Integrating Spiritual Assessment into a Psychiatric Inpatient Unit

Abstract

This paper describes a successful effort to quantitatively assess and address different domains of spirituality as part of a “biopsychosocialspiritual” treatment model on an inpatient psychiatry unit. A “spiritual health profile” can be easily obtained and integrated into the treatment planning, actual treatment, and discharge planning processes. Spiritual functioning varies in meaningful ways that correlate with psychiatric impairment. Addressing spiritual health status holds promise as a way of enhancing psychiatric outcomes.

Introduction

Numerous studies have shown spiritual health to correlate with both health and healing.^1,2 To date, no inpatient psychiatric program to our knowledge has systematically integrated spiritual assessment and intervention into their program in order to promote clinical outcomes. When available, spiritual care is traditionally provided ad hoc to patients and family members without integration and coordination of their efforts with those of other clinicians.

This paper describes the design and implementation of a methodology for systematically integrating spiritual assessment and intervention into a “biopsychosocialspiritual” treatment paradigm in order to address spiritual health needs in psychiatrically hospitalized inpatients.

Method

Integration of chaplains into treatment planning process. The first part of this initiative was to integrate a chaplain into our treatment team meetings, thus expanding our team to make it a biopsychosocialspiritual multidisciplinary team. Chaplains are trained to take an ecumenical approach to spiritual care that addresses spiritual issues independent of religion while simultaneously honoring and referencing patients' religious beliefs. Chaplains now attend team meetings once a week to discuss the spiritual care issues of patients on the unit. The master treatment plan was modified to add a new section for writing in the spiritual care needs and interventions for each patient.

Assessment of spiritual care needs. There are multiple assessment tools and methodologies for assessing spirituality.³ We chose the “Multidimensional Measurement of Religiousness/Spirituality for use in Health Research” assessment developed by the Fetzer Institute to obtain a “Spiritual Profile” on our patients.⁴ We chose this instrument for the following reasons:

1. The Fetzer is the most widely used instrument for health research on religion and spirituality, with 58 citations in the literature as of September, 2004.⁴

2. The Fetzer is a self-report instrument that provides a quantitative measurement of several spiritual domains that have been associated in the literature with wellness and recovery.²

3. The 29-Likert scale questions of the Fetzer that we selected to administer are easy to answer with minimal respondent burden, taking generally less than six minutes to complete.

This instrument measures 11 domains of spirituality and religiosity (Table 1). For our purposes, we pared this instrument down to a 29-item questionnaire that measures the six domains that we felt were most relevant to psychiatric inpatients (Table 2). We modified the initial nursing assessment to add four screening questions in order to identify patients who are appropriate for completing a Fetzer Assessment (Table 3). These questions were adapted from the American College of Physicians spirituality screen.⁵ They solicit if patients have spiritual care concerns and also rule out patients with a Mini Mental Status Exam (MMSE) score of less than 20. We chose a MMSE cutoff of 20 because this is a generally recognized cutoff between patients with mild dementia and more moderate dementia. We excluded patients with moderate to severe dementia because of the difficulties these patients often have in completing self-report assessments and resultant concerns about reliability and validity of any responses that could be obtained. These concerns also apply to patients with severe psychoses and/or mood disorders that impair reality testing, attention, concentration, and motor performance so as to make completion of a self-report assessment either impossible or unreliable.

Table 1.

Fetzer domains of spirituality and religiosity

Daily spiritual experiences

Meaning

Values

Beliefs

Forgiveness

Private religious practices

Religious/spiritual coping

Religious support

Religious/spiritual history

Commitment

Organizational religiousness

Table 1.

Fetzer domains selected for psychiatric inpatient assessment

Daily spiritual experiences

Meaning

Forgiveness

Private religious practices

Religious/spiritual coping

Religious support

Table 3.

Nursing Assessment Screen

SPIRITUAL DIMENSION
1. Is faith (religion, spirituality) important to you at this time?	Y	N
2. Has faith (religion, spirituality) been important to you at other times in your life?	Y	N
3. Would you like to discuss spiritual matters with someone while you are here in the hospital?	Y	N
4. How else might we address your spiritual needs?
Interpretation: If yes is the answer to any question, and the MMSE score is >;20, consult Spiritual Care and complete the full Fetzer form.

All patients complete the initial spiritual assessment screen upon admission to the unit as part of their admission intake process. In order to avoid any implict coercion, only patients who indicate that their spirituality is important to them and who wish to discuss spiritual matters during their treatment are offered the opportunity to complete a Fetzer assessment. As with all assessments, we explain that completion of the Fetzer is completely voluntary and patients' decisions to complete this assessment will in no way adversely impact the treatment they receive.

We programmed the Fetzer assessment into a Microsoft Access database so that we can enter the assessment responses and produce a graphical report for the chart. This report serves as the “spiritual health profile” to assist in treatment planning.

Once a patient completes a Fetzer assessment, a spiritual care consult is requested and the assessment report is provided to the chaplain, who then uses this information in formulating and implementing a spiritual care plan for the patient.

Control comparison. In order to get a sense of how our patient profiles compared to people without psychiatric illness who are “spiritually healthy,” we administered the Fetzer to a sample of people who have received recognition from our hospital for their contribution to the mission and core values of the hospital. The mission is to provide compassionate care. The hospital core values include compassion, excellence, integrity, collaboration, and stewardship. This group served as our “ideal benchmark” for comparisons of individual patient results because these individuals are subjectively recognized by the hospital community to be happy, loving individuals who lead lives of excellence and integrity in all aspects. We recognize the inherent bias in using a group that has been recognized for their achievements in this way, but we chose this method as a practical method that was based on an objective consensus criterion of “spiritual health” that is recognized by the hospital community. Our comparison sample (Figure 1) showed relatively high scores on all domains, ranging in the 85- to 95-percent range, with the exception of private religious practices, which was 60 percent.

Figure 1.

Our comparison sample showed relatively high scores on all domains, ranging 85–95%, with the exception of private religious practices, which was 60%.

Results

The following case histories illustrate Fetzer assessment results for various patients, how these results correlate with clinical impairments, and how our treatment teams used these results to augment our clinical interventions in a “biopsychospiritual” framework. All clinical inferences and formulations were based upon detailed multidisciplinary evaluations of patients and their family members as well as input from other collateral caregivers. Each case was discussed in detail at team meetings, which took place three times a week and included chaplains in order to arrive at a consensus formulation.

Patient A. Patient A was an 84-year-old widowed man with alcohol dependence who was hospitalized for depression. He spent most of the prior 40 years drinking with his wife up until her death several months prior to his hospitalization. After her death, he broke his hip and had to be cared for by his son. He lost his independence, the companionship of his wife, and his ability to drink, prompting his depression. Although his son and grandson were available and caring to him, he could not take in or appreciate their care. He had no close connections in his life, no belief in God, and no meaningful activities or connections with the world. He wanted to be left alone until he died, feeling that there was no reason or purpose to go on. He was pleasant enough in his interactions, not showing significant signs of depressed affect, but was inanitious, with no motivation or will to live.

The Fetzer profile for Patient A showed a near total absence of spiritual experience and meaning along with an absence of private spiritual practice (Figure 2). Discussions with the chaplain revealed that this profile reflected a lifelong situation that was unmasked by the loss of his wife, with whom Patient A spent almost half of his life drinking and in which drinking was the only activity that provided sustenance and solace to his life. The spiritual profile confirmed our clinical appraisal based upon the clinical history provided by the patient and his son, which was that Patient A was a broken man who had never been able to access meaning and sustenance from the resources that were available to him (son, grandchildren) and that medication treatment was unlikely to change this situation. Indeed, the patient showed a minimal response to medication treatment and was transferred to a nursing home where he continued to do poorly. Post-discharge spiritual care was suggested to help the patient address the areas of impairment noted on this Fetzer assessment.

Figure 2.

Patient A profile showed a near total absence of spiritual experience and meaning along with an absence of private spiritual practice.

Patient B. Patient B was a male 62-year-old married entrepreneur with mild vascular dementia, which had forced him to hand over the management of his business to his son after almost 40 years of building and running it himself. He had worked seven days a week for many years, had few close friends, and had no leisure activities or community involvement. He was not involved with a religious community. Although he had been happy and content for most of his life, with the loss of his work he became depressed and suicidal.

Patient B's spiritual assessment predictably showed the greatest impairment on the meaning subscale (Figure 3). He still derived some satisfaction from going to work each day, but found that the transition to a peripheral role in his own company left him feeling that he no longer had any meaning or worth in his life. His lower scores in the religious support and coping and private religious practice domains also mirrored the relative lack of support he found in his life at this time of crisis.

Figure 3.

Patient B profile showed the greatest impairment on the meaning subscale.

The chaplain and other staff used Patient B's spiritual assessment to focus discussions with Patient B and his family on how to help Patient B develop new areas of meaningful activity in his life given his limitations and losses. The issue of spiritual support and practice spurred efforts to help Patient B reengage in his local religious community after discharge.

Patient C. Patient C was a 53-year-old divorced woman who was readmitted for alcohol detoxification following a relapse after almost a year of sobriety with the help of Alcoholics Anonymous (AA). Her Fetzer revealed relatively low scores on religious and spiritual coping and religious support (Figure 4). Patient C had had negative experiences with her church and was only peripherally involved with her religious community. Her relapse occurred after she stopped going to AA meetings. Further exploration revealed that Patient C had never developed contacts in AA or obtained a sponsor because she was terrified of saying or doing something that would result in others being angry with her or disapproving of her. Clinical discussions with her and the chaplain then ensued as to how to engage in a religious community or 12-step program while “protecting” herself emotionally. In this case, the Fetzer revealed difficulties with obtaining support rooted in low self esteem and difficulties maintaining boundaries and assertiveness in intimate relationships.

Figure 4.

Patient C profile revealed relatively low scores on religious and spiritual coping and religious support.

Patient D. Patient D was a 76-year-old divorced mother of two who was admitted for severe insomnia and somatization disorder that both masked an underlying depression. She had suffered severe physical abuse at the hands of her second husband, who had also sexually abused one of her daughters. She lived with severe guilt and anger toward herself for marrying him and for the abuse her daughter suffered. Her Fetzer revealed relatively low scores on meaning, private religious practice, forgiveness, and daily spiritual experiences, showing the impact her trauma had had on her spiritual wellbeing (Figure 5). Discussions with the chaplain and clinical staff focused on trauma work, grief work, and forgiveness. Referrals were made for ongoing involvement in a religious community and for spiritual counseling with a focus on private religious practices, forgiveness, and meaning.

Figure 5.

Patient D profile revealed relatively low scores on meaning, private religious practice, forgiveness, and daily spiritual experiences.

Patient E. Patient E was a 56-year-old woman hospitalized for suicidal ideation after a fight with her son-in-law, who had confronted her on her over-controlling and critical behavior. She showed relatively low scores on the more “internal” domains of spiritual functioning despite her extensive involvement in her religious community, in which her husband was a deacon (Figure 6). These impairments were consistent with her generally angry and controlling stance toward others in her life.

Figure 6.

Patient E profile showed relatively low scores on the more internal domains of spiritual functioning despite her extensive involvement in her religious community.

These issues were discussed with the patient. A referral was made for ongoing spiritual counseling to work on forgiveness and private spiritual practices in order to reduce controlling and critical behaviors and enhance her acceptance and compassion for others.

Discussion

In all of the preceding cases, we found that the process of team discussions of clinical history and status along with Fetzer data and chaplain input resulted in a “rounding out” of the formulation to include a discussion of spiritual dimensions of functioning. The Fetzer provided additional constructs for understanding patients and their dilemmas. What is striking is the appeal of the Fetzer data to the team's collective clinical intuition. Although other inferences or explanations for the Fetzer results in these and other cases might exist, the above cases demonstrate a strong coherence between the Fetzer and clinical data in arriving at a clinical formulation that is inclusive of spiritual functioning.

Several findings this initiative produced are enumerated below:

1. It is possible to easily and quantitatively assess different domains of spirituality on an inpatient psychiatric unit. This can be done with negligible burden on caregivers.

2. Spiritual care staff can be integrated into treatment planning and treatment to create a “biopsycho-socialspiritual” treatment model.

3. Spiritual health, as measured by the Fetzer, was impaired in at least one and usually several domains in psychiatric inpatients.

4. Impairment in specific spiritual domains seems to correlate in meaningful ways with clinical impairments.

5. Assessment of spiritual functioning facilitates spiritual care interventions by providing feedback to patients and directing the focus of the chaplain's and other clinician's interventions.

In actual practice, we recommend that all patients receive an initial screening assessment of the importance of spirituality and religion and their desire for spiritual or religious issues to be addressed as a part of their treatment. Appropriate patients who express a wish to discuss spiritual concerns as a part of their treatment can then be offered the opportunity to complete a more detailed spiritual assessment such as the Fetzer. Permission to administer a spiritual care assessment to a patient should always be sought with the clear communication that treatment will not be adversely affected if the patient declines to participate. We have found that the quantitative assessment of spiritual domains provides a useful resource for guiding chaplains' interventions with patients, aiding multidisciplinary team discussions of spiritual issues that impact on clinical status. Spiritual assessment aids in directing spiritual care discharge planning.

Integrating spiritual assessment into a traditional biopsychosocial inpatient treatment program is easily achieved and enhances the overall treatment process by adding an additional, important dimension to the clinical process.

Assessing spiritual domains allows for an additional dimension for addressing healing and well-being. This is not only complementary to standard clinical approaches but, in our experience, actually seems to enhance overall care. Questions arise as to how to best integrate data on spiritual status and functioning into psychotherapy and how to best coordinate psychotherapy with spiritual counseling. A biopsychosocialspiritual approach to treatment calls for training in spirituality and mental health so that clinicians can competently provide “spiritually informed” treatment. Clinicians also need to simultaneously collaborate with spiritual care professionals who provide spiritual counseling or coaching for their patients. Data on spiritual status such as that provided by the Fetzer give a common language for clinicians and spiritual care staff to discuss mental and spiritual health and their interaction with each other, thereby promoting collaboration.

Further research needs to be done to assess the impact of spiritual assessment and intervention on clinical outcomes. It would be useful to provide follow-up spiritual care post-discharge and then assess the impact of spiritual care interventions on both psychiatric status as well as spiritual health.