perspective, with the individual choosing her way to self fulfilment. Because of this there is not stress on the need for spiritual discipline, or accountability. The spiritual life is a positive pick and mix. Finally, the narratives of this spirituality are in fact from a very narrow culture base. As Michael Perry notes, the majority of New Agers are articulate, middle class and verging on the middle age. (2)

New Medicine.

Quite a different perspective emerges from the mainline professional health bodies and practitioners, in what might be termed the scientific view of spirituality. Here too there has been an attempt at liberation from the oppressive medical model of health. Attacked endlessly by figures such as Ivan Illich, this views the body as a passive physical organism, with technological medicine sovereign in attacking illness. In response many in the health care professions have accepted the spiritual dimension of care but seek to go further and to test the practical outcomes of attention to spirituality, and to develop professional process and procedure which can address spiritual needs.

Such approaches require greater precision in dialogue about spirituality. All too often spirituality, even in some nursing texts, becomes so vague or all encompassing as to be quite meaningless.

However, this proper concern for greater clarity can lead to several problems;

- The primacy of process over relationship. Hay, for instance, has developed a spiritual assessment questionnaire, which in some detail identifies spiritual suffering, diminished spiritual capacity, belief system, and religious need (3)

- The fragmentation of spirituality from the rest of the person. This is partly in an attempt to make clear the difference between the spiritual and psychological dimensions. Hence, there are attempts to define spiritual needs, suffering, outcome and so on. Ironically, this leads to the kind of specialism and fragmentation which was objected to in the medical model of health care.

If the New Age has no discipline then the new medicine is in danger of having too much and of missing the point. To find that point we must face up to definitions.

Some would argue that a definition of spirituality is not possible. Janet Bellamy, for instance, notes that 'definition is a tool of rationality, an instrument which seeks to enclose. The term spiritual, however, needs to remain elusive if it is not to betray its very identity'. (4 ) Hence spirituality can only be described. The point is taken, but if we avoid looking too closely at what the term means and how we can discover the meaning of the term there is a danger of sliding back to the ethereal, and simply enjoying the ride we know not where.

Hence, I offer a working definition of spirituality. First, the spirit can be seen as the essence of the human self. It involves both the general- the person as one of the human species- and the particular the unique self embodied in this human being. Spirituality then involves the practice of the spirit and the different ways in which it is developed, sustained and understood. It can be summed up under three heads:

- development of awareness of the other. This includes the self, the other person, the group/community, the environment and deity. Deity is broader than simply God, and can refer to who or whatever provides the ground of faith.

- developing the capacity to respond to the other. This involves embodying spirituality.

-developing life meaning based on both the holistic awareness of the other and the response to the other.

At the core of awareness of the other is empathy. Empathy is not as some would have us believe, exclusively a basic counselling skill. It is rather a way of attending to the other which enables us to genuinely reach out and be open to them. It is the fundamental mode of spiritual awareness, therefore, not a 'bolt on' skill but something about the very being of the person and their relationships.

Max Scheler views empathy in terms of transcendence, ' a genuine reaching out into the other person and his individual situation, a true and authentic transcendence of one's self' (5) The dynamic is one of moving away from the things which concern or obsess the self- fears, guilt etc.-, and which block our openness to the other. Hence, as Scheler puts it, 'personal dignity' is abandoned. It is not a self conscious process but rather one which is allows' the instinctive life to look after itself.

Empathy involves several important factors:

It is holistic. Hence, it involves cognitive, affective and somatic awareness. The more that this awareness is developed the more the relationship between these different aspects becomes clear- for instance, how far they are integrated or not. With the awareness comes the capacity to develop meaning in all these ways

It enables awareness of the ambiguities of the other. As the person becomes more aware of the other so the 'false self which seeks to provide an acceptable exterior is replaced by a more truthful picture. Empathy enables the other to reveal herself gradually, as trust is established, and enables the person to handle and accept the ambiguities which are found in all the relationships noted above. (6) The person, for instance, becomes aware of herself as both limited (physically, emotionally, cognitively and even morally) and also capable of creative change. The self is also seen as same and different from others, something critical to the way in which a patient begins to handle major physical or psychological illness. Other persons in the light of empathy can be seen as both enemy and neighbour. The family can be seen as both a ground faith and possibly a threat. The environment can be seen as both that which sustains, and therefore appropriately referred to in familiar terms, but also that which cannot be controlled. (7 ) Even the divine is ambiguous, both close and distant, committed yet capable of anger (Hebrews 12: 28/29)

Responding to the other.

Awareness of the other reveals not simply the ambiguity of the other but also their need. With the revelation of need comes a moral and pastoral challenge. In effect the other is calling the person to respond. Response may not be automatic or even clear, and ultimately depends upon a process of negotiation as to what is the response, and how and by whom it may be achieved. Such negotiation, exemplified in families, enables the development of purpose and a shared public image which provides the basis for moral and spiritual identity. (8)

Meaning.

Life meaning emerges from the awareness of and response to the other, and is focused on the formation of the identify of the self. At one level this is about the awareness of the other as a source of care- whatever the limitations. Awareness of the acceptance by another which is largely unconditional enables the development of faith. James Fowler notes the that faith need not be specifically religious. Indeed his first two definitions see faith as a generic quality of human beings:

‘the foundational dynamic of trust, and loyalty underlying selfhood and relationships....

a holistic way of knowing, in which persons shape their relationships with the self, others and the world in the light of an apprehension of and by transcendence.’ (9)

The development of faith is then 'meaning making', involving as much belief in as belief about an other. The other may change and with that the faith change or develop. Equally, in and through the negotiation of responsibility and the embodiment of a response to the other, through the active contribution of the person, and the development of purpose, there is another important dimension of meaning. This too will change and develop, with the spiritual identity of the person and the group being 'made and remade'. ( 10 )

In this dynamic of awareness, and discovery of meaning through relating and responding it becomes clear that spirituality is essentially relational. We only begin to know the self in and through our relationship with others, not least because our self is only revealed as we open out to care of the other, or in and through our response to the other. We only begin to know the other in and through their revelation of themselves and their embodiment of spirituality in response to us. Meaning then is created in and by the self and beyond the self in collaboration with others. It is then also a continual journey and learning process.

At the base of such developing awareness and meaning is agape. Nonconditional and inclusive love, this enables commitment and faithfulness whatever the other reveals. It is agape which sustains empathy, enabling the acceptance of ambiguity in the other. Without this there is the danger of distorted perception, denial of and alienation from the other and thus inability to respond.

Health.

Spirituality as described above relates directly to health, not least because the development of meaning in and through acceptance of mutual responsibility and interdependency sees its ultimate expression in the idea of shalom- often translated as peace, health or welfare. Shalom involves a dynamic view of peace which is not simply the absence of conflict , but the continued creation of right relationships, which we respond to the needs and challenges of others.

Such a spirituality provides us with a context of humanity within which we can properly describe health. As Moltmann reminds us, health as the sense of absence of disease or as general well being can never be the supreme human value, and cannot be equated with being human. ' On the contrary', he continues, a person 'has to prove the meaning he has found in his own life in conditions of health and sickness. Only can stand up to both health and sickness, and ultimately to living and dying, can count as a valid definition of what it means to be human' (11)

There is a danger in this definition of seeing those who cannot stand up to both as being less than human. However, the spirituality described above is not about success in finding meaning but rather about openness to the other which enables the continued development of that meaning, so that relational humanity remains the key value in life.

Such spirituality is not simply about arguing for a different world view from the medical model of health. More than that, it seeks to see how spiritual awareness can be embodied in practice of medicine and care, and it is to that practice we must now turn.

Health Care.

Faith and identity.

Alastair Campbell cites Terry Waite and his hostage ordeal as good example of how the spirit is sustained despite continued suffering. (12 ) Waite linked back to his most profound faith, through reciting to himself the Anglican worship offices. This was a means of enabling him to be aware of and link in to the community of his faith life, God and the church. Through this he was able to retain his life meaning, and thus his identity. This example also stresses the importance of ritual and discipline in spirituality, be it grounded in a religious or any other faith.

In spiritual terms the medical model of health sees faith as focused largely in the healing professionals. Moreover the experience of hospitalisation, even at its briefest, has the effect of cutting off the person from other faith relationships.

Care then has to enable the person to connect with or develop this sense of life faith or purpose. This may involve affirmation or exploration of faith) apart from the faith in the medical professions. Clearly, there is need for faith in the competence of the doctor or nurse. At the same time this competence cannot be the ground of all faith and meaning for the patient as they face the experience of illness. In terms of spirituality this focuses on an awareness of the professional which can begin to handle her ambiguity, that she is both competent with and available to the patient, but that they also have limitations- not least of time and energy. Such limitations may be made clear in any initial negotiation about the care plans, or may emerge as the healing/care relationship grows.

There is increasing empirical evidence in psychological and general medicine that careful reflection on the faith world of the patient is directly helpful to the healing process. (13 )

Spiritual narrative.

Spirituality as described above is about ways of relating. It does not then predetermine particular meaning for any individual. On the contrary the dynamic of agape is to give power to the other so that she can develop as her own subject and thus develop her own meaning. Critically this means that any focus on spirituality has to be person centered i.e. has to allow the patient the time and the space to work through her own reflection. This means providing the right environment for the patient to develop her narrative. It is precisely through the articulation of narrative that the she begins to own her life meaning and reflect on the relational context of that meaning.

For the health carer this means being alive to four broad areas of spirituality:

- well formed spirituality which might be already expressed in the attitude and practices of the patient. This can be affirmed, enabling the patient to connect it to experience of illness;

- any form of dis-ease or distance. The carer can enable the patient to reflect and develop spiritual meaning in working through these feelings;

- patients who have no practice in reflection and no sense of faith or purpose. Many, especially if seriously ill, may feel a need for faith, and the carer may be the only one who can help her explore this. One of the problems about use of assessment forms is that they tend to assume that the patient has a conscious spirituality, when in fact for many the first time for such reflection is precisely at a life crisis such as ill health.

- patients who have no cognitive skills, and whose spirituality is expressed in affective and somatic ways. Here the carer has to be alive to meaning expressed through feelings and body language, and to enable such meaning to be sustained through action, ritual and presence.

Several things arise from this approach. Firstly, the process of assessment, with its resulting forms and questionnaires remains important for systematic care, but it cannot be used as the basis for spiritual reflection. Only through enabling the patient's narrative can this be explored. Secondly, the carer her self becomes the critical focus of spiritual care. This may mean as enabler- linking the person into faith networks and feelings-, or the carer herself acting as the focus or ground of faith, especially at moments of extreme crisis. Such faith may be very quickly established, or only tentatively explored, with no real progress before the patient has to leave hospital With no certainty of outcome then the key to the spiritual dimension of care is in the presence offered by the carer.

Spirituality as described is about change and transformation, being open to the different others and how relationships with them can provide life meaning. The development of this openness is not smooth and invariably leads to new experience and awareness which will challenge previous views of life meaning. At different levels then the patient will need to be able to deal with live dialogues between different groups in her life, herself and others, herself and the ground of her faith, whatever or whoever that is, and also between different aspects of her self not least how her life meaning relates to her feelings. Only through careful dialogue can the patient begin to re-negotiate her relationship with other and the self, including responsibilities for the self and others. With that comes the transforming of relationships and life meaning. It is precisely this dialogue which makes patient centered spirituality more than simply an uncritical acceptance of undigested relativistic meaning. It is also such dialogue which enables the development of shared meaning. Shared meaning does not necessarily involve agreement about spiritual and moral ideas. It may involve both affirmation of sameness in ideas and also understanding and awareness of difference. Both sameness and difference may be accepted or lead to further change. At the heart of the patient / carer experience then is both affirmation and testing, involving all levels of awareness.

A great deal of the spirituality of health care has in the past centered on health care as the return to normal rather than responding to the changes and chances of the experience of illness. Increasingly, however, this spirituality of change is seen as a focus of care, not least in cardiac care. (14)

However, such change cannot be assumed or forced. The essence of spirituality as described above is that the person takes responsibility for reflection and for the development of life meaning. Hence the spiritual dimension of health care involves providing the environment in which the person can be empowered to reflect and change if they wish. This facilitates a greater involvement from the patient in reflecting on her illness, her feelings about that illness, and how the experience affects her life and the life of those around her. This is a much deeper level of democracy than the patients' charter, which focused on the rights of the patient and the delivery of health care. If the patient really is to embrace appropriate change in her experience then she has to be involved in the dialogue about herself and her treatment in the context of her life meaning at that time. This is the basis of genuine empowerment.

Health Care Professions.

The spirituality of health care inevitably moves beyond the care of the patient and the role of the particular professional to questions of faith in and the purpose of the professions and professional bodies. The very nature of professions depends upon the development of trust. Such trust tends to be based upon the competence of the practitioner, leading to an increase in litigation when things go wrong. This in turn tends to lead to a false spirituality which demands success in terms of outcome and is not willing to accept the limitations of care professions.

Regular reflection then is demanded in and between the professions about purpose and trust, and about how the care of presence relates to the care of competence. Just as the individual can only develop her spirituality through particular reflection so the professions need to enable reflection at all levels.

This in turn inevitably will affect the spirituality of the particular professional. Nouwen's concept of the wounded healer is very real, but in the context of the professional role this needs to be worked through, firstly to see how the practitioner can be given the space and the support to reflect and link in her narrative of care to her life meaning, and secondly to see what counts as acceptable limitations and frailty in the professional. Furthermore, whilst the relationship between carer and patient has a power imbalance this does not preclude mutuality, and therefore the likelihood that the carer will also experience challenge and change in the caring relationship. Again the possibility of such change has to be seen as part of the professional's life and enabled, perhaps as part of any professional development programme. This would stress the connection of spiritual awareness to the professional skills usually focused on in such programmes.

In all this it is important not to see spirituality as demanding an extra level of expertise or competence which the already hard pressed professional has to master. Spirituality involves basic life skills and qualities. In other words it is about being human, and developing meaning which recognises the significance of humanity. Moreover, such life skills, especially empathy, underpin all our relationships, in care,in developing moral meaning, and even in professional tasks such as diagnosis.

It also must be reinforced that the care of the patient is not individualistic, but involves the whole team, and beyond that the family. Again the importance of responsibility negotiation is key to a care which takes spirituality seriously.

What is true for the profession is also true for the total enterprise of health care. When there is no conscious reflection on the life meaning in a public enterprise then such meaning tends to be either forgotten in the rush to deliver, or simply be assumed. When life meaning is assumed in fact it quickly erodes, leading to the development of polarised narratives, none really addressing the need of the organisation as a whole to share some sense of trust and purpose, which is necessary if all involved are to accept mutual responsibility for the care. Such shared responsibility demands an awareness of the other professions and groups in the service, and the negotiated collaboration between them, leading to a continually evolving shared purpose. Once again this involves dialogue which will test all the different professions involved, inviting reflection on their own identity and spiritual meaning and how that relates to others. Such development demands space for the members to reflect on their life meaning both together and in different departments. It also demands response in the organisation and procedures, be that in a hospital or primary care centre, such that the disciplines and rituals of those organisations embody the spirituality, the life meaning, arrived at. This may be part of an annual or bi-annual review, or part of staff training, especially where different professions can train together. Peter Doble in the University of Leeds has done important work in education, enabling organisations to reflect purposefully on what they mean by spirituality and how its ties in to practice, and this might easily be applied to the health service. (15 )

These areas are but a few examples of how the practice of spirituality can be developed as part of the day to day practical care of health care workers. It is at the very heart of the health enterprise- not a bolt on extra or a sub-specialism. It can be spoken of and practiced in ways which are clear, and demands dialogue and reflexivity to ensure that meaning is relevant to the particular organisation or team. Ultimately, it is from the development of this awareness at all levels within the health service that the most effective critique of the culture of product, consumer and customer in the health service will emerge.

1. See Michael Perry, God's Within, SPCK, 1992.

2. Michael Perry, 'Idealism and Drift' in James Watt ( ed.), The Church, Medicine and the New Age, ed. ,CCHH, 1995, P 15 ff.

3. See M. Cobb and V. Renshaw ( eds.) The Spiritual Challenge of Health Care, Churchill Livingstone, 1998, p.112 ff

4. Janet Bellamy, 'Spiritual Values in a Secular Age', in Cobb and Renshaw, p.185.

5. Cited in A. Campbell, Moderated Love, SPCK, 1984, P.75.

6. See Heinz Kohut, 'Introspection, Empathy and the Semi-Circle of Mental Health' International Journal of Psychoanalysis, 1982, Vol.63, p.397.

7. See Emmanuel Lartey, In Living Colour, Cassell, 1997, p.121 ff

8. See Janet Finch and Jennifer Mason, Negotiating Family Responsibilities, Routledge, 1993.

9. James Fowler, 'Faith Development', in R. Hunter ( ed.) Dictionary of Pastoral Care and Counselling, Abingdon, 1993, p.394 ff

10. Finch and Mason, 166-169.

11. J. Moltmann, God in Creation, SCM, 1985, p.272.

12. See A. Campbell, Health as Liberation, Pilgrim Press, 1995, p.37 ff

13. See W. Miller ( ed.) Integrating Spirituality into Treatment, American Psychological Association, 1999, p.11

14. Miller p.13

15. For details contact Peter Doble, Dept of Theology University of Leeds, Leeds LS2 9JT. For how reflection on ethical and spiritual meaning in the profession of engineering compares see J. Armstrong, R. Dixon, S. Robinson, The Decision Makers: Ethics and Engineering; Thomas Telford, 1999.

Rev. Dr. Simon Robinson, Senior Anglican Chaplain, University of Leeds.

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