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MGH, Chaplaincy Grand Rounds, March 10, 2009

MGH, Chaplaincy Grand Rounds, March 10, 2009. Integrating spiritual issues in clinical practice Andrés G. Niño, Ph.D. [summary] Integrating spiritual issues in clinical practice.

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MGH, Chaplaincy Grand Rounds, March 10, 2009

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  1. MGH, Chaplaincy Grand Rounds, March 10, 2009 Integrating spiritual issues in clinical practice Andrés G. Niño, Ph.D.

  2. [summary]Integrating spiritual issues in clinical practice. 1. Achange of paradigm in the health professions that includes the dimension of spirituality. 2. A holistic, integrative frame of reference, - based on a broadened concept of health. - oriented to help people achieve a level of functioning that goes beyond the treatment of symptoms toward a deeper level of inner restoration - useful as an interdisciplinary instrument that facilitates dialog, study and research. 3. A case of dual diagnosis that illustrates the task at hand: negotiating spiritual concerns within a narrative context. 4. Implications for professional interventions.

  3. 1. A change of Paradigm • Spiritual issues: once set apart, “repressed”, are now object of recognition in theory and practice.Accepted by institutions of care, ed. programs, etc • The integration of a spiritual dimension into medical (therapeutic) care is still a challenge. -the prevalence of models of care that neglect a holistic / systemic view of the person. -the lack of unified concept of spirituality and use of narrative as primary tool. • Operational concept of spirituality in this perspective: “A normative process of inquiry and engagement through which people bind together experiences and events into an overarching construction of meaning, with a sense of transcendence” (i.e.: associated with an ultimate referential value). Through inquiry/engagement, the individual identifies “fundamental strivings”, (personal values, ideals, ultimate concerns) and brings them to bear upon the realities of a personal life context. This activity is frequently associated with “raising big questions”: Ex: why me, why now, why this much suffering… the many variations of ”where is your God” challenge … judgments: life is unfair, senseless, not worthy, what is left to do? … breeding powerful feelings: anger, despair, resentment, unhappiness… The health professional always faces a suffering person who has “deeper questions waiting for deeper attention”.

  4. 2. A holistic, integrative life structure based on personal narratives. The process of healing/change includes the interaction of basic components of the human experience. L I F E S T R U C T U R E LEARNING OCCUPATION (cultivation of meaning) (mastering of reality) MARRIAGE PAST EXPERIENCE (commitment of love) (continuity and change) SPIRITUAL DIMENSION Recognition FAMILY of fundamental strivings LIFE STYLE (primal narrative) toward meaning/transcendence (Inner/outer self) (raising the ‘big questions’) expressed through Interiority, Relationality, Generativity >2a,2b,2c. FAITH COMMUNITY FRIENDS/GROUPS (shared experience of transcendence) (experience of empathy) SOCIAL, POLITICAL CAUSES (engagement beyond self) @ Nino, A. (1997) “Assessment of spiritual quests in clinical practice”. International Journal of Psychotherapy.

  5. 3. A case ofDUAL DIAGNOSIS David, ICE: 03-31-2003---{writings 4/26/03 ---4/05/06}. *Last session: 9/8/08 Case: A Caucasian man in his early 40’s, with Hx of chronic poly-substance dependence. Since age 14 he experienced numerous relapses followed by hospitalizations, detox programs, and jail terms. Background: Dysfunctional nuclear contexts: parents failed to provide basic empathy. Early relations (siblings, friends) marked by severe pathology. His early life style consistently self-destructive. Life structure. Unexplored (until he begins his first OP treatment). Spiritual issues: - Vague image of God; conflictive relationship with the sacred confabulated by internal thought disorganization and unhealthy practices. - Faith community, absent due to his inner anxiety and fear of people. Clinical picture: marked symptoms of unresolved trauma, severe inner fragmentation and sense of powerlessness for survival.

  6. 3 a.Therapeutic process: rehabilitation in an OP context (holistic-integrative approach) Initial Interview: request for psychotherapy and medication shows basic motivation to face the reality of condition and to engage in sustained effort. Empathic stance: recognition, valuation, ‘good enough environment’ , facilitating self-affirmation, trust. Working through(*): towards change and internal coherence. - emphasize compliance with Tx towards stabilization; -Guide “life structuring” : unfolding narrative - Explore “fundamental strivings”raising ‘big questions’ towards cognitive re-organization and meaning-making. - Support change in the course of Tx towards ‘better prognosis’. Time frame: long term. From ICE to last writings/end of therapy: five years

  7. 3 b. Fundamental Strivings Questionnaire (FSQ) 1. I see myself now as someone who is: (a) incapable of handling a relationship outside of business and family; (b) as someone who would very much like to amend or change his life; (c) as someone who would very much like to freely be myself with others without of fear or condemnation. 2. I think God has and continues to punish me in the way of spiritual rebuke and correction. Has also showed me the extent of consequences of past actions. Shows me wrong from right. Has let me take my own course, my own way. 3. The people I have loved, I have hurt in the past. I love them and would like to be a better human being for them. I cannot change the past but I can change now. 4. Reflecting upon my past, I feel guilt, remorse, regret, and tend toward self condemnation. I beat myself up. Would like to change and be a better person. 5. When I feel fragmented I feel as though I am more than one person; that I am many, that there are others within me. That I have my thoughts and the presence of others' thoughts also. 6. My relation to God is kind of rocky as I bounce around different spiritual ideas especially in relation to my experience with the darker side of religion. I've got a way to go before I feel at ease with my relationship with God. 7. Realizing that things are transitory it's good to know that bad times pass. That things change and that I can too. 8. A meaningful life is to me spiritual fulfillment in Christ. Fulfillment in family life and perhaps some personal fulfillment in being useful to someone. 9. The best I have ever done has been five months of sobriety and sharing me with others in the program and family as well as attendance in church and therapy. 10. What I really would like to do is maintain sobriety, have an even better relationship with family, continue therapy, get closer to God, possibly go to College.

  8. 2 a. The core of a life structure: fundamental engagements • Interiority, a capacity that emerges in the adult self from a sustained effort of introspection and the recurrent appraisal of the meaning and value one creates through life. • * Exercising a reflective stance conducive to the unfolding of a • narrative (oral/written/represented) • * Deciphering transcendence, i.e.: exploring and incorporating • events and their meanings into a unified core of ultimate values.

  9. 2 b. The core of a life structure: fundamental engagements Relatedness, in which the experience of empathy nourishes and transforms the self offering also the possibility of transcending the boundaries of significant others toward an ultimate Other: * Recognizing vs. using the other (interdependence, mutuality) * Negotiating losses of empathy, traumatic injuries from others. Openness to closures: forgiveness, hope and renewal. * Uncovering the meaning of an unfailing, ultimate Other, beyond all others.

  10. 2 c. The core of a life structure: fundamental engagements Generativity, that strives for continuity and resonance of one’s life into the future, beyond the boundaries of present time through parental care (Erikson), cultural (Kotre) and ethical endeavors (Kung). Spiritual dimension expands in the construction of social meaning: -Finding a common ground for the experience of transcendence in a context of different beliefs and traditions. -Empathic, concerted responses to the major problems affecting peace and well being of people in the world. -Aiming at ‘success in life’ within a moral space that preserves one’s integrity and identity. Testimony of spiritual wisdom. It is the degree and quality of engagements in these areas that has the potential to facilitate internal coherence and resilience in the person and reinforces the sense of transcendence in the life structure.

  11. 4. Implications for professional interventions • The imperative of interdisciplinary dialog and team work within a multi-faith, complex social and professional clinical context. • -Who initiates the exploration of spiritual issues? • -Is the negotiation of those issues part of the professional’s role? • -Is a meaningful intervention feasible in the time frame available? • -Is it within the boundaries set by the institution? • -Is the professional equipped to deal with this area of patient’s experience? • -What common ground framework is utilized to facilitate an effective teamwork and how that can be utilized? • What objectives can be set for medical/health professionals/religious advisors working together?

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