- Email: [email protected]
Spirituality and healing
Spirituality and Healing Michael H. Torosian and Veruschka R. Biddle Spirituality can exert a tremendous impact on one’s health and promote recovery from trauma and illness, including cancer. Throughout the history of mankind, spirituality and religion have played a major role in healing a variety of physical and mental illnesses. Cancer is one of the most devastating illnesses, as it affects one’s physical, emotional, psychological, and spiritual well-being. An increasing body of scientific literature supports the concept that spirituality can significantly improve healing from cancer and promote the coping response of caregivers and healthcare professionals. We believe that spirituality is an important component of the healing process and should be integrated with conventional medicine to treat this complex disease. Semin Oncol 32:232-236 © 2005 Elsevier Inc. All rights reserved.
E
ssentially every human culture has used a form of spirituality or religion during times of illness or death. As long as 100,000 years ago, rituals with a religious or spiritual dimension were used by people when burying their dead. In the earliest recorded history, healing and recovery from illness were routinely sought by appealing to the gods or a higher power or spirit. Religious leaders and shaman of these early cultures also frequently acted as the healing powers or medicine men of those societies. It is interesting that the connections between spirituality, religion, and medicine developed independently and in very disparate cultures throughout the world. These cultures arose in widely different geographic regions of the world with no known communication or association. Cultures from the Mediterranean region of Europe, the Far and Middle Eastern regions of Asia, Africa, and North and South America developed medical practices around their spirituality and religion. Despite dramatic differences in other customs and behaviors among these cultures, they shared a common belief that faith, spirituality, and religion played a powerful role in the healing process. In early Greek and Egyptian cultures, the greatest physicians such as Aesculapius and Imhotep were elevated to the level of gods after their death.1 Temples and shrines were built for the purpose of healing the sick by prayer and religious practice. Physician-priests were prominent and respected members of these societies who ultimately derived their healing power from the gods. As science and medicine progressed, healing was not left exclusively to the domain of Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA. Address reprint requests to Michael H. Torosian, MD, Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111. E-mail: [email protected]
232
0093-7754/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.seminoncol.2004.11.017
gods and religious leaders but increasingly included practical medical remedies. An enormous amount of practical and academic theories of disease and treatment arose in these early cultures. Detailed medical papyri have been discovered in Egypt dating back to at least 1500 BC.2 These manuscripts extensively describe the diagnosis, treatment, and theories on the pathogenesis of many illnesses and diseases. The Ebers Papyrus, for example, consists of 110 sheets and 900 prescriptions for a wide array of medical problems. Religious rituals and incantations were incorporated throughout the text of these medical prescriptions, indicating the persistent relationship between healing and religious beliefs at that time. The eminent Greek physicians Hippocrates and Galen and the great philosophers Aristotle and Plato created volumes of work that greatly influenced the direction of Western medicine until the 19th century.1,2 Disease and illness were being increasingly defined by objective, physical symptoms with specific biologic causes. Other ancient cultures, such as those in China, Mesopotamia, India, and elsewhere, also made tremendous contributions to the development of modern medicine.2,3 Each of these cultures devised their own theories of disease and wellbeing around their religious and cultural beliefs. Eastern medicine, in particular, has always firmly believed that health is maintained by an intricate balance involving mind, body, and spirit. When this harmonic balance is disturbed, illness and disease result. Treatment of illness in these cultures, therefore, requires that attention be given to not only the physical aspects of disease but also to its mental and spiritual components. The great divide between religion and medicine in Western cultures occurred almost 500 years ago.2,4 The clash between religion and science occurred during the Renaissance
Spirituality and healing with the most significant event being the prosecution of Galileo by the Catholic Church in 1633. Galileo championed the recently published Copernican theory of the universe, postulating that the sun (not the earth) was the center of the universe. Galileo was an outspoken proponent of this theory, which was in strong opposition to the doctrine of the Catholic Church at that time. Furthermore, Galileo confronted the Church on many other doctrines as his scientific rigor left him unable to accept concepts by faith alone—Galileo required measurable, physical proof. Since that time, religion and spirituality have continued to diverge from the fields of medicine and science. Medicine and science have become increasingly technical and sophisticated, particularly over the past several decades. Despite the high-technologic nature of our current medical practice, the clinical impact of religion and spirituality is beginning to be recognized once again. Although great advances have been made in the diagnosis and treatment of many diseases, including cancer, patients and healthcare providers alike realize that conventional medicine has limitations. In fact, burgeoning fields of alternative and complementary medicine have been established based on this concept. In addition, scientific literature now exists to document that spirituality can improve recovery from illnesses such as cancer, cardiovascular disease, neurologic disorders, musculoskeletal disease, trauma, and mental health problems.5 We firmly believe that spirituality should be integrated into conventional medicine to treat patients with cancer and other major illnesses in today’s healthcare environment.
Multidimensional Aspects of Cancer Cancer is a devastating disease to treat for a variety of reasons. The biologic characteristics of cancer can be challenging and difficult to treat, particularly due to its ability to recur locally and to metastasize to distant sites. But this disease offers more than just physical challenges to treat—there are emotional, psychological, and spiritual consequences to the diagnosis of cancer as well as the obvious physical effects. There are clearly important physical aspects to the diagnosis and treatment of cancer. Today there is an extensive armamentarium of medical treatments used against cancer, including surgery, radiation therapy, chemotherapy, hormone therapy, molecular therapy, biologic therapy, and experimental treatments. Each of these approaches has its role to play in treating cancer but can also have significant physical and psychological side effects. Conventional cancer medicine is primarily concerned with the physical aspects of antineoplastic therapy. Over the past 25 years, medicine has made great progress in the surgical, medical, radiation, and biologic treatment of cancer. Methods have been devised to limit the radical nature and debilitating effects of surgery for many types of cancer. Advances in anesthesia and critical care have helped to reduce morbidity and mortality from cancer surgery. The field of radiation therapy has enjoyed similar success with precise, computer-
233 based technology to improve tumor response while reducing radiation-induced injury to surrounding normal tissues. Finally, supportive medications and revised treatment schedules for chemotherapy, hormone therapy, and biologic therapy have decreased side effects for these systemic therapies. Despite these modern advances in antineoplastic therapy, the diagnosis of cancer is associated with emotional, psychological, and spiritual consequences.6 The cancer diagnosis effects a traumatic, abrupt change in all phases of the patient’s life. Significant life changes can occur on a personal, familial, social, psychological, and, perhaps, spiritual level. There is uncertainty and unpredictability about the outcome of the newly diagnosed cancer. Patients are faced with questions such as “Can I be cured?,” “What treatments are needed?,” “What caused my cancer?,” and “Is my family at increased risk of cancer?” The loss of control in this situation can be anxiety-provoking and very threatening to many individuals. Fear of the cancer diagnosis and its ultimate outcome plays an important role in the emotional and psychological effects of this illness. Fear can cause many physical and mental symptoms, including anxiety, panic, depression, fatigue, anorexia, irritability, insomnia, weakness, pain, apathy, and hopelessness.7 This physical and mental distress is extremely debilitating and can severely impair one’s quality of life. These adverse feelings can affect not only the patient but also his/her family, friends, and caregivers. These associated effects can have a negative impact on the care-giving and coping abilities of the patient’s support team, secondarily affecting his own health. In fact, fear is perhaps the most powerful antagonist to our human spirit. Our spirit thrives on hope, faith, love, and trust, and fear negates these important values and feelings.6,7 Spirituality promotes hope and is a unique, flexible, and dynamic part of every individual. Spirituality is distinct from religion, which promotes a common set of beliefs, principles, doctrines, and behaviors for all who endorse that religion. In contrast, spirituality is as unique as one’s fingerprint or genetic makeup and definitions include: faith in a Greater Power, purpose in life, faith, hope, prayer, meditation, and others. Patients with a strong spirituality and faith can find a great source of comfort and peace when confronted with the difficult challenges of cancer.6 For example, spirituality, faith and hope can dramatically reduce one’s fear and anxiety during this traumatic time. The peacefulness, serenity, and tranquility of a strong spiritual foundation can overcome the anxiety, depression, and hopelessness of fear. The human spirit is a tremendously powerful and valuable resource that can be used to promote healing from cancer and should be used in everyone’s daily life and quest for well-being.
Clinical Impact of Spirituality Spirituality has been shown to significantly improve recovery from many illnesses, including cancer, cardiovascular disease, neurologic disorders, musculoskeletal disease, and mental health problems.6,8-11 Objective results from numerous scientific studies demonstrate reduction in stress, relief of
234 pain, improved recovery from surgery, reduced depression and anxiety, and prevention and recovery from substance abuse.6,7 Church attendance, the strength of one’s faith and religious commitment, and prayer have been associated with improved recovery and healing in many clinical studies. Recent polls have indicated that both patients and their healthcare providers believe that spirituality and faith can significantly affect the healing process.6,12,13 King and Bushwick polled 203 inpatients in Kentucky and North Carolina and showed that 77% wanted their physicians to consider their spiritual needs.12 Almost half of those studied wanted their physicians to pray with them if possible. In a poll conducted by the American Academy of Family Physicians, an overwhelming 99% of 296 physicians stated that religious belief could heal.14 In this study, 75% of physicians believed that prayers of others (ie, intercessory prayers) could promote healing and recovery. Scientific evidence now exists to indicate that spirituality can significantly improve recovery, create a greater sense of purpose in life, promote hope, achieve peace of mind, and enhance coping skills in the cancer patient. John and Spica in 1991 reported that 85% of breast cancer patients indicated that religion helped them cope with their illness.15 In melanoma patients, Holland et al found that religion supported those patients when facing life-threatening events.16 Kaczorowski et al in 1989 studied 114 cancer patients and showed an inverse relationship between spiritual well-being and anxiety, ie, those with the greatest spirituality had the least symptoms of anxiety.17 This inverse relationship between spirituality and anxiety was independent of gender, age, marital status, diagnosis, group participation, or time from diagnosis of cancer. Roberts et al in 1997 studied 108 women with gynecologic cancer and demonstrated that religion played an important role in 76% of these patients.18 Interestingly, almost half of these women became more religious after the diagnosis of cancer and none became less religious. In 93% of these patients, religion specifically helped them to sustain hope. Hermann in 2001 identified 29 unique spiritual needs in hospice patients with cancer.19 These spiritual needs were categorized into six thematic groups, including religion, companionship, involvement and control, business, nature, and positive outlook. Halstead and Hull in 2001 studied women with breast cancer, ovarian cancer, or non-Hodgkin’s lymphoma and recognized a three-phase process for incorporating spirituality into their patients’ cancer care.20 First, the patient had to realize the possibility of their own vulnerability, distress, and even death. Second, the patients needed to ask themselves difficult and probing questions—that is, they had to challenge their own basic priorities and belief systems, including practical, everyday matters, as well as their religion and spirituality. Finally, these individuals needed to redefine their meaning and purpose in life and identify means for spiritual growth. Some interesting results of spirituality on the immune system have been found in several studies of cancer patients. Sephton et al in 2001 studied the effect of spirituality on the immune system of 112 breast cancer patients.21 This study
M.H. Torosian and V.R. Biddle found that spirituality was associated with a greater number of circulating white blood cells, total lymphocyte counts, increased helper T cells, and increased cytotoxic T cells. Koenig et al in 1997 analyzed the relationship between religious attendance and various immune parameters in 1,718 adults.22 These researchers found that religious attendance was inversely related to interleukin-6 levels, indicating a healthier immune system, as interleukin-6 is an inhibitory cytokine. Covariates other than religious attendance were unable to account for the observed immunologic change in this large clinical study. Increased natural killer (NK) cell function has also been associated with effective social support in breast cancer patients. Spiritual integrated therapy is an innovative, comprehensive treatment approach that we have developed and pioneered to integrate the dimensions of spirituality/religion and clinical psychotherapy.6 Spiritual integrated therapy recognizes the physical, spiritual, emotional, and intellectual dimensions of human life and is not limited by traditional scientific and physical boundaries. This integrated treatment approach offers a perspective that science alone is unable to provide. During spiritual intervention, the patient looks introspectively to identify his own strengths and weaknesses and spiritually connects to God. Spiritual integration promotes the use of one’s spiritual resources to better cope and recover from traumatic events, difficult life transitions, and spiritual crises. The diagnosis of cancer can be so overwhelming that an acute emotional, psychological, and spiritual crisis abruptly occurs. Spiritual integration can effectively combat the multidimensional and complex aspects of these difficult and challenging situations. Major aspects in dealing with cancer patients include the fear of death and the uncertainty of one’s prognosis; the resultant anxiety can create a state of vulnerability, emotional instability, and severe stress. Spirituality can help these patients shift from anxiety, fear, and despair to hope; overcome the struggles of trauma; adjust to illness; gain a deeper meaning and purpose in life; and undergo spiritual growth and transformation. Hope is found in the spiritual realm and is the answer to our human need for spiritual meaning and salvation. Hope represents finding meaning and purpose in the future and is essential for spiritual survival and growth. In contrast, hopelessness is a common and important clinical component of depression and anxiety. By integrating spiritual strategies with conventional medical practice, enormous spiritual resources can be accessed to promote healing and improve coping in the cancer patient. Spiritual integrated therapy has successfully helped patients with cancer, depression, anxiety, post-traumatic stress disorder, and other physical and mental diseases. Anxiety, depression, and hopelessness can be dramatically reduced when spiritual therapy is combined with medical practice. Deep-rooted fears and emotions can be released during prayer and surrendered to God. Surrendering to God and forgiveness imply cognitive, behavioral, and spiritual elements that diminish anger and promote spiritual growth. The aim of spiritual integrated therapy is to awaken and utilize one’s spiritual resources to provide strength, faith, and hope
Spirituality and healing to overcome even the most difficult of life’s challenges, including cancer. Thus, spirituality and religion can exert a significant, positive impact on the clinical outcome of cancer patients. Similar results have been found in patients with a variety of other physical and mental illnesses. These studies are complex to conduct and analyze due to the multifactorial, subjective phenomena being tested. Nevertheless, the vast majority of scientific studies support a very positive correlation between spirituality and the process of healing and coping in the cancer patient.
Potential Mechanisms of Action Fascinating research has recently been conducted to elucidate potential biologic mechanisms to explain the effects of spirituality and religion on human health and recovery from disease. Changes in brain electrical activity as measured by electroencephalography (EEG) were documented during meditation by Hirai as early as 1974.23 Significant electrical changes were found in the frontal lobe of the brain during the meditative state. Others have implicated specific changes in brain neurotransmitter levels, for example, serotonin, by spiritual experiences. However, specific, reproducible biologic changes in the human body and brain have been difficult to correlate with spiritual and religious activity. Despite the complexities of this research, neurochemical, electrophysiologic, and functional studies of brain activity are currently underway to identify specific physiologic changes effected by prayer, spirituality, meditation, and other noetic practices. Newberg et al in 2001 studied nuns in prayer and monks during meditation using the nuclear medicine technology of single-photon emission computed tomography (SPECT) imaging.24 High-technology SPECT imaging measures brain activity based on radioactivity as determined by differential blood flow to various parts of the brain. Their exciting results demonstrate similar functional changes in the brain during prayer in Franciscan nuns and meditation in Buddhist monks. Decreased brain activity was found in the left orientation association area (posterior superior parietal lobe) during the height of prayer and meditation in these individuals. This region of the brain normally establishes our physical relationship to the outside world. During these religious and spiritual experiences, this neurologic function is reduced and may account for the feelings of being close to God during prayer and at one with the universe during meditation. Other researchers have focused on the interaction between spirituality and the neuroendocrine-immune systems. It is known that stress and anxiety cause a physiologic response characterized by increased cortisol levels and reduced circulating T cells.7 The net result of these stress-induced changes is suppression of the immune system. It has been postulated that spirituality might prevent or impair these endocrine and immune changes by reducing stress, anxiety, depression, and hopelessness.22,25 Further scientific and clinical research is clearly needed to unravel the fascinating interaction between
235 spirituality and its complex biologic effects on the human body and mind.
Conclusions Spirituality, faith, and religion can have a tremendous impact on our physical and mental well-being. Clinical studies have demonstrated that improved recovery from illness and surgery, reduction of stress and anxiety, relief of pain, and improved coping skills are associated with strong spirituality. The spiritual integrated treatment approach combines the beneficial effects of spirituality with the modern treatments of conventional medicine. We propose that spirituality be integrated into the practice of traditional medicine to promote healing in the cancer patient.
References 1. Ellis H: A History of Surgery. London, Uk, Greenwich Medical Media, 2001 2. Porter R: The Greatest Benefit to Mankind; A Medical History of Humanity. New York, NY, Norton, 1997 3. Kiple KF (ed): The Cambridge World History of Human Disease. Cambridge, MA, Cambridge University Press, 1993 4. Suplee C: Milestones of Science. Washington, DC, National Geographic, 2000 5. McCollough ME: Prayer and health; conceptual issues, research review, and research prospectus. J Psychol Theol 23:15-29, 1995 6. Torosian MH, Biddle VR: Spirit to Heal; a Journey to Spiritual Healing With Cancer. Wayne, PA, Spirit Press International, 2003 7. Benson H: Timeless Healing; the Power and Biology of Belief. New York, NY, Fireside, 1996 8. Ornish D, Brown SE, Scherwitz LW, et al: Can lifestyle changes reverse coronary heart disease? The lifestyle heart trial. Lancet 336:129-133, 1990 9. Propst LR, Ostrom R, Watkins P, et al: Comparative efficacy of religious and nonreligious cognitive-behavioral therapy for the treatment of clinical depression in religious individuals. J Consult Clin Psychol 60:94103, 1992 10. Pressman P, Lyons JS, Larson DB, et al: Religious belief, depression, and ambulation status in elderly women with broken hips. Am J Psychiatry 147:758-760, 1990 11. Post SG, Pulchalski CM, Larson DB: Physicians and patient spirituality; professional boundaries, competency, and ethics. Ann Intern Med 132: 578-583, 2000 12. King DE, Bushwick B: Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Prac 39:349-352, 1994 13. Astrow AB, Pulchalski CM, Sulmasy DP: Religion, spirituality, and health care; social, ethical, and practical considerations. Am J Med 110:283-287, 2001 14. Eisenberg DM, Kessler RC, Foster C, et al: Unconventional medicine in the United States. N Engl J Med 328:246-252, 1993 15. John SC, Spica B: Coping with breast cancer; the roles of clergy and faith. J Religion Health 30:21-33, 1991 16. Holland JC, Passik S, Kash KM, et al: The role of religious and spiritual beliefs in coping with malignant melanoma. Psychooncology 8:14-26, 1999 17. Kaczorowski JM: Spiritual well-being and anxiety in adults diagnosed with cancer. Hospice J 5:105-116, 1989 18. Roberts JA, Brown D, Elkins T, et al: Factors influencing the views of patients with gynecologic cancer about end-of-life decisions. Am J Obstet Gynecol 176:166-172, 1997 19. Hermann CP: Spiritual needs of dying patients; a qualitative study. Oncol Nurs Forum 28:67-72, 2001 20. Halstead MT, Hull M: Struggling with paradoxes; the process of spiritual development in women with cancer. Oncol Nurs Forum 28:15341544, 2001
236 21. Sephton SE, Koopman C, Schaal M, et al: Spiritual expression and immune status in women with metastatic breast cancer; an exploratory study. Breast J 7:345-353, 2001 22. Koenig HG, Cohen HJ, George LK, et al: Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. Int J Psychiatry Med 27:233-250, 1997
M.H. Torosian and V.R. Biddle 23. Hirai T: Psychophysiology of Zen. Tokyo, Japan, Igaku Shoin, 1974 24. Newberg A, D’Aquili E, Rause V: Why God Won’t Go Away; Brain Science and the Biology of Belief. New York, NY, Ballantine, 2001 25. Cacioppo JT, Berntson GG, Malarkey WB, et al: Autonomic, neuroendocrine, and immune responses to psychological stress; the reactivity hypothesis. Ann NY Acad Sci 840:664-673, 1998
E
ssentially every human culture has used a form of spirituality or religion during times of illness or death. As long as 100,000 years ago, rituals with a religious or spiritual dimension were used by people when burying their dead. In the earliest recorded history, healing and recovery from illness were routinely sought by appealing to the gods or a higher power or spirit. Religious leaders and shaman of these early cultures also frequently acted as the healing powers or medicine men of those societies. It is interesting that the connections between spirituality, religion, and medicine developed independently and in very disparate cultures throughout the world. These cultures arose in widely different geographic regions of the world with no known communication or association. Cultures from the Mediterranean region of Europe, the Far and Middle Eastern regions of Asia, Africa, and North and South America developed medical practices around their spirituality and religion. Despite dramatic differences in other customs and behaviors among these cultures, they shared a common belief that faith, spirituality, and religion played a powerful role in the healing process. In early Greek and Egyptian cultures, the greatest physicians such as Aesculapius and Imhotep were elevated to the level of gods after their death.1 Temples and shrines were built for the purpose of healing the sick by prayer and religious practice. Physician-priests were prominent and respected members of these societies who ultimately derived their healing power from the gods. As science and medicine progressed, healing was not left exclusively to the domain of Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA. Address reprint requests to Michael H. Torosian, MD, Department of Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA 19111. E-mail: [email protected]
232
0093-7754/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.seminoncol.2004.11.017
gods and religious leaders but increasingly included practical medical remedies. An enormous amount of practical and academic theories of disease and treatment arose in these early cultures. Detailed medical papyri have been discovered in Egypt dating back to at least 1500 BC.2 These manuscripts extensively describe the diagnosis, treatment, and theories on the pathogenesis of many illnesses and diseases. The Ebers Papyrus, for example, consists of 110 sheets and 900 prescriptions for a wide array of medical problems. Religious rituals and incantations were incorporated throughout the text of these medical prescriptions, indicating the persistent relationship between healing and religious beliefs at that time. The eminent Greek physicians Hippocrates and Galen and the great philosophers Aristotle and Plato created volumes of work that greatly influenced the direction of Western medicine until the 19th century.1,2 Disease and illness were being increasingly defined by objective, physical symptoms with specific biologic causes. Other ancient cultures, such as those in China, Mesopotamia, India, and elsewhere, also made tremendous contributions to the development of modern medicine.2,3 Each of these cultures devised their own theories of disease and wellbeing around their religious and cultural beliefs. Eastern medicine, in particular, has always firmly believed that health is maintained by an intricate balance involving mind, body, and spirit. When this harmonic balance is disturbed, illness and disease result. Treatment of illness in these cultures, therefore, requires that attention be given to not only the physical aspects of disease but also to its mental and spiritual components. The great divide between religion and medicine in Western cultures occurred almost 500 years ago.2,4 The clash between religion and science occurred during the Renaissance
Spirituality and healing with the most significant event being the prosecution of Galileo by the Catholic Church in 1633. Galileo championed the recently published Copernican theory of the universe, postulating that the sun (not the earth) was the center of the universe. Galileo was an outspoken proponent of this theory, which was in strong opposition to the doctrine of the Catholic Church at that time. Furthermore, Galileo confronted the Church on many other doctrines as his scientific rigor left him unable to accept concepts by faith alone—Galileo required measurable, physical proof. Since that time, religion and spirituality have continued to diverge from the fields of medicine and science. Medicine and science have become increasingly technical and sophisticated, particularly over the past several decades. Despite the high-technologic nature of our current medical practice, the clinical impact of religion and spirituality is beginning to be recognized once again. Although great advances have been made in the diagnosis and treatment of many diseases, including cancer, patients and healthcare providers alike realize that conventional medicine has limitations. In fact, burgeoning fields of alternative and complementary medicine have been established based on this concept. In addition, scientific literature now exists to document that spirituality can improve recovery from illnesses such as cancer, cardiovascular disease, neurologic disorders, musculoskeletal disease, trauma, and mental health problems.5 We firmly believe that spirituality should be integrated into conventional medicine to treat patients with cancer and other major illnesses in today’s healthcare environment.
Multidimensional Aspects of Cancer Cancer is a devastating disease to treat for a variety of reasons. The biologic characteristics of cancer can be challenging and difficult to treat, particularly due to its ability to recur locally and to metastasize to distant sites. But this disease offers more than just physical challenges to treat—there are emotional, psychological, and spiritual consequences to the diagnosis of cancer as well as the obvious physical effects. There are clearly important physical aspects to the diagnosis and treatment of cancer. Today there is an extensive armamentarium of medical treatments used against cancer, including surgery, radiation therapy, chemotherapy, hormone therapy, molecular therapy, biologic therapy, and experimental treatments. Each of these approaches has its role to play in treating cancer but can also have significant physical and psychological side effects. Conventional cancer medicine is primarily concerned with the physical aspects of antineoplastic therapy. Over the past 25 years, medicine has made great progress in the surgical, medical, radiation, and biologic treatment of cancer. Methods have been devised to limit the radical nature and debilitating effects of surgery for many types of cancer. Advances in anesthesia and critical care have helped to reduce morbidity and mortality from cancer surgery. The field of radiation therapy has enjoyed similar success with precise, computer-
233 based technology to improve tumor response while reducing radiation-induced injury to surrounding normal tissues. Finally, supportive medications and revised treatment schedules for chemotherapy, hormone therapy, and biologic therapy have decreased side effects for these systemic therapies. Despite these modern advances in antineoplastic therapy, the diagnosis of cancer is associated with emotional, psychological, and spiritual consequences.6 The cancer diagnosis effects a traumatic, abrupt change in all phases of the patient’s life. Significant life changes can occur on a personal, familial, social, psychological, and, perhaps, spiritual level. There is uncertainty and unpredictability about the outcome of the newly diagnosed cancer. Patients are faced with questions such as “Can I be cured?,” “What treatments are needed?,” “What caused my cancer?,” and “Is my family at increased risk of cancer?” The loss of control in this situation can be anxiety-provoking and very threatening to many individuals. Fear of the cancer diagnosis and its ultimate outcome plays an important role in the emotional and psychological effects of this illness. Fear can cause many physical and mental symptoms, including anxiety, panic, depression, fatigue, anorexia, irritability, insomnia, weakness, pain, apathy, and hopelessness.7 This physical and mental distress is extremely debilitating and can severely impair one’s quality of life. These adverse feelings can affect not only the patient but also his/her family, friends, and caregivers. These associated effects can have a negative impact on the care-giving and coping abilities of the patient’s support team, secondarily affecting his own health. In fact, fear is perhaps the most powerful antagonist to our human spirit. Our spirit thrives on hope, faith, love, and trust, and fear negates these important values and feelings.6,7 Spirituality promotes hope and is a unique, flexible, and dynamic part of every individual. Spirituality is distinct from religion, which promotes a common set of beliefs, principles, doctrines, and behaviors for all who endorse that religion. In contrast, spirituality is as unique as one’s fingerprint or genetic makeup and definitions include: faith in a Greater Power, purpose in life, faith, hope, prayer, meditation, and others. Patients with a strong spirituality and faith can find a great source of comfort and peace when confronted with the difficult challenges of cancer.6 For example, spirituality, faith and hope can dramatically reduce one’s fear and anxiety during this traumatic time. The peacefulness, serenity, and tranquility of a strong spiritual foundation can overcome the anxiety, depression, and hopelessness of fear. The human spirit is a tremendously powerful and valuable resource that can be used to promote healing from cancer and should be used in everyone’s daily life and quest for well-being.
Clinical Impact of Spirituality Spirituality has been shown to significantly improve recovery from many illnesses, including cancer, cardiovascular disease, neurologic disorders, musculoskeletal disease, and mental health problems.6,8-11 Objective results from numerous scientific studies demonstrate reduction in stress, relief of
234 pain, improved recovery from surgery, reduced depression and anxiety, and prevention and recovery from substance abuse.6,7 Church attendance, the strength of one’s faith and religious commitment, and prayer have been associated with improved recovery and healing in many clinical studies. Recent polls have indicated that both patients and their healthcare providers believe that spirituality and faith can significantly affect the healing process.6,12,13 King and Bushwick polled 203 inpatients in Kentucky and North Carolina and showed that 77% wanted their physicians to consider their spiritual needs.12 Almost half of those studied wanted their physicians to pray with them if possible. In a poll conducted by the American Academy of Family Physicians, an overwhelming 99% of 296 physicians stated that religious belief could heal.14 In this study, 75% of physicians believed that prayers of others (ie, intercessory prayers) could promote healing and recovery. Scientific evidence now exists to indicate that spirituality can significantly improve recovery, create a greater sense of purpose in life, promote hope, achieve peace of mind, and enhance coping skills in the cancer patient. John and Spica in 1991 reported that 85% of breast cancer patients indicated that religion helped them cope with their illness.15 In melanoma patients, Holland et al found that religion supported those patients when facing life-threatening events.16 Kaczorowski et al in 1989 studied 114 cancer patients and showed an inverse relationship between spiritual well-being and anxiety, ie, those with the greatest spirituality had the least symptoms of anxiety.17 This inverse relationship between spirituality and anxiety was independent of gender, age, marital status, diagnosis, group participation, or time from diagnosis of cancer. Roberts et al in 1997 studied 108 women with gynecologic cancer and demonstrated that religion played an important role in 76% of these patients.18 Interestingly, almost half of these women became more religious after the diagnosis of cancer and none became less religious. In 93% of these patients, religion specifically helped them to sustain hope. Hermann in 2001 identified 29 unique spiritual needs in hospice patients with cancer.19 These spiritual needs were categorized into six thematic groups, including religion, companionship, involvement and control, business, nature, and positive outlook. Halstead and Hull in 2001 studied women with breast cancer, ovarian cancer, or non-Hodgkin’s lymphoma and recognized a three-phase process for incorporating spirituality into their patients’ cancer care.20 First, the patient had to realize the possibility of their own vulnerability, distress, and even death. Second, the patients needed to ask themselves difficult and probing questions—that is, they had to challenge their own basic priorities and belief systems, including practical, everyday matters, as well as their religion and spirituality. Finally, these individuals needed to redefine their meaning and purpose in life and identify means for spiritual growth. Some interesting results of spirituality on the immune system have been found in several studies of cancer patients. Sephton et al in 2001 studied the effect of spirituality on the immune system of 112 breast cancer patients.21 This study
M.H. Torosian and V.R. Biddle found that spirituality was associated with a greater number of circulating white blood cells, total lymphocyte counts, increased helper T cells, and increased cytotoxic T cells. Koenig et al in 1997 analyzed the relationship between religious attendance and various immune parameters in 1,718 adults.22 These researchers found that religious attendance was inversely related to interleukin-6 levels, indicating a healthier immune system, as interleukin-6 is an inhibitory cytokine. Covariates other than religious attendance were unable to account for the observed immunologic change in this large clinical study. Increased natural killer (NK) cell function has also been associated with effective social support in breast cancer patients. Spiritual integrated therapy is an innovative, comprehensive treatment approach that we have developed and pioneered to integrate the dimensions of spirituality/religion and clinical psychotherapy.6 Spiritual integrated therapy recognizes the physical, spiritual, emotional, and intellectual dimensions of human life and is not limited by traditional scientific and physical boundaries. This integrated treatment approach offers a perspective that science alone is unable to provide. During spiritual intervention, the patient looks introspectively to identify his own strengths and weaknesses and spiritually connects to God. Spiritual integration promotes the use of one’s spiritual resources to better cope and recover from traumatic events, difficult life transitions, and spiritual crises. The diagnosis of cancer can be so overwhelming that an acute emotional, psychological, and spiritual crisis abruptly occurs. Spiritual integration can effectively combat the multidimensional and complex aspects of these difficult and challenging situations. Major aspects in dealing with cancer patients include the fear of death and the uncertainty of one’s prognosis; the resultant anxiety can create a state of vulnerability, emotional instability, and severe stress. Spirituality can help these patients shift from anxiety, fear, and despair to hope; overcome the struggles of trauma; adjust to illness; gain a deeper meaning and purpose in life; and undergo spiritual growth and transformation. Hope is found in the spiritual realm and is the answer to our human need for spiritual meaning and salvation. Hope represents finding meaning and purpose in the future and is essential for spiritual survival and growth. In contrast, hopelessness is a common and important clinical component of depression and anxiety. By integrating spiritual strategies with conventional medical practice, enormous spiritual resources can be accessed to promote healing and improve coping in the cancer patient. Spiritual integrated therapy has successfully helped patients with cancer, depression, anxiety, post-traumatic stress disorder, and other physical and mental diseases. Anxiety, depression, and hopelessness can be dramatically reduced when spiritual therapy is combined with medical practice. Deep-rooted fears and emotions can be released during prayer and surrendered to God. Surrendering to God and forgiveness imply cognitive, behavioral, and spiritual elements that diminish anger and promote spiritual growth. The aim of spiritual integrated therapy is to awaken and utilize one’s spiritual resources to provide strength, faith, and hope
Spirituality and healing to overcome even the most difficult of life’s challenges, including cancer. Thus, spirituality and religion can exert a significant, positive impact on the clinical outcome of cancer patients. Similar results have been found in patients with a variety of other physical and mental illnesses. These studies are complex to conduct and analyze due to the multifactorial, subjective phenomena being tested. Nevertheless, the vast majority of scientific studies support a very positive correlation between spirituality and the process of healing and coping in the cancer patient.
Potential Mechanisms of Action Fascinating research has recently been conducted to elucidate potential biologic mechanisms to explain the effects of spirituality and religion on human health and recovery from disease. Changes in brain electrical activity as measured by electroencephalography (EEG) were documented during meditation by Hirai as early as 1974.23 Significant electrical changes were found in the frontal lobe of the brain during the meditative state. Others have implicated specific changes in brain neurotransmitter levels, for example, serotonin, by spiritual experiences. However, specific, reproducible biologic changes in the human body and brain have been difficult to correlate with spiritual and religious activity. Despite the complexities of this research, neurochemical, electrophysiologic, and functional studies of brain activity are currently underway to identify specific physiologic changes effected by prayer, spirituality, meditation, and other noetic practices. Newberg et al in 2001 studied nuns in prayer and monks during meditation using the nuclear medicine technology of single-photon emission computed tomography (SPECT) imaging.24 High-technology SPECT imaging measures brain activity based on radioactivity as determined by differential blood flow to various parts of the brain. Their exciting results demonstrate similar functional changes in the brain during prayer in Franciscan nuns and meditation in Buddhist monks. Decreased brain activity was found in the left orientation association area (posterior superior parietal lobe) during the height of prayer and meditation in these individuals. This region of the brain normally establishes our physical relationship to the outside world. During these religious and spiritual experiences, this neurologic function is reduced and may account for the feelings of being close to God during prayer and at one with the universe during meditation. Other researchers have focused on the interaction between spirituality and the neuroendocrine-immune systems. It is known that stress and anxiety cause a physiologic response characterized by increased cortisol levels and reduced circulating T cells.7 The net result of these stress-induced changes is suppression of the immune system. It has been postulated that spirituality might prevent or impair these endocrine and immune changes by reducing stress, anxiety, depression, and hopelessness.22,25 Further scientific and clinical research is clearly needed to unravel the fascinating interaction between
235 spirituality and its complex biologic effects on the human body and mind.
Conclusions Spirituality, faith, and religion can have a tremendous impact on our physical and mental well-being. Clinical studies have demonstrated that improved recovery from illness and surgery, reduction of stress and anxiety, relief of pain, and improved coping skills are associated with strong spirituality. The spiritual integrated treatment approach combines the beneficial effects of spirituality with the modern treatments of conventional medicine. We propose that spirituality be integrated into the practice of traditional medicine to promote healing in the cancer patient.
References 1. Ellis H: A History of Surgery. London, Uk, Greenwich Medical Media, 2001 2. Porter R: The Greatest Benefit to Mankind; A Medical History of Humanity. New York, NY, Norton, 1997 3. Kiple KF (ed): The Cambridge World History of Human Disease. Cambridge, MA, Cambridge University Press, 1993 4. Suplee C: Milestones of Science. Washington, DC, National Geographic, 2000 5. McCollough ME: Prayer and health; conceptual issues, research review, and research prospectus. J Psychol Theol 23:15-29, 1995 6. Torosian MH, Biddle VR: Spirit to Heal; a Journey to Spiritual Healing With Cancer. Wayne, PA, Spirit Press International, 2003 7. Benson H: Timeless Healing; the Power and Biology of Belief. New York, NY, Fireside, 1996 8. Ornish D, Brown SE, Scherwitz LW, et al: Can lifestyle changes reverse coronary heart disease? The lifestyle heart trial. Lancet 336:129-133, 1990 9. Propst LR, Ostrom R, Watkins P, et al: Comparative efficacy of religious and nonreligious cognitive-behavioral therapy for the treatment of clinical depression in religious individuals. J Consult Clin Psychol 60:94103, 1992 10. Pressman P, Lyons JS, Larson DB, et al: Religious belief, depression, and ambulation status in elderly women with broken hips. Am J Psychiatry 147:758-760, 1990 11. Post SG, Pulchalski CM, Larson DB: Physicians and patient spirituality; professional boundaries, competency, and ethics. Ann Intern Med 132: 578-583, 2000 12. King DE, Bushwick B: Beliefs and attitudes of hospital inpatients about faith healing and prayer. J Fam Prac 39:349-352, 1994 13. Astrow AB, Pulchalski CM, Sulmasy DP: Religion, spirituality, and health care; social, ethical, and practical considerations. Am J Med 110:283-287, 2001 14. Eisenberg DM, Kessler RC, Foster C, et al: Unconventional medicine in the United States. N Engl J Med 328:246-252, 1993 15. John SC, Spica B: Coping with breast cancer; the roles of clergy and faith. J Religion Health 30:21-33, 1991 16. Holland JC, Passik S, Kash KM, et al: The role of religious and spiritual beliefs in coping with malignant melanoma. Psychooncology 8:14-26, 1999 17. Kaczorowski JM: Spiritual well-being and anxiety in adults diagnosed with cancer. Hospice J 5:105-116, 1989 18. Roberts JA, Brown D, Elkins T, et al: Factors influencing the views of patients with gynecologic cancer about end-of-life decisions. Am J Obstet Gynecol 176:166-172, 1997 19. Hermann CP: Spiritual needs of dying patients; a qualitative study. Oncol Nurs Forum 28:67-72, 2001 20. Halstead MT, Hull M: Struggling with paradoxes; the process of spiritual development in women with cancer. Oncol Nurs Forum 28:15341544, 2001
236 21. Sephton SE, Koopman C, Schaal M, et al: Spiritual expression and immune status in women with metastatic breast cancer; an exploratory study. Breast J 7:345-353, 2001 22. Koenig HG, Cohen HJ, George LK, et al: Attendance at religious services, interleukin-6, and other biological parameters of immune function in older adults. Int J Psychiatry Med 27:233-250, 1997
M.H. Torosian and V.R. Biddle 23. Hirai T: Psychophysiology of Zen. Tokyo, Japan, Igaku Shoin, 1974 24. Newberg A, D’Aquili E, Rause V: Why God Won’t Go Away; Brain Science and the Biology of Belief. New York, NY, Ballantine, 2001 25. Cacioppo JT, Berntson GG, Malarkey WB, et al: Autonomic, neuroendocrine, and immune responses to psychological stress; the reactivity hypothesis. Ann NY Acad Sci 840:664-673, 1998