Primary Psychiatry. 2008;15(9):82-90
Dr. Galanter is professor of psychiatry and director, Dr. Glickman is assistant clinical professor, Dr. Dermatis is research associate professor, Dr. Tracy is assistant professor, and Ms. McMahon is research assistant, all at the Division of Alcoholism and Drug Abuse of New York University School of Medicine and Bellevue Hospital Center in New York City. Drs. Galanter, Dermatis, and Glickman are also research scientists at the Nathan S. Kline Institute for Psychiatric Research in Orangeburg, New York.
Disclosures: Drs. Galanter and Dermatis receive research support from the John Templeton Foundation. Dr. Glickman and Ms. McMahon report no affiliation with or financial interest in any organization that may pose a conflict of interest. Dr. Tracy receives grant support from the National Institute on Alcohol Abuse and Alcoholism.
Acknowledgments: The authors thank Hannah Barbash, BA, New York University Divisional research assistant, for assistance in the preparation of this article. The authors also thank Lynda Curtis, Drs. Eric Manheimer and Marc Gourevitch, and Irene Torres.
Please direct all correspondence to: Marc Galanter, MD, Professor of Psychiatry, NYU School of Medicine, 550 First Ave, Room NBV20N28, New York, NY 10016; Tel: 212-263-6960, Fax: 212-263-8285;
• Many patients have strong spiritually grounded feelings related to their ability to cope with illness.
• Addressing patients’ spiritual needs in the general medical setting can improve their satisfaction with caregivers and their adherence to treatment plans.
• There are emerging approaches to address this issue in the clinical setting.
Medical care has long been associated with religion and spirituality, but in recent years a trend has arisen to introduce diverse spiritually oriented approaches in the context of empirically grounded practice. This article reviews the application of these approaches in contemporary medical practice. It highlights the relative utility of such applications, the use of spiritual assessment of the patient, and the role of the clergy and nursing in introducing spirituality into the clinical setting. It then presents findings from a program developed by the authors to employ spiritual support groups in the general hospital in order to aid patients in coping with illness, and to develop among them a more positive identification with their treatment providers.
In the Western tradition, medicine and religion have always been linked—sometimes closely and sometimes farther apart—and religious influences on medical practice and on the profession’s ethics are longstanding.1-3 The growth of interest in the interaction of medical practitioners with religion and spirituality over recent years has paralleled similar developments in the larger society, as many healthcare providers with a strong spiritual orientation have sought to bring this spiritual aspect of their personal lives more into their clinical work. A major aspect of this movement has involved legitimating the positive relationship between religious involvement, spirituality, and health in many publications in the professional literature.4 Of comparable importance has been the growing recognition that spirituality and religion permeate the lives of patients as well as many medical encounters. A question to be considered has become not only how to deal with the religious and spiritual aspects of health care, but how they can be introduced into the treatment context. This article focuses on recent attempts to establish the utility of such interventions, and provides by way of illustration such a program that the authors have developed and implemented in the general hospital setting.
The distinction between religion and spirituality is important to this work, though it is not without controversy. Spiritual or religious choices often reflect a very personal and private aspect of a person’s life, which makes any definition subject to intense scrutiny. It is counterproductive to the purposes of research to settle on a definition of spirituality that is either too broad and vague or too individualized.5 There is, however, general agreement on a fundamental level that both religion and spirituality are related to a search for the sacred or transcendental.6,7 This commonality has led to divergent notions of how spirituality and religion are related. According to the theoretical framework posited by Pargament,8 spirituality and religion are inextricably intertwined. Spirituality is viewed as a core component of the more “broadband concept” of religion.8 However, an increasingly widely held view is more in line with Koenig and colleagues’4 contrasting definitions. He casts religion as “an organized system of beliefs, practices, rituals, and symbols” in relation to the sacred, as opposed to the “personal quest for understanding” of spirituality.5 These conceptualizations of religion and spirituality allow for the option of being religious but not spiritual, spiritual but not religious, both, or neither. In this article, spirituality is defined as that which gives people meaning and purpose in life.9 It can be achieved through participation in a religion but can be much broader than that, such as involvement in family, humanism, or the arts.10 In much of the literature and in American culture, spirituality has come to be seen as a human dimension particularly useful in bridging sectarian divisions common to religion.
The Spiritual Assessment
A key technique for addressing spirituality in clinical practice is the spiritual assessment.9 Spiritual assessments focus on learning whether the patient is part of a supportive faith community, ascertaining unmet spiritual needs that should be addressed in the course of treatment, identifying religious beliefs that might influence medical treatment decisions, and identifying potentially harmful spiritual practices such as spiritual struggles that patients associate with their illness. Spiritual struggles are defined as “efforts to conserve or transform a spirituality that has been threatened or harmed” and are expressed in terms of conflict and questioning of one’s spiritual/religious convictions.11 With a patient who professes neither to be religious nor spiritual, the physician can still inquire into what they are doing to cope with their illness. Puchalski9 has developed an approach adapted to general clinical settings she terms FICA, involving inquiry into “F”aith and healing, “I”mportance of faith in the patient’s life, “C”ommunities of faith and healing they may be part of, and “A”ddressing unmet needs.
Practitioners developing long-term relationships with dying patients have developed questions probing deeper into their sense of how their illnesses relate to “what it all means” to aid patients in identifying spiritual interventions that might benefit them.10 Spiritual interventions refer to therapeutic strategies that are designed with a spiritual or religious dimension as their central component12 and include but are not limited to spiritual assessments.
Kristeller and colleagues13 designed an intervention to improve patients’ well being and adjustment to cancer and showed that a 5–7-minute patient-centered intervention by an oncologist made a small contribution in patient well being. Patients included in the intervention were recruited at random from the waiting rooms of oncologists’ offices, as were controls who received usual care. The short intervention introduced the topic of spiritual or religious beliefs and encouraged patients to identify ways they used spiritual or religious resources. Questioned after 3 weeks, 33% said they thought the intervention would influence how they coped with cancer, while >40% thought it made them more satisfied with their overall care. Improvement after 3 weeks in quality-of-life measures among patients in the study group compared to those in the control group reached levels associated with clinically meaningful impacts in drug or other behavioral trials. Improvements were most pronounced among those scoring low on a spiritual well-being scale at baseline. Spiritual well being was assessed by the Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale. This scale consists of two subscales, namely, meaning/peace and faith.14 The spiritual well-being composite score combining both subscale scores was moderately correlated with measures of emotional and functional well being (r=.58 for each) suggesting that it was an empirically distinct dimension. This study provides support for the benefit of a short, nondenominational empathic intervention in physicians’ offices, even absent a physician’s incorporating the acquired information into treatment. Attention, however, should be paid to whether any aspect of the intervention produces distress in the patient and/or clinician. How often spiritual interventions are conducted, and to what effect, remains unknown.
Approximately 85% of all United States hospitals employ chaplains, while an estimated 20% of all hospitalized patients receive a chaplain’s visit.15 The growing professionalization of chaplains within a medical model, however, has contributed to their acceptance as members of a supportive care and palliative medicine team in the intensive care unit of a large trauma hospital, a team including physicians, advanced practice nurses specializing in pain, intensive care unit and palliative care, social workers, pharmacists, and music therapists. Chaplains provide spiritual support to patients who are dealing with issues related to finding meaning in life and coping with suffering, and help patients utilize their beliefs in coping with illness.9
Major barriers identified by chaplains included inadequate staffing, inability of healthcare providers to identify patients’ spiritual needs, and being called in too late to provide proper care to families.16 Physicians are often advised to refer serious spiritually-related problems to clergy or a chaplain affiliated with their hospital; some advocates of greater inclusion of spiritual matters within medicine consider the lack of such appropriate referrals to be a form of negligence.17 Shadowing a chaplain can be a key component of the spiritual education program for many palliative care fellows.
More recently, at Memorial Sloan-Kettering Cancer Center in New York City, approximately 20% of all chaplain interventions came as a result of a referral, mostly from nurses; 33% of the interventions involved working with family and friends.18 A similar survey at a suburban community hospital found that nurses made >50% of referrals to chaplains; 75% of all referrals were to see patients and the remainder were to see friends and family.19 Although referrals by nurses to chaplains most often come in times of crisis, some nursing leaders see a need to develop more ongoing collaboration to address a wider range of situations.20,21 Patients are frequent sources of requests for pastoral care—more frequent than nursing referrals in a study of adolescent inpatients in a pediatric tertiary care hospital.20
Studies of self-reported spiritual nursing interventions and ideal, complex spiritual nursing competencies shed some light on the vast range of activities nurses see as falling under this rubric to address the spiritual needs of their patients.22,23 Such research stems from the desire to capture the considerable spiritual care delivered by nurses that goes undocumented. Prayer and active listening are the most commonly reported nursing interventions.24 Other commonly reported interventions include conveying acceptance, being present with a patient, therapeutic touch, and instilling hope. Presence as an intervention refers to both being physically present without expecting interactional responses and a psychological component wherein the nurse is attentive and demonstrates an understanding of the patient’s experiences.24
Narayanasamy and Owens25 identified different patterns of nurses’ responses to critical incidents they regard as involving spirituality. In the personal approach, nurses, using counseling, become involved in a mutual sharing of spiritual concerns, usually framed in nonreligious terms. In the procedural approach, the nurse sticks to standard routines, often referring to the expert, the chaplain, or colluding with the patient’s relatives, often without the patient’s involvement. In the evangelical approach, nurses, often sharing the same religious background with patients, attempt to rekindle the patient’s faith. Ethical concerns that arise relate to the potential for nursing staff to impose their specific spiritual/religious beliefs on the patient and/or family and to blur the boundary between nurse professional and clergy.9
Incorporating Spirituality in Psychosocial Treatment
One approach to incorporating spirituality in treatment involves integrating a spirituality dimension into an established treatment modality such as psychotherapy. Various attempts have been made to develop psychotherapeutic approaches to accommodate Christian values, including prayer and religious materials. Results of an early study26 showed that although cognitive-behavioral therapy (CBT) and a modified CBT with religious content resulted in improvement among depressed patients, improvement was greatest among depressed patients in the religiously modified program. A small meta-analysis, however, found that religion-accommodative approaches to counseling depressed patients had essentially the same overall efficacy as non-religious approaches.27
Another approach involves integrating spirituality in an existing psychosocial rehabilitation program. A small study among patients with serious psychiatric disabilities in an inner-city community program found that all participants receiving a spiritually oriented support group intervention to improve program functioning met their treatment goals related to symptom management, community integration, and improvement in overall quality of life as opposed to only 50% in the standard rehabilitation program.28 A study by Worthington and Sandage29 included patients with depression who were assigned either to a Beck-oriented CBT program or a Christian accommodative one. Both approaches were found to be equally effective in reducing depression, while the religiously oriented program was associated with greater improvement in spiritual well being.
A recent review12 of the worldwide literature on spiritually modified cognitive therapy in the Islamic, Taoist, and Christian traditions classified these treatments as experimental for anxiety disorder, neurosis, obsessive-compulsive disorder, and other conditions except for depression, which was considered to meet American Psychological Association criteria for a well-established intervention.
Models for Intervention
Pargament and colleagues30 and McConnell and colleagues31 have conducted a substantial body of research supporting the view that some forms of spiritual struggles are linked to psychopathology, and that a spiritually integrated psychotherapy can effectively address this problem and others. They have developed interventions based on these ideas, including a short intervention with an individual therapist for female survivors of sexual abuse with spiritual struggles designed to improve spiritual well being.32 A group intervention for people with serious mental illness following Pargament’s theory of positive and negative implications of religious coping33 incorporated issues such as spiritual striving, spiritual struggles, and hope.
Cole and Pargament34 also developed a group psychotherapy program for cancer patients, “Re-Creating Your Life: During and After Cancer,” combining concern with core existential issues and positive religious coping. Numerous models of group psychotherapy have been developed for work with cancer patients.35,36 Although most such groups focus on providing education, a forum for emotional expression, and strengthening coping skills as elements of overall support, spiritual and religious issues are often raised as well directed at reducing spiritual suffering and distress at end of life.
The field of palliative medicine, with its focus on end-of-life care, has been a source of considerable innovation in connecting spiritual issues to its form of medical practice. One such program developed by Breitbart35 at Memorial Sloan-Kettering Cancer Center employs a meaning-centered approach, drawing on the logotherapy developed by Frankl, to develop an eight-session program that explicitly addresses issues of meaning, peace, and ultimate purpose.35,37 Participants, all with advanced cancer and a limited prognosis, are given assigned readings and homework related to group session topics such as “Meaning and Historical Context of Life,” “Cancer and Meaning,” and “Limitations and Finiteness of Life.” The goal here is to help strengthen patients’ sense of being at peace with themselves in the face of the spiritual suffering and hopelessness they often experience.
A more extensive three-level program to enhance patients’ level of spirituality, mood, and self-efficacy for patients with a range of cancer diagnoses and severity was implemented in a metropolitan cancer hospital in Toronto, Canada.38 Level 1 consists of four group sessions dealing with cancer stress; level 2 is comprised of eight group sessions on skills for coping by drawing on the “Inner Healer” through meditation and other modalities. Meditative techniques are not the core of the intervention. Rather, meditative chanting is done for the first few minutes of all the sessions before the main topics are covered. The third level consists of eight sessions on spiritual healing, with a follow-up program of twice-monthly groups available to all who complete the program. This multi-staged model allows patients to decide for themselves which level of spiritual involvement is comfortable for them. In an exploratory study to assess the efficacy of this program, a battery of psychometric tests was administered at entry, 8 weeks, and 6 months, and written homework assignments were completed by study participants. Ninety-seven patients completing the third level showed significant improvement in mood, self-efficacy, and spirituality over the 8-week intervention period. After 6 months, only improvement in spirituality remained significant. Based on the written assignments which showed patients struggling with their spiritual issues, the investigator suggested that this model can provide advanced spiritual training to highly motivated individuals within a resource-constrained environment.
Randomized controlled trials can help assess the relative value of spiritually oriented interventions compared to standard interventions and can also help identify subgroups for which they may be most helpful. A recent clinical trial39 conducted at the Mayo Clinic points in a direction this area is likely to go, namely, integrating spiritual concerns into multidimensional and multidisciplinary interventions with the goal being to improve the overall quality of life of cancer patients. In this trial, advanced cancer patients set to undergo radiation therapy participated in a manualized 3-week program consisting of eight sessions each with a cognitive, emotional, physical, social, and spiritual interventional component. Sessions were lead by a psychiatrist or psychologist, with a chaplain, social worker, and advanced practice nurse as co-facilitator, depending on the session’s content. Quality of life at 4 weeks and 6 months following the intervention was compared with patients receiving standard care supervised by their radiation oncologist. Compared to the controls, the intervention group experienced a significantly better quality of life at 4 weeks; however, at 6 months this difference largely disappeared. The major benefit of the intervention appeared to be averting the sharp decline in quality of life during and shortly after the radiation treatment.
Stefanik and colleagues40 caution against concluding that religion and spirituality affect treatment outcomes in cancer due to methodologic weaknesses in much of the research, including the preponderance of cross-sectional studies, use of small samples sizes and samples of convenience, lack of correction for multiple statistical comparisons, failure to control for confounding variables, and questionable reliability and validity of study instruments.
Efforts to include spiritual and religious concerns in the treatment of HIV/AIDS take many forms, but most of them have not been evaluated. Community health workers in one innovative outpatient HIV Palliative Care Program in the Bronx, New York, provided material resources and a dialogic partner in the search for meaning for patients undergoing the process of dying and bereavement and their families.41 In another study, Pargament and colleagues42 developed an eight-session nondenominational group program tailored for urban black women with HIV/AIDS. The program uses exercises such as writing a letter to God about guilt and shame, and identifying dreams still possible despite their illness, to encourage participants to acquire spiritual resources that may contribute to their health and well being while living with illness.
Another intervention designed to improve quality of life is exemplified in a randomized controlled pilot study43 of patients at an AIDS-dedicated skilled nursing facility. The independent and additive effects of meditation and massage on spirituality and quality of life were examined. Patients in a program that combined both modalities showed substantially greater improvement on measures of overall and spiritual quality of life than patients receiving either a meditation or a massage intervention alone or patients receiving standard care. Interventions designed to reduce HIV/AIDS risk combining spirituality and cognitively-based approaches include a nontheistic Buddhist-based program targeting risk behaviors among inner city methadone patients and a spiritual coping group for patients with HIV.44-46
A recent study47 which has implications for the value of spirituality based interventions among people receiving a potentially life-altering diagnosis examined whether changes in spirituality occur after receiving an HIV diagnosis and whether changes are related to disease progression as reflected in CD4 cell counts and viral load. People who had an increase in spirituality/religiousness showed less disease progression on both measures even after controlling for church attendance and initial disease status. These findings support continued efforts to develop spirituality based interventions for people diagnosed with HIV.
Numerous concerns have been reported regarding implementing spiritual interventions in medical and psychiatric treatment settings. Healthcare professionals may feel they lack sufficient expertise to discuss spirituality, are uncertain as to what their role is in relation to that of the chaplain, or construe such inquiries as intruding into the patient’s private life.17 When patient spirituality is addressed within the physician-patient relationship there is the possibility that certain beliefs held by the patient may undermine the physician’s treatment plan resulting in treatment refusal or futile requests for treatment.17 Another issue relates to whether the spirituality intervention is designed to meet the needs of the patients. Healthcare professionals and patients may not agree on what dimensions of spirituality are needed in the care of patients. In a review of nursing research papers published on spiritual care, Ross21 reported that there appears to be a discrepancy between provider and patient understanding of spirituality and the nature of spiritual care desired by patients.
A Program for Spiritually Oriented Support Groups
Despite impressive advances in the technology of acute care in general hospitals, the limited adherence by many patients to medical treatment plans regularly compromises their clinical outcome. This results in recidivism, increased morbidity, and undue cost to the healthcare system. In relation to primary care, for example, the World Health Organization has estimated that no more than 50% of patients with hypertension adhere to their prescribed medication regimens.48 Much of this is due to a limited sense of mutuality and trust felt by patients toward their caregivers as well as the impersonal quality perceived in their medical encounters.49
This need has been operationalized by the Joint Commission of Accreditation of Health Care Organizations, the principal certifying body for American hospitals. Its requirements stipulate that, “spiritual and cultural values [should] be gathered during the initial assessment of patients,” and that “Each patient has the right to have his or her . . . spiritual and personal values and beliefs, and preferences respected.”50 Importantly, however, there is little if any programmatic experience published on how spiritually grounded values and beliefs can be effectively addressed in hospital settings.
In order to address this need, the authors of this article conducted focus groups with patients at Bellevue Hospital Center, New York University’s principal teaching hospital, and found that one issue that contributes to this problem is that many patients feel that their core personal and spiritual beliefs are neither recognized nor addressed by hospital personnel. In previous research, staff and patients rated the importance of spiritually related resources relative to medical and material ones in addiction recovery.51,52 Staff rated the spiritual resources lowest, while patients rated them highest. Furthermore, when staff gave ratings to how they thought the patients would respond, they erroneously scored spiritual resources lowest, not recognizing the importance of spirituality to patients’ understanding of how they achieve recovery from their illness.53 Staff underestimated the importance patients placed on spirituality focused groups in the recovery process.51,52 Given this experience, the authors developed a pilot clinical program to determine if patients would discuss how they can draw on their spiritual resources and strengths to enhance their recovery and rehabilitation with support of hospital staff. The authors drew on experience54-56 in related clinical and research projects on the feasibility of such discussion groups in diverse clinical settings, and established groups for patients in a primary care clinic setting and on units dedicated to the treatment of comorbid general psychiatric disorders and substance abuse.
All groups were facilitated by volunteer medical or allied professional staff who have given their time because of their appreciation of the value of this effort, with the goal being to elicit feedback from all participants concerning how their spiritual attitudes, beliefs, and behaviors can help to promote health and cope with illness. The tone of the groups has reflected a mutual respect for each other’s religious (or non-religious) orientations. It would emerge that an underlying spiritual orientation was the primary focus of exchanges. The format of the group meetings is outlined in Table 1.
The groups were established in a primary care clinic setting in which 221 patients participated in one or more group meetings. The authors chose the primary care clinic to ascertain the applicability of this approach in a general medical population. They were also established in three inpatient (131 participants) and two outpatient (48 participants) psychiatry units. There were six different facilitators, each dedicated to his or her respective unit. The psychiatric patients were chosen to compare singly diagnosed psychiatric patients to those with comorbid substance use disorder; a report on the psychiatric patients will appear elsewhere. In the primary care clinic reception area, posters were prominently displayed and flyers were distributed to patients containing information concerning the group meetings and inviting all patients to attend. On the psychiatry units all patients were invited to attend the discussion groups by staff. This would usually occur at the beginning of the weekly community meeting. Participation in the spirituality discussion groups was completely voluntary and did not in any way affect the medical or psychiatric services received by patients. For purposes of the present report, only participant data collected in the medical outpatient setting will be presented.
In the medical outpatient setting a survey assessing spiritual orientation to life using the Spirituality Self-Rating Scale (SSRS)53 was administered to 52 consecutive patients at their first group session. These patients had as high a mean SSRS score, as did the addiction inpatients, but significantly higher than medical students. In a subsequent survey again administered to consecutive attendees at their first group session, 113 participants were asked items assessing their spiritual and religious views and practices concerning worship service participation. These items had been used in previous national probability surveys.57 The sample was predominantly female (64%) with a mean age of 53 (SD 14). Ethnicity included 27% African-American, 25% Hispanic, 25% White, and 23% other designation which was mainly multiracial. Patients varied with regard to religious preference with 31% Catholic, 15% Protestant, 10% Muslim, 6% Jewish, 28% other religious preference such as “higher power,” and 10% no preference. The results indicated that a greater percentage of the medical outpatients described themselves as being both religious and spiritual and report a higher frequency of spiritual-related practices involving worship service attendance compared to national samples (Table 2).57 These findings suggest that primary care patients perceive spirituality to be important to them and are as active, if not more so, than the general population.
Feedback from patients attending the group indicate that they value the opportunity to discuss their spiritual experiences with professional healthcare staff in the primary care setting, they feel more positively connected to treatment, and they endorse treatment’s integration in the formal healthcare system. In order to document themes that were discussed during the group sessions, a project assistant had recorded the comments made by the medical outpatients. Patient responses over the course of the sessions have been categorized, and numerous themes emerge prominently.
The Meaning of Spirituality
When participants were asked whether they considered themselves to be spiritual, the most common response was belief in a higher power which embodied a connection to God or a higher power. The diversity of the participants’ backgrounds was reflected in the different forms of this higher power, eg, Christian participants spoke of praying to Jesus and God; others, for example, self-identified as Buddhists, believed that this higher power was present in everyday objects.
Comparing Spirituality and Religion
Some participants discussed certain aspects of their spirituality in terms of their specific religious practices (eg, prayer, reading of scriptures, rituals) but also articulated distinctions between religion and spirituality.
Resources They Draw On
Participants described numerous aspects of their spirituality that reinforced their belief in a higher power, including prayer, recitation of religious or personal mantras, direct communication with the external force (eg, singing), scripture reading, and meditation. These served to calm them, combat depression or discontent, and alleviate physical pain or emotional suffering.
Some Personal Experiences
Some participants described their spirituality in terms of internal processes that served to instill hope, empowerment, and general well being. They referred to transformative experiences including revelations, miracles, or rebirth.
Quest for Spiritual Fulfillment
Some participants described themselves as emotionally drained and in search of a spiritual connection. Many of these individuals recalled being more spiritual when they were younger, but due to their illness and the physical changes accompanying aging, they became more cynical and spiritually detached.
Alienation from the Bellevue Physicians
Some patients were disenchanted with the medical staff. As one said, “All they do is give you pills, and when they do not work they just give you more pills.” Some spoke of “student doctors,” who “do not have time to listen to my story.”
Relationship to Treatment and Recovery
Participants discussed various aspects of their spirituality relating to connections with others based on trust, as with a family physician, or a group such as a 12-step fellowship. Many shared their spiritual experiences as a means of helping others to cope with their illness and better adhere to treatment. To a lesser extent, patients expressed the view that their spiritual beliefs could provide a means to a cure for their physical ailments not available through modern medicine, although they rarely endorsed refusal of all medical recommendations.
This article highlights progress that has been made in translating a growing interest in the medical field in spirituality and religion into interventions that may be effective and possibly become part of standard medical care. One notable aspect of this development is how spiritually and religiously based interventions have been adapted to diverse forms of clinical practice. Uncontrolled clinical trials have provided most of the information required to describe the complex dynamics involved in the relationship between spiritual interventions and medical care. One approach, developed at New York University and Bellevue Hospital in New York City, illustrates some of the particulars of helping patients to draw on their spiritual resources in order to cope with illness.
Spiritually oriented programs may pose ethical issues like those that have been raised regarding interventions that are specifically religiously oriented. By broadening the scope of discussion to include the many interests subsumed under the rubric of spirituality, however, concerns over sectarianism and religiously grounded bias are mitigated. Given this, diversity of commitment and affiliation among participants in spiritually oriented groups should be accepted and respected. With this proviso in mind, such interventions may be effective in improving patients’ outlook on their medical care as well as their ability to identify with the mission of hospital staff, thereby promoting greater compliance with the treatment regimens proposed. PP
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