You probably know that The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition recognizes religion and spirituality as relevant sources of either emotional distress or support^1-3. But did you know that The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) encourages spiritual assessments of patients for health care institutions?

“Spiritual assessment should, at a minimum, determine the patient's denomination, beliefs, and what spiritual practices are important to the patient. This information would assist in determining the impact of spirituality, if any, on the care/services being provided and will identify if any further assessment is needed. The standards require organization's to define the content and scope of spiritual and other assessments and the qualifications of the individual(s) performing the assessment.” - JCAHO required standards

Spiritual assessment tools can help to identify religious beliefs concerning a host of health care decision making problems around long-term care, end-of-life issues, organ donation, food restrictions and so forth. They can be immensely useful to the clinician if they are used and used properly. On the other hand, if spiritual assessment tools are improperly prepared they may suggest to the patient that he or she is somehow morally bad and spiritually responsible for their illness or may suggest to some patients that religion is to be treated as nothing more than as a means to an end…in this case health⁴. Improper uses of spiritual assessment tools can only be avoided through the development of instruments that draw on current scientific conceptions on the nature of religiousness and its effects on health, as well as through the elimination of questions that blame the patient for illness.

The most thorough spiritual assessment tool currently available is the ‘Brief Multidimensional Measure of Religiousness/Spirituality’ for Use in Health Research (BMMRS,⁵). The BMMRS contains 38 statements with Likert-type items that cover 11 religious domains.

Developed by a panel of experts convened by the Fetzer Institute and the National Institutes of Health and of Aging, the BMMRS has excellent psychometric properties as well as publicly available norms for healthy individuals (Idler, et al. 2003). The scales are contained in an 88 page booklet available free from Fetzer or downloadable from the Internet. It contains long and short forms, with explanation, background and discussion for the dimensions mentioned above. According to the new Preface in the 2003 reprint, more than 3000 copies had been distributed, and 80% of recipients had rated the instruments as useful. An abbreviated version of the BMMRS has been included in the general Social Survey of the National Opinion Research Center⁶. In addition, Mokuau and colleagues have tested a revised version of the Fetzer/NIA BMMRS in a native Hawaiian population⁷.

Other instruments to assess spirituality include the Duke University Religion Index (DUREL;⁸) and The index of Core Spiritual Experiences (INSPIRIT;⁹). Some effort has gone into developing scales that are culturally sensitive which may be useful among minorities in health-related studies (e.g., African Americans; ^10-13). Instruments for specific disease groups, such as cancer (e.g., Santa Clara Strength of Religious Faith Questionnaire [SCSORF];^14-15) and HIV/AIDS patients (Ironson-Woods SR Index;¹⁶) have also been developed.

Some limitations of current instruments for spiritual assessment include the fact that there are no available instruments that can effectively and gently uncover ‘spiritual distress’ - yet spiritual distress may seriously impact coping strategies¹⁷. Further, current instruments for assessing religiosity, do not typically incorporate information on specific ritual practices - yet ritual practices are often the most effective elicitors of religious emotion. Finally, a persistent problem in instrument development results from the lack of reliance on a background science of religiosity. When inadequate definitions of spirituality and religion are employed, the validity of measures suffers.

Featured Course

Biobehavioral Pathways That Mediate the Effects of Spirituality and Religion on Health

(3 CEs) Patrick McNamara, Ph.D.

Measures of religiosity such as frequent prayer, frequent attendance at religious services and ‘intrinsic’ forms of religiosity appear to have beneficial effects on some aspects of physical and mental health^{10, 18-23}. These positive effects range from improved subjective reports of enhanced well-being to objective reductions in somatic complaints and rates of hypertension, pain, cancer and mortality ^{22, 24-27}.

Some forms of religiosity, however, can be associated with negative effects on health. On the far end of the continuum, fanatical/obsessional forms of religiosity can propel an individual into extreme ill-health and even suicide. Even in the absence of fanatical forms of religiosity, religiousness and/or fatalistic beliefs about illness can be associated with poor health-related decisions, such as delayed cancer screening ²⁸ or inappropriate medical care^29-30.

Religious striving itself can induce emotional distress and ill-health. Feeling distant from God or feeling difficulty trusting God, has been associated with depression and suicidality ²⁹ and greater likelihood of panic disorder in samples of adult psychotherapy outpatients ³¹. Feeling anger toward God, after an illness or injury has been demonstrated to be a powerful predictor of compromised physical recovery ^{e.g., 30, 32}. In fact, religious struggle may be associated with greater mortality in the medical context ^32-33. 

The data suggest that many patients want their spiritual needs to be integrated into their healthcare ^34-37 with desire for spiritual interaction increasing with the severity of the illness ³⁸. Taken together with the emerging guidelines of organizations like the JCAHO, it seems clear then that ‘spiritual assessments’ - already widely practiced in the nursing profession ^{10, 39} - will become an integral part of medical care in the near future.

Interestingly, while more than 90% of the health care providers said that they thought it appropriate to discuss religious or spiritual issues when a patient brings them up, virtually none report having received any training or information on religion or on how to discuss religion with their patients ⁴⁰. Toward this end, this online continuing education course offers healthcare professionals an opportunity to familiarize themselves with major themes in the literature on spirituality and health, including evidence implicating particular biobehavioral pathways in mediating effects of spirituality on health, assessment tools to assess spiritual coping strategies and guidelines for discussing spirituality with patients who wish to do so.

After completing this course, health professionals will be able to:

1. Articulate prominent themes that emerge from current biobehavioral studies of religion’s effects on health.

2. Identify biobehavioral pathways that mediates religion’s effects on health including effects that enhance and impede health-related outcomes.

3. Indicate available assessment tools to measure religiosity/spirituality in patients.

4. Recognize potential barriers/facilitators to discussing the health-related effects of spirituality and religious coping strategies with patients in the medical context.

About the Author Patrick McNamara, PhD – Director of Evolutionary Neurobehavior Laboratory, Department of Neurology, Boston University School of Medicine and the VA New England Healthcare System. Trained in neurolinguistics and brain-cognitive correlation techniques, he developed an evolutionary approach to problems of brain and behavior. He has published extensively in this area, as well as pioneered the investigation of the role of the frontal lobes in mediation of religious experience. He serves as Series Editor for the Praeger series of books on the evolutionary and biological roots of religion, Where God and Science Meet: How Brain and Evolutionary Studies Alter Our Understanding of Religion and is the author of Nightmares: The Science and Solution of Those Frightening Visions during Sleep (Brain, Behavior, and Evolution). Interests: The evolution of the frontal lobes, the evolution of the two mammalian sleep states (REM and NREM) and the evolution of religion in human cultures.

References

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27. McCullough, M. E., Hoyt, W. T., Larson, D. B., Koenig, H. G., & Thoresen, C. (2000). Religious involvement and mortality: A meta-analytic review. Health Psychology, 19(3), 211-222.
28. Mitchell, J., Lannin, D. R., Mathews, H. F., & Swanson, M. S. (2002). Religious beliefs and breast cancer screening. Journal of Womens Health (Larchmt) 11(10), 907-915.
29. Exline, J. J., Yali, A. M., & Sanderson, W. C. (2000). Guilt, discord, and alienation: The role of religious strain in depression and suicidality. Journal of Clinical Psychology, 56, 1481-1496.
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34. Daaleman, T. P., & Nease, D. E., Jr. (1994). Patient attitudes regarding physician inquiry into spiritual and religious issues. Journal of Family Practices, 39(6), 564-568.
35. King, D. E., & Bushwick, B. (1994). Beliefs and attitudes of hospital inpatients about faith healing and prayer. Journal of Family Practice, 39(4), 349-352.
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