Spiritual Assessment and Intervention Model: An Interactive Workshop

1. Spiritual Assessment and Intervention Model: An Interactive WorkshopAllison Kestenbaum, MA, MPA, BCC, ACPE Supervisor Jewish Theological SeminarySpiritual AIM Project Chaplain, Lead InvestigatorThe Rev. Michele Shields, D.Min., BCC, ACPE SupervisorFmr. Director, UCSF Spiritual Care ServicesSpiritual AIM Project Chaplain, Lead InvestigatorLaura B. Dunn, MDProfessor of Psychiatry and Behavioral SciencesDirector, Geriatric Psychiatry Fellowship Training Program Department of Psychiatry and Behavioral SciencesStanford UniversitySpiritual AIM Project Director

2. Objectives • Review Spiritual Assessment and Intervention Model (Spiritual AIM) • Describe process of creating manual for teaching Spiritual AIM • Utilize the new manual to learn this model • Highlight qualitative and quantitative research findings • Present future research directions

3. Core Spiritual Needs PERSONA • Spirituality encompasses the needs to seek meaning and direction, to find self-worth and to belong to community, and to love and be loved, often facilitated through seeking reconciliation when relationships are broken. • When a person faces a crisis, 1 of 3 spiritual needs surfaces most urgently – referred to as the person’s “core spiritual need” Shields M, Kestenbaum A, Dunn LB. Spiritual AIM and the work of the chaplain: A model for assessing spiritual needs and outcomes in relationship. Palliative and Supportive Care. 2014 Mar 10:1-15. PMID: 24612751

5. Spiritual AIM: Background • Developed during 21 yrs of Spiritual Care/Clinical Pastoral Education (CPE) by Rev. Dr. Michele Shields, focused on what occurs between the patient and chaplain • Begun in chaplaincy mentorship in a CPE supervisory training group with Rev. Dennis Kenny, D.Min. for first 2 yrs • Developed with theological reflection and psychological theory, plus critique from professional peers and students • Refinement with the Spiritual AIM Research Team during this study for last 3 years

6. Spiritual AIM: Theology/Philosophy • The Golden Rule or Ethic of Reciprocity: • “Treat others as you wish to be treated.”“Love your neighbor as yourself.” (Lev. 18:18, Matt.22:37-40) • “What you do not wish for yourself, do not impose on others.” (Confucianism) • Spiritual maturity requires autonomy enough to love oneself and connection enough to achieve fairness in balancing love for oneself, others and God (if one’s belief includes God).

7. Spiritual AIM: Psychology • Object Relations: • Personality takes shape through people’s experiences of relationships and social context, specifically how a child appropriates, internalizes and organizes early experiences in the family. • Spiritual AIM: • Spiritual dynamics and spiritual needs are shaped in a similar manner and may be changed or met in relationships, even in adulthood.

8. Spiritual AIM: How does it work? • Assessment of spiritual need based upon: • comments • behavior • attribution of blame • questions • concerns • chaplain’s own internal response to person • Assessment of where person is along path to healing

9. Spiritual AIM: How does it work • Embodiment: stance of • Guide • Valuer • Truth-teller • Interventions in the process of healing • Healing happens in relationship • Desired outcomes to meet the spiritual need

10. Spiritual AIM: Distinctiveness • Assessments, corresponding interventions, desired outcomes • Psychological and theological/philosophical theory underpinnings • Broad definition of “spirituality” • Communicates well to the interdisciplinary team • Inclusive of a variety of faith—or no faith—traditions • Useful in fast-paced, clinical setting (it is not an interview approach)

11. Objectives • Review Spiritual Assessment and Intervention Model (Spiritual AIM) • Describe process of creating manual for teaching Spiritual AIM • Utilize the new manual to learn this model • Highlight qualitative and quantitative research findings • Present future research directions

12. Development of the Spiritual AIM Manual • Met with an oncology/integrative medicine colleague • He had manualized an Ayurvedic medicine intervention for fatigue in cancer patients • He walked us through his process and referred us to two articles on manualization • Aha! We realized manualization isn’t rocket science • We had a manual from another study, which was based on yet another manual • ACT for Fear of Recurrence in breast cancer patients

13. Development of the Spiritual AIM Manual • Outlined chapters. • Filled in material from our previous journal article into the chapters.  • Determined that we needed examples to test the readers • Realized we could take these examples from the study transcripts. • Allison got working on the examples.

14. Chapter Outline Chapter 1: Introduction Chapter 2: Overview of Spiritual AIM Chapter 3: Assessments Chapter 4: Embodiment and Interventions Chapter 5: Outcomes Chapter 6: Case Studies Chapter 7: Communicating with Chaplains and Other Professionals Chapter 8: Clinical Issues Bibliography List of Additional Resources Appendices

15. References on Manualization • Schnyer & Allen: Bridging the Gap in Complementary and Alternative Medicine Research: Manualization as a Means of PromotingStandardization and Flexibility of Treatment in Clinical Trials of Acupuncture • Blance et al.: Manualization of Occupational Therapy Interventions: Illustrations From the Pressure Ulcer Prevention Research Program

16. What is coding? • Marking that data • Describing the themes – what is going on?

17. Codebook (example)

18. Key Questions in our study How do chaplains assess patients’ spiritual needs? How do chaplains intervene to address these needs? What outcomes do chaplains seek? How can chaplains tell if these outcomes are achieved?

19. Exercise #1: How do you evaluate a spiritual assessment model? This exercise will acquaint you with the building blocks of spiritual assessment models by guiding you through evaluating a model. Integrative Exercise #1: Choose one model and evaluate it using the Spiritual Assessment Evaluation Matrix. Fun fact: If you develop or claim a spiritual assessment model, you can replicate our study using that tool.

21. Coding & Manual Development • Coding - analysts mark passages of data according to a unique “coding scheme” to facilitate later retrieval and analysis. • Coding schemes - reflect the project’s substantive questions and conceptual framework; evolves over time in an iterative fashion. • Coding gave us the foundation for the manual. • It yielded empirically collected and analyzed examples/quotations of the various bullet points of Spiritual AIM assessment, interventions and outcomes.

22. What is coding? • Marking that data • Describing the themes – what is going on?

23. Codebook (example)

24. Sneak Peak at the Manual We are going to give you the opportunity to test drive some parts of the manual during our session today. This will help you: • deepen your knowledge about spiritual assessment • allow you to learn more about Spiritual AIM that you can use in your clinical practice Your participation will also help us strengthen the manual.

25. Exercise #2 – What is assessment and how do you do it? This exercise will allow you to learn more about the art and science of assessment, as described by Spiritual AIM.

26. Exercise #3 This exercise will provide you with the opportunity to practice making assessments. Break up into groups of 3. Use the handout to: 1) Name the patient’s core spiritual need and 2) Provide a rationale for your choice Remember to include language from the Table in the article.

27. Example Quote from M&D patient – “Something was going astray. And so the marital counseling, she [my wife] and I thought well, this is the best we can do to try to analyze or objectify whatever the imbalance was.” P37 Question: Name the patient’s core spiritual need and provide a rationale for your choice (include language from the Table) • Sample answer: The patient’s core spiritual need is Meaning & Direction. The patient indicates that “something” was going “astray” but does not assign blame to self or others (“Patient does not place blame”). The patient’s comment about marital counseling is intellectual. He uses the word “thought” and relies on “analysis” to identify and address the problem (“Patient tends to intellectualize circumstances”). • (From coding scheme: “sees both sides” and “intellectualizes”)

28. Name the patient’s core spiritual need and provide a rationale for your choice 1) “I’ve found that helpful partly because I’m not as bad off as a lot of people in the [support] group. In a way that’s a terrible way to feel, but I think oh, my goodness, I don’t have any problems compared to this person.”

29. Name the patient’s core spiritual need and provide a rationale for your choice 2) “She was just this stranger who comes across kind of harsh, who’s been hurting her father for years and years and years. She just disappears for two, three years at a time and then will call him up when she needs money or something.”

30. Name the patient’s core spiritual need and provide a rationale for your choice 3) “I’m back at the starting point. I’ve trudged out and trudged back – I grew up in the Midwest and your field is hard, it’s been plowed under and it’s going out in those fields during winter and it’s usually been rainy and it’s just pretty bloody mucky. It’s not easy walking and you sort of walk several yards and your boots are full of mud and you go back. So it’s tiring. And that’s how I’ve been feeling, I think, this last year – more so than I had before.”

31. Feedback about Exercises • What did you learn? • Which modalities were most/least helpful? • Didactic presentation • Socrative polling • Breaking up into small groups • Working with patient quotations to practice making interventions • If you were engaging in an in depth training in Spiritual AIM, what would you hope to learn?

32. Study Aims Aim 1. To describe the content and processes of spiritual assessments conducted by chaplains to identify core spiritual needs among patients with advanced cancer. Aim 2. To describe the content and processes of spiritual care interventions developed based on these assessments. Aim 3. In order to calculate effect sizes for future intervention research, to measure changes in spiritual, psychological, and physical symptoms and to assess the value added to outpatient palliative care interdisciplinary teams (IDTs) by certified chaplains. Aim 4. To evaluate the feasibility and tolerability of recruitment, assessment, and intervention research focused on evaluating Spiritual AIM in the outpatient palliative care setting.

33. Project Description Adults with advanced cancer (target n=30, recruited 31) Symptom Management Service (outpatient palliative care service of UCSF HDFCCC) Each participant had three individual sessions with a chaplain; audiotaped and professionally transcribed Pre- and post-intervention booklet of self-report rating scales Exit interview with research coordinator Weekly team meetings (audiotaped, transcribed  auto-ethnography)

34. Study Measures (1) • Symptoms (ESAS) - e.g., fatigue, pain • Spiritual well-being (“I feel at peace”) • Overall quality of life (1 item) • Spirituality (FACIT-Sp-12; 3 subscales: Faith, Meaning, Peace) • “I find comfort in my faith or spiritual beliefs” • “I feel a sense of purpose in my life” • Religious coping (Brief R-COPE; Positive & Negative) • “Sought help from God in letting go of my anger” • “Wondered what I did for God to punish me”

35. Study Measures (2) • Dignity (Patient Dignity Inventory) • “Feeling like I am no longer who I was.” • Cancer-related adjustment (Mini-MAC) • 5 subscales: Fatalism, Fighting Spirit, Helplessness/Hopelessness, Anxious Preoccupation, Avoidance • Alternatively: 2 subscales Adaptive, Maladaptive Coping • State anxiety (STAI-S, “now”) • “I feel at ease”; “I feel nervous” • Depressive symptoms (CES-D, “past 7 days”) • “I felt sad”; “I could not get ‘going’”

37. Core Spiritual Needs

38. Core Spiritual Needs by Age Group p < 0.05

42. Future Research Directions • Evaluate the feasibility and efficacy of manual for teaching and implementing Spiritual AIM • Expand scope of Spiritual AIM research to other patient and caregiver populations • Compare efficacy of Spiritual AIM to other interventions, controls (RCT) • Develop and evaluate method/measure for identifying a patient’s core spiritual need (assessment tool) • Identify “mechanism of action” of Spiritual AIM

43. Thank you!!Please contact us:laura.dunn@stanford.edualkestenbaum@jtsa.edumichelershields@me.com

44. Acknowledgements • With gratitude to the John Templeton Foundation and HealthCare Chaplaincy • UCSF Helen Diller Family Comprehensive Cancer Center • UCSF Symptom Management Service • UCSF Spiritual Care Services • The Jewish Theological Seminary – Center for Pastoral Education • The patients

45. Project Team Michael W. Rabow, MD, FAAHPM - Co-Investigator The Rev. Will Hocker, MSW, MDiv, BCC – Consultant/ Interviewer Jennifer James, MSW, MSSP - Research Coordinator Daniel Dohan, PhD - Consultant (Qualitative Research) Stefana Borovska, BS and Joshua Carroll, BA – Medical Students Laura B. Dunn, MD - Project Director Allison Kestenbaum, BCC, MA, MPA, ACPE Supervisor - Project Chaplain, Lead Investigator The Rev. Michele Shields, D.Min., BCC, ACPE Supervisor – Project Chaplain, Lead Investigator