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Features

Spirituality on the Operating Table

Geoff Lachlan

Could it be that an epidemic of depression is finally waking up modern medicine to the importance of treating both body and soul? Former surgeon GEOFF LACHLAN reports on a mainstream shift in the understanding of spiritual health.

featureLachlan1.jpgAs David Taylor waited for his double bypass operation, he knew he had heart trouble in more than one sense. Sitting in his hospital bed, he found himself dwelling on unnerving thoughts: 'My heart stopped - I could have died. What does life really mean for me now? Why did I waste so much energy at the office - what was it all for? Why am I alive in the first place?' So pressing were these questions that, on the day before his operation, he waived his lifelong aversion to organised religion and called for the hospital chaplain. A kindly, open-hearted man, the chaplain seemed instinctively to understand David's anguish, and encouraged him to continue his search, though without pushing any particular answers. In the operating theatre the following day, he felt a strange kind of peace as he succumbed to the anaesthetic. Convalescing afterwards, he began to look at personal issues he had long avoided, groping towards a kind of acceptance. When he was fit enough to go home, he knew the chaplain had been as important to his healing as the surgeon. For in tending his spirit, David had given his body vital space for recovery.

This story - which for privacy's sake is a composite of many we have encountered - illustrates an important shift in modern medicine. While we can now regenerate tracheas (windpipes) using state-of-the-art stem cell techniques, the World Health Organisation predicts that in just ten years time clinical depression will be the number one disease in our 'developed' societies. What has caused this paradoxical situation within our 21st century scientific medicine? We know that increasing levels of material affluence have negative effects on our happiness and general wellbeing. What is now being discovered is that this then has a profound effect on our body's immune system, resulting in poorer general health and a reduced ability to fight disease.

The statistics are startling.1 Patients who develop new or first-time depression after their heart attack have an increased mortality rate of 18% in the first year following the incident, compared to 3% in those who do not become depressed. This is because the trauma of the heart attack has caused an existential crisis of meaning in life2, as David and thousands like him have discovered. This can result in a depression, which has a significant negative effect on that person's long term recovery following the physical illness.

HOLISTIC HEALTH
This patient's spiritual crisis needs to be understood using the modern holistic definition of health, which is 'a complete sense of physical, mental, social, and spiritual wellbeing.' In the healthcare context spirituality refers to a sense of meaning and purpose, hope, self-esteem, and enabling to feel connected with family, friends, and the wider community and world. It always assumes showing love, compassion, and in particular, empathy, which can often enable patients to transcend or rise above their present suffering. While scoring systems have been developed to measure spiritual wellbeing, the difficulty here is in approaching the elements of mystery and awe which give each life its unique and profound depth.

It was Teilhard de Chardin, the French Jesuit priest, who described all people as 'spiritual beings simply trying to express their humanity.'3 We all have spiritual needs which we would like to have met. While some people find these needs are met by following established religion, most people are no longer religious, although many retain a sense of believing in a supernatural 'Force' without actually belonging to a particular creed ('Believers-not-belongers,' as described by Grace Davie, Professor of Sociology, Exeter)4. The working definition of spirituality as used above is inclusive whether one's life view is humanist, believer-not-belonger, or religious. There is an atheistic description of spirituality which would sit very easily with any religious mystical one.

This inclusive spirituality approach has been endorsed in my own country by the Scottish Government Health Directorates since the Health Department Letter of 2002 stated that chaplains will offer spiritual care to any patient or staff member, whether of any faith or none. It established Spiritual Care Teams and Committees in all NHS Health Boards, and a chief executives letter of 2008 reinforced the central guidance. Spiritual care is now to be '....an integral part of the holistic care of patients.' The comments in a typical hospital sanctuary visitors book say the same thing in less scientific language: 'I give thanks for the people in this hospital who helped me to value my own life again and have given me the strength to carry on,' writes one patient. Another clearly rates spiritual healing as highly as physical: 'The time I spent inside here made me see a new and better way, and let me see the goodness in myself.'

SHIFTING PARADIGMS
Indigenous cultures (Native American or Aboriginal, for example) and Eastern religions regard spirituality as core to health. It is only our Western secularised culture that has separated the two, following the so-called Enlightenment of the 17th and 18th centuries which culminated in the triumph of rational, scientific discourse. However, there is no doubt that this prevailing materialistic paradigm is now being challenged, and most surprisingly this is coming from within science itself. As quantum physicist Dr Amit Goswami of the University of Oregon Institute for Theoretical Physics recently stated: 'A paradigm shift in science is taking place. This shift is taking us from a divisive, God-denying, matter-based science to one that integrates science and 'God' or spirituality. This new paradigm rests on solid theory based quantum physics and solid evidence based empirical data, not on fanciful ideas. And, like all creative endeavours, the paradigm shift has come with a surprise: that science itself has to operate within a spiritual metaphysics.'5

featureLachlan2.jpgDavid Tacey, Professor of Psycho-analytical Studies at Melbourne University, links this shift to the recent renewal of interest in spirituality which has been described by sociologists in academia over the last 30 years: 'Significantly this Spirituality Revolution is found at the heart of the new sciences, where recent discoveries in physics, biology, psychology, and ecology have begun to restore dignity to previously discredited spiritual visions of reality. Science itself is experiencing its own revolution of the spirit, and is no longer arraigned against spirituality in the old way.'6

The recently 'discovered' scientific methodology to explain this influence of spirituality on health has been termed psychoneuroimmunology, or PNI for short. It describes how external factors, particularly stress, affect our psychological state. These, through neuronal and biochemical pathways in the brain, have a direct influence on our immune system.

'The neat flat medical world that used to separate the body from the mind is turning out to be round,' explains David Reilly, Professor at the Glasgow Homeopathic Hospital. 'Yet on this separation we built a medical system organised into head doctors and body doctors, with some of them specialising in smaller bits. Thinking of the cardiac system and its diseases as unrelated to the emotions, or separate from the individual, is proving to be unscientific… We should now speak of the 'mindbody' - for the brain talks to the white blood cells [of the immune system], and it seems they talk back!'7

WHAT IS WELLBEING?
All of this explains how an existential or spiritual crisis after a heart attack can affect mortality, as discussed earlier. But in order to fully appreciate this spirituality/health relationship we need to understand the concept of 'wellbeing', a term which is almost as slippery and diffuse as spirituality. For our purposes personal wellbeing refers to one's happiness and contentment, and relationship both with oneself and the world - family, friends, work colleagues - and more deeply with one's perceived meaning and understanding of life. Apart from the need for a certain level of basic material provision, it is definitely not related to income and ownership of more luxury goods. Wellbeing promoters include experiences of  love, hope, joy, peace and, especially, an identified meaning to life. Thus illbeing can be understood in terms of isolation, despair, sadness, anxiety, and the absence of any meaning or purpose to life.

Recent research has shown the positive relationship of wellbeing on health, in a key paper that reviewed over 150 such studies: 'Wellbeing positively impacts both short and long term health outcomes ... and disease and symptom control.'8 Meanwhile other evidence points to positive links between Religion/ Spirituality and Personal Wellbeing9 - which means that ultimately spirituality is good for your physical health.

HARD EVIDENCE  
Last year the Royal College of Psychiatrists of the UK published a new textbook with a revealing name: Spirituality and Psychiatry. It is edited by Cook, Powell, and Sims, all members of the Spirituality and Mental Health special interest group, which is the most popular in the college. This is because evidence now shows that if patients' spiritual needs are supported as well, they recover more quickly and relapse less frequently with treatment for the addictions of alcoholism and drugs, depression and certain of the psychoses, and with a lower successful suicide rate. Patient's spiritual distress must be recognised during illness.

The 'existential crisis' is really an even more severe form of acute spiritual distress, which can be viewed as spiritual pain where a state of disharmony exits between a person's hopes, values, beliefs and life experiences. Recent evidence suggests that existential struggle or crisis can negatively impact on clinical outcomes.10 For example, loss of hope (low spiritual wellbeing) has been shown to be a predictor for adverse clinical events in patients who have undergone stenting of a coronary artery - the insertion of a catheter through the skin, eventually reaching a narrowed coronary artery, leaving a thin metal stent which dilates the artery and increases the blood flow.  

Patients who experience an existential crisis or spiritual struggle immediately prior to cardiac surgery have been shown to have high blood levels of a chemical (interleukin 6) that is normally released in small amounts during the trauma of surgery to promote healing. This results in poorer surgical outcomes, compared to those not struggling spiritually and with normal levels of this chemical. Another study looking at spiritual wellbeing and immune status among women living with HIV/AIDS found that patients with the least depressed immune response to the disease were those with the best spiritual wellbeing and existential wellbeing scores.11

POSITIVITY OR PLACEBO?
The fascinating feature of these last two studies was the evidence that our spirituality can influence the level of measurable chemicals in the body that support the immune system. Insights like this help us to understand how our own innate healing can work to influence the outcome of a disease process.  This inner healing ability of the body, more pronounced in some patients than others, has always been a source of embarrassment for the materialist scientific basis of medicine which we all studied in great detail for years in our medical training.

 

featureLachlan3.jpgThe Concise Oxford Dictionary defines 'placebo' in this way: 'Medicine prescribed for the psychological benefit to the patient rather than for any physiological effect. A substance that has no therapeutic effect used as a control in testing new drugs ... the placebo effect is due to the patient's belief.' Contrast this with the following description of the placebo effect by a neuroscientist: 'Placebo is the significant healing effect created by a sick person's belief and expectation that a powerful remedy has been applied, when the improvement cannot have been the physical result of the remedy. This is quite different from the body's natural healing that can happen in any given condition.'  

This definition quite subtly states that the placebo effect is in fact over and above any natural healing process that may occur. More importantly, it is described as a significant healing effect created by the belief of the patient, and is none other than the ability to drive the body's healing system by harnessing the PNI methodology described above.12 It is estimated that this 'belief response' accounts for as much as 45-60% of the 'activity' of manufactured drugs. Prozac, the most commonly prescribed of the new generation of antidepressant drugs, only increases the success rate of treating depression by a margin of as little as 10-15% more than a 'non-active' placebo drug! And, of course, all clinicians who have practised for any significant length of time, have seen a miracle cure, when a patient makes a complete recovery that should just never have happened.

RELIGIOUS OR SPIRITUAL?
Unfortunately religion carries a considerable amount of negative baggage with both patients and staff, and is often conflated with spirituality, which is a word that is probably more contested and misunderstood than any other. For example, our Christian cultural heritage remains very suspicious of people who may identify their spirituality with neo-Pagan, and especially Wiccan,  practises. The Enlightenment and its subsequent evolution into the age of rational scientific modernity has resulted in the sidelining of religious (and any other spiritual) beliefs as 'irrational and superstitious.' Of course, the existence of God cannot be scientifically proved, but neither should people's actual experience of God (or the postmodern non-anthropomorphic terms such as The Force, the Supernatural, the Greater Consciousness, the Other etc.) be denied.

There has been a recent attack against the use of 'non-scientific' complementary therapies in the NHS, in this case targeting homeopathy. Again, this is to be expected, as the gold standard for validating any treatment for use in the NHS is the randomised blind control trial. This is where the new therapy is tested against either an older one or, in the case of drugs, a placebo, and the patient is not aware which of the two treatments he is receiving. Large numbers of patients are usually recruited in order to ensure that there is enough statistical power in the study to demonstrate an improvement. This latter point is obviously particularly important if 50% of the patient's improvement can be due to their own inner healing or placebo response!

Unfortunately, the whole nature of the complementary therapeutic encounter does not easily lend itself to such huge studies. Differences in the complementary compared to the average 'scientific medical' consultation include a vast increase in personal time between physician and patient, often over 90 minutes per session. Touch is particularly important in many therapies, such as aromatherapy, massage, reflexology, acupuncture, osteopathy, chiropractic and craniosacral techniques.  These therapies would be difficult to perform in a randomised blind trial. In fact, with most of them there is an increasingly very well-documented scientific basis, but the bottom line is that for the vast majority of patients they do work.

With the combination of personal time spent by the therapist and the use of touch, (the most highly sensual of all the senses), all this is much more likely to encourage the patient's own inner healing abilities, the often scientifically-derided placebo response. In any standard clinical consultation there is barely enough time for the patient to sit down and be told what is wrong with them - and that is only when the clinician looks above the computer screen. What is even more interesting is that the medical profession itself is becoming aware of the loss of the 'bedside manner' and the importance of generating an empathetic response with the patient. A new scoring system has been devised to assess whether clinicians generate  empathy during their consultations, and unsurprisingly those who score highly seem to instil more confidence and satisfaction in the patient following the encounter. This can only result in helping to drive the patient's inner healing.

Perhaps, after the scientific revolution of the past two centuries, the science of medicine may yet regain its art, which was the most effective therapeutic tool the doctor had.

Geoff Lachlan

 

NOTES
1  Carney RM, et al, 'Treatment resistant depression and mortality after acute coronary syndrome'. Am. J. Psychiatry, 2009, 166:4, 410-418.
2  Spindler H. and Pedersen S, 'Post traumatic stress disorder in the wake of heart disease: prevalence, risk factors, and future research directions. Psychosom'. Medicine, 2005: 67: 715-723.
3  De Chardin, T, The Phenomenon of Man, Harper Perennial, 2008.
4  Davie, G, Religion in Britain Since 1945, Wiley-Blackwell, 1994.
5  Goswami, A, God Is Not Dead: What Quantum Physics Tells Us About Our Origins and How We Should Live, Hampton Roads, 2008.
6  Tacey, D, The Spirituality Revolution: The Emergence of Contemporary Spirituality, Routledge, 2004.
7  Reilly, D (2002), 'Creative Consulting: Psychoneuroimmunology and the Mindbody'. Student BMJ, Vol. 10, 97-99.
8  Ryan T. et al, 'Meta-analysis of impact of wellbeing on health outcomes'. Health Psychology Review, Vol.1, Issue 1, 2007.
9  Carlisle S, Cultural Influences on Health and Wellbeing: Religion and Spirituality, Glasgow Centre for Population Health Research, 2007.
10  Pedersen S. et al, 2007, Journal of  Psychosomatic Research, Vol. 62, Issue 4, 455-461.
11  Dalmida SG et al, 2009, Women and Health, 49 (2-3); 119-143, March- May.
12  Beauregard, M. and O'Leary, D, The Spiritual Brain, Harper Collins, 2008.