Innovations in End-of-Life Care
an international journal of leaders in end-of-life care

Dr. Christina Puchalski is an internist and geriatrician who has recently designed a Spiritual Assessment consisting of four basic questions that physicians or others can integrate into patient interviews. The assessment is remembered by the acronym FICA, for the four domains it touches on: Faith, Importance, Community and Address. This tool has been published elsewhere¹ and can be accessed here by clicking on the hypertext link at the beginning of the paragraph. In this interview conducted by Anna L. Romer, EdD, associate editor of Innovations in End-of-Life Care, Dr. Puchalski explores how she came to develop the spiritual history, how she sees it as distinct from a careful psychosocial history and what she has learned as she has trained physicians across the United States to incorporate it into their medical interviews. [Citation: Puchalski C. Taking a spiritual history allows clinicians to understand patients more fully: An interview with Dr. Christina Puchalski, by AL Romer, Innovations in End-of-Life Care, 1999;1(6), www.edc.org/lastacts].

First, let’s review how you understand spirituality and the context for using the spiritual history or assessment.

I see spirituality as that which allows a person to experience transcendent meaning in life. This is often expressed as a relationship with God, but it can also be about nature, art, music, family or community — whatever beliefs and values give a person a sense of meaning and purpose in life. So, a spiritual history is a beliefs or values history that explicitly opens the door to a conversation about the role of spirituality and religion in the person’s life.

This conversation is extremely important for patients who are gravely ill and for dying patients. Spiritual questions that come up for these patients include: What gives my life meaning? Why is this thing happening to me? How will I survive this loss? What will happen to me when life ends?

We as clinicians don’t know the answers, but I do see it as our role to support and encourage people as they search for their own answers to these questions. Their spiritual beliefs, religious faith and values are resources, and it is also important to see this work as a team effort and to refer patients to chaplains and spiritual directors as needed.

How do spirituality and health care intersect?

Patients learn to cope with and understand their suffering through their spiritual beliefs, or the spiritual dimension of their lives. And it is also through that dimension that I think the compassionate, caring part of the doctor/patient relationship is enacted. We don’t normally think of it that way, but to me, it’s a very spiritual interaction. Physicians are called to a service profession—our job is caring for people—I think that in and of itself, is spiritual work.

What’s happened over the last 30 years is that science has really led medicine, and a lot of the non-technical aspects of medicine have been neglected. The spiritual assessment reclaims or brings us back to those compassionate, caregiving roots of the patient-doctor relationship. I see a spiritual assessment as an opportunity for physicians or nurses or other health care practitioners to start discussing these spiritual issues, which are so important with patients. Doing the spiritual history also helps health care providers understand the role that spirituality plays in the patient-clinician relationship itself.

Can you say a little more about that?

Let me speak specifically about doctors because that’s the group I’m part of, and that I work with the most, and every profession has some differences; however, I believe this applies to all the healthcare professions. For physicians, we are so burdened by time now and stress and an enormous amount of technical knowledge that we have to learn, that many of us come out of medical school not very well trained to communicate with patients about things like end-of-life decisions or non-physical suffering. So we tend to rely on what we’re most comfortable with, which is our technical training. But in fact, patients are very dissatisfied with that sort of patient-doctor relationship because they want doctors to be caring, in addition to being technically skilled. A Gallup survey was done in 1997, which looked at what people said they would want if they were dying. Having warm, caring relationships with their physicians was one of the responses. These same respondents also reported that doctors are lacking in these relationship skills. I think that part of the reason for this gap is that, as physicians, we don’t take that time to get to know the person in the patient. We walk into the office, act very quickly, focus on the things we’re comfortable with, i.e., medications and prescriptions, and then leave.

When you get involved in a discussion with a patient about his or her spirituality, you enter the domain of what gives that person meaning and purpose. When you begin to find out about why the person is suffering, and to listen to that person, you can’t help but notice a change in the quality of the relationship. Physicians who have incorporated the spiritual assessment write back and tell me about it. They say that the nature of the patient-doctor relationship changes— as soon as they bring up these questions, they feel that it establishes a certain level of intimacy in terms of really understanding who that person is at a much deeper level than they are accustomed to. The relationship feels less superficial.

How would you distinguish between a very careful psychosocial approach to an interview and what you’re referring to as a spiritual approach?

I think traditionally in a psychosocial approach, what people ask is, "How are you coping with this illness? What are the stresses in your life? Are you fearful about dying? Do you have any fears of the future? How do you think your family is coping with all this? How are you coping with it?" Those are very important and relevant questions, and some spiritual aspects may emerge from those questions, but these questions are more targeted at psychological or social issues, such as how the person is feeling, financial pressures, or physical well-being.

The spiritual domain includes more than questions about how a person is coping. The questions I’m interested in are: Are there issues of despair? Meaning? Purpose? Belief in a god or an afterlife? People often feel, particularly when they’re dying, that their life has no meaning. And a patient might be able to answer all of those psychosocial questions by saying, "My family helps me cope," or "I have a social worker that works with me to resolve my financial problems." Although a person may be able to answer these questions, still, at a very deep place inside him or herself, the person is despairing. The patient might feel that life has lost its purpose, which might not come out in a psychosocial interview. Certainly belief in God, belief in afterlife, all those kinds of things probably won’t come out in a typical medical interview, and yet we’re seeing from a number of surveys that spiritual issues are very important to a lot of people. And oftentimes they need permission to talk about those kinds of issues. Without some signal from the physician, patients may feel that these topics are not appropriate or welcome.

In a spiritual assessment, my opening question is about the presence of faith or belief (F) so I ask, "Do you consider yourself spiritual or religious?" I find this is a very different opening from "What helps you cope?" I open the interview up to however that person wants to answer it. I don’t have an agenda and that’s very important. Religious people will right away feel an affinity for that question. People who are not religious, but who are spiritual will understand it that way. Occasionally, I’ve had someone say that they’re neither, and then I ask, "What gives your life meaning and purpose?" However, following a question that talks about spiritual or religious beliefs, then the meaning or purpose question takes on a different tone. Then, I take the patient’s lead.

I have a patient who feels that nature is very important, and she said something like, "I’m a naturalist, and looking at trees makes me feel really centered and with purpose." In fact, one of the things she said was that if she were dying, she would want me to refer her to a hospice with a window next to some trees, because that’s what gives her meaning and purpose in life. Now, I don’t think I would have gotten that kind of information out of a strict psychosocial type of interview.

Many of my patients are very religious, so they welcome the opportunity to not be laughed at, but to be able to talk about those issues. Answers vary from "I go to church every day, or every week, and my belief in God is central, it’s really important to me, it’s the way I cope with things. I use prayer every day." Or "I have rituals, or I meditate, or I do yoga." There are a lot of ways people will answer that question.

However, it’s not enough just to know whether a patient is spiritual or religious. In the past, spiritual assessment has been rather simplistic or limited, merely asking patients about their religious denomination. So I developed the second domain where I am striving to get at how a person’s spiritual beliefs— if it’s nature, music, art, or a particular religion—how these beliefs influence that person in the way that that person cares for him or herself. This is the domain I refer to as "I", in the acronym for "Importance", or the influence of those spiritual beliefs on the person’s life. So, with a dying patient, the question would be, "How do these beliefs influence the ways you are coping with dying? How do they influence the ways you are making end-of-life decisions?"

People have intrinsic spiritual beliefs but they may also have extrinsic ways of expressing these beliefs. The third domain, known as "C", refers to the person's community. The community aspect may be what’s important and that may be a formal religious community or some other sort of community. A lot of our religious or spiritual beliefs are expressed intrinsically. Meditation. Prayer. Relationship with God. Nature. Whatever. But there’s also an extrinsic element that has to do with how a faith is practiced in the context of a community. That could be church, temple, or mosque. It might be a group of like-minded friends. It could be lots of alternative spiritual groups that have formed. This question about community has important practical implications because many times those are the people who will help a patient.

For example, I have a patient who is 88 years old and her husband is 93. He’s dying, and she’s not strong enough to lift him and do all of the caregiving. People from her church come almost every day and help them. This kind of community is a phenomenal resource. A fellow in Geriatrics working with me was presenting the case to me, and he told me, "They have no support! They don’t have a social worker coming in. The home health aide comes maybe once a week. How is she managing?" So I said, "Well, have you asked about their spiritual history?" Well, he then did that and he came back and said, "You know, in fact they’re Catholic, and people from their church come in every day. It’s an incredible support!" Now, if he hadn’t asked that question, he wouldn’t have known that. Plus, the belief system is a support, too.

The fourth part of the assessment which I call "A", for application or address, leads to the part where I think, "How is it that I can intervene in this situation or address these issues?" For example, when patients are healthy and come in for a regular physical exam, they may tell me briefly about their belief systems but spiritual issues don’t really seem to be a big issue, then I may not do anything with that content. But if someone comes in and says something that I hear as a warning sign, I might want to refer to a trained chaplain to help sort that out. For example, a person may see God as punitive and the spiritual assessment may allow me to make a link between this attitude and the patient’s not wanting to take medicines, or not taking care of him or herself. Or if someone’s dying, spiritual concerns may be the only thing we talk about. I may bring a patient back the following week just to talk about these issues of life and death and how his or her spiritual beliefs affect any suffering the person may be feeling.

I think the whole issue with end-of-life care is that many people say they do good palliative care, and what they define as good palliative care is being able to give narcotics and manage pain and other symptoms appropriately. While that’s extraordinarily important, that’s not the only aspect of suffering. Again, we tend to focus on the physical suffering–what we see in front of our eyes. But it is crucial to attend to the spiritual dimension of suffering, and it’s distinct from emotional suffering.

Can you give an example to clarify that distinction?

A patient may be depressed, or may feel down in the dumps or may have anxiety, and while that may be related to spiritual suffering, it’s not the whole picture. I have many people who are healthy emotionally, but who suffer tremendously spiritually. Here’s a good example: A patient with several children was dying and the staff thought she was depressed, so they gave her medication for her depression, which only created new side effects. The medication didn’t help alleviate her mood as they described it.

I was called in to consult and went to go talk to her. I didn’t find her depressed at all. She was just feeling that her life had no purpose and that she had nothing more to do in whatever time she had left. Her biggest concern was, "My two-year old is not going to remember me." So we talked about what she could do to help her youngest daughter remember her. One tool is to write a legacy, or a document where the patient articulates the things that are important to her and that she hopes to give to her daughter. What are the kinds of values she wants to impart to her daughter? So, for the next month, that’s what she worked on. She wrote a legacy for her daughter. The first part was devoted to who she felt she was, as a person and as this two-year-old’s mother. "This is what I’ve tried to do, this is what being a mother means to me. These are the central values that are important to me and some of the highlights of my life experiences." She also wrote things like, "These are my hopes for you. These are my dreams for you." In addition, one of the nurses videotaped her. This document and videotape then became a legacy, something her daughter could have as she grew up. And with all of these activities to address her concerns about the meaning of her life, the "depression" lifted right away, without any medication.

There are other examples. I have patients in the nursing home who are not depressed or anxious. Yet there’s something unsettled which you wouldn’t necessarily be able to pick up on. But when asked, "How are you doing?", they’ll say, "You know, I don’t know." When I take a spiritual history, what comes out is, "You know, I really believe in God, I’ve believed in God my whole life, but I’m really wondering if He’s here for me right now. I’m feeling very abandoned by him." But that doesn’t necessarily result in a depression or an anxiety. It’s just part of a spiritual journey, but it nevertheless causes spiritual distress. So with people like that, either I talk to them, or I refer to a chaplain who comes and works with them every day or every other day on those kinds of issues to help them sort it out. There’s no magic fix. You can’t give a pill for that, nor can you tell them, "Oh, sure, God’s there for you. Don’t worry about it." You can’t even give people an answer. However, you can listen and support them, and you can call on people who have particular training in this domain, such as trained chaplains, or spiritual directors, who can help patients work through this issue of God not being there for them and come to some kind of resolution.

How did you get involved in thinking about spiritual issues as a physician?

I was a biochemist at NIH, where I did a lot of basic research, which I found personally unfulfilling. So I started volunteering at a state mental hospital here in Maryland on the weekends. I worked with people with chronic mental illness. I saw a lot of spiritual distress, which was being overlooked. People who were able to find some sort of peace were the ones who were able to tap into that spiritual dimension in their lives. So when I went to medical school, I thought, "Well, obviously, I’m going to learn a lot about this." And I didn’t. I saw nothing on spirituality. Even with something like alcoholism, there was nothing on 12-step programs. Nothing. It was all very biomedical. I was amazed by that absence. In my own life, I also experienced the death of someone close to me, a loss, and so took part in bereavement groups and observed how other people deal with loss. I thought, "Hmm. Nothing on that. Nothing on death and dying." So I started an elective course on spirituality and medicine back then, as a medical student at George Washington University. The other students loved this course. I remember this one classmate of mine, who was Jewish. We rotated through Holy Cross, a Catholic hospital here in the Washington D.C. area, and he mentioned that at first he was very anxious about going to a Catholic hospital. He had this image of nuns and priests walking down the hall and of Catholicism being imposed on him. So he was delighted when, in fact, that wasn’t his experience at all. Instead, he found that it was his favorite hospital because he experienced a sense of hope there. Chaplains go on rounds in the intensive care unit at Holy Cross, and for him that created a real sense of hope and that people were well cared for. So the students responded to this very well.

We have since integrated the content of that course into the required curriculum at GW (George Washington University). For example, when learning to do a medical history, students learn to do a spiritual history as part of the overall history. Now there are about 61 medical schools in the country that include some teaching about spirituality and medicine. Most of them have required courses on spirituality in medicine, based on that same model of integrating it throughout different courses.

What about the issue of time? We continue to hear about how physicians are hard pressed to spend time with patients, and this spiritual history seems to add one more thing to the litany of topics doctors are expected to ask about as they do a medical interview.

There is a lot that’s being thrown at doctors, even more now because in the standard history that we’re teaching, we really want you to do a good social history. There are questions about domestic violence, there’s a sexual history, I mean everything is in there. All of that is important, but you have to use your judgment. So clearly, if someone comes in with chest pains, I’m not going to sit there and ask him or her a spiritual history. If the patient is clutching his or her chest, I’m going to do a quick EKG and figure out what’s going on. The patient may need rapid intervention. On the other hand, if someone comes in for a regular physical, I would suggest addressing all these issues. It can be done in a brief amount of time. The FICA takes about two minutes.

It depends on how much the other person talks.

Exactly! But that’s true of everything. So if you ask a domestic violence question, and someone tells you, "My husband, my wife, beats me up every day. I’ve been in the hospital three times this week." You’re going to stop and say, "This is the issue I have to deal with today." That's what I hate about managed care. Managed care strongly encourages clinicians to follow protocols. I think that puts people in a box. If it’s a sore throat, this is the protocol you follow and that’s it. The patient with a sore throat may actually be depressed and that’s why they’re there. You’re off the protocol. We’re not cars. That’s the same thing that happens with these questions. If someone comes up and he’s depressed, and he tells you he’s suicidal, you’re going to focus in on that. Similarly with the spiritual history, when patients are despairing, and they don’t know how to put their life together, they’re at a loss, they’re confused, I’m going to focus more attention on that than I might on something else.

Spirituality is central to the care of the dying. When people are dying, the spiritual history is essential. I think if we don’t address these issues with someone who comes in with a sore throat, that’s okay. But if we don’t ask about spiritual beliefs with someone who’s dying, I think we’re being really remiss in our duties.

Are you training physicians around the country to do this spiritual assessment? And are you targeting that training toward end-of-life care, since it seems to be such a vast area of need?

Yes. I don’t want to say that I’m only targeting it to end-of-life care because it’s so important across the whole spectrum. My interest is in end-of-life care, so I tend to be in that circle of people. When I do give a presentation to clinicians working in end-of-life care, I present the spiritual history as something appropriate to do across the lifespan. A good analogy is to advance care planning, which we know shouldn’t be done at the very end, either. Many advocates of advance care planning talk about doing advance care planning early on when the person is "healthy." The nature of the conversation changes over time. So, too, for spiritual assessment. It may be for your 25-year old, perfectly healthy person on a routine physical, you ask a couple of questions, you jot it down, maybe it’s an issue, maybe it isn’t. But it’s probably going to be the case if that person is suddenly faced with a diagnosis of being HIV-positive, or having cancer or a chronic illness that those discussions are going to become more frequent.

And these topics are related. I’ve found that when doing advance care planning, even under difficult circumstances with a patient I don’t already know, that if I start by taking a spiritual history, the conversation changes. If a patient can’t talk, I do a spiritual history with the family. Once I’m engaged in that conversation, it is so much easier to go into what gives that person meaning and purpose in life and how the patient might want to die, or under what circumstances. Most people are much more comfortable talking about end-of-life decisions in that context. So we focus a little more on spiritual concerns when I talk with people on end-of-life issues.

Please describe the training you do.

Ideally, the workshop lasts about an hour and a half to two hours, because that just gives people a lot of time to role-play and discuss and work in small groups, but I can do it in 45 minutes as well. I give a brief presentation on the assessment tool. I talk about why we do it; what the key issues are; how you look for what I would call "positive" versus "negative" spirituality. It’s not that any spirituality is negative, but just to kind of give you an idea of what spiritual symptoms might be. For example, the concept of God being a punitive god and how that might be linked to a patient not willing to go on with treatment because of that and ways to deal with that issue.

Then, I give some case examples, and I have people role-play with each other. If we have the longer period of time, we break up into smaller groups and discuss how that experience was and ways that they might integrate it in whatever their particular professions are. I do this with physicians, nurses, social workers, and others. Interdisciplinary groups are my favorite, because this kind of care doesn’t belong in any one person’s domain. So, the best workshops, I’ve had included chaplains, physicians, nurses, social workers, LPNs, and home health care aides. When this happens, people across all of these roles end up interacting together, and particularly in the small-group discussion they see how it might be different in each of their different professions, as well as what they share. Then we come back into a large group and address issues about how the interview went and maybe share in the large group. That usually works pretty well. I try to follow up with people. I give a handout. Most people find that helpful. I’m now working in more detail about a checklist that people can take back with them, because sometimes people just forget, they just don’t know the exact specifics.

What kinds of things would be on the checklist?

Basically it’s the FICA, but I would just outline in a little more detail about what the different belief systems might be when you might want to refer one to a chaplain right away, when not, etc.

Can you give me another example of what you’re calling "negative spirituality?"

Some people have less mature relationships with God—similar to a four-year-old’s relationship with a parent. What I mean here, is that they have a very concrete and quid pro quo relationship. "If I pray, God will cure me." If that doesn’t happen, then their faith is challenged and they can feel abandoned and despairing. I would suggest that spiritual support might allow a person to develop a more mature faith.

It sounds like your own spirituality has been central, even though you haven’t explicitly said that, to your being in this place and doing this work. Do you address the participants’ spirituality in your workshops, in terms of what their values are and what gives their life purpose?

Exactly. That’s what happens in the small group when people pair up to do a spiritual assessment. They come to recognize their own spirituality. I have some questions targeted to that experience in the small group exercise. But one of the things several people often say is that you can’t address a patient’s spirituality until you address your own. And I believe that. I don’t think it’s a "prerequisite," because I think people are addressing it unconsciously whether they know it or not. But I think it is important to be in touch with our own spirituality. It doesn’t have to be formal, but there needs to be an awareness. There’s actually been a lot done on this. Dr. Daniel Sulmasy, whom you may know, has written a book on spirituality and the health care provider ².

Sulmasy talks about how we use our own spiritual beliefs to care for our patients, and to cope with the stress of medicine. It’s very difficult when your patients die. We talk about the family experiencing a loss, but we experience a loss, too. How do we as doctors, particularly doctors that work with chronically ill and dying patients, understand this? How do we avoid getting burned out? Dr. Rachel Naomi Remen is coming out with a book on the call to service. She spoke at one of my conferences, and observed that in California where the managed care rates are the highest in the country, the physician suicide rates are also the highest, as well as the physician dropout rates for medicine. One of the things we have to reclaim is our own spiritual roots, as a profession. The spiritual roots of the calling to be a physician. It’s not just a job. We’re coming back to the beginning of the conversation where I said that bringing spirituality into the history changes the patient-doctor relationship. Once a physician starts engaging in these conversations with patients, he or she immediately becomes aware of that aspect inside him or herself, and, I think, becomes a more open and compassionate doctor as a result. I don’t have data for that, but I can tell you from what patients and physicians have told me. Physicians become more open and more compassionate. Patients also become more open and trusting. Often, opening up this conversation about purpose and meaning touches that part of the doctor that made him or her want to be a physician in the first place. I see being a physician as a spiritual calling. We put our patients’ needs above our own, that’s one of the first things. We give of ourselves, we’re available. We hold someone’s hand or we walk through that journey with them, and unfortunately, the systems of health care right now are mitigating against that. But I think the profession really wants to recapture a lot of that domain. This is one of the reasons the spiritual assessment is so popular right now.

So it doesn’t sound as though you’ve met much resistance from physicians to this training. Do you think that’s because you’re preaching to the converted?

Resistance is an interesting word. There is some resistance, and the resistance is when people have a pre-conceived notion that this is a Christian, right-wing kind of endeavor, which it isn’t. When clinicians think that the spiritual assessment is going to be a platform for evangelizing doctors, to proselytize, then I sense resistance. Once I get beyond that, and they see that I’m not talking about a specific belief system, I think the resistance falls. Clearly the fact that there’s some data now to suggest that spirituality is helpful, as well as the fact that there are so many courses, makes a big difference. Right now many medical schools offer courses on spirituality or faith and medicine^3,4. The Association of American Medical Colleges (AAMC) co-sponsors a conference with the National Institute for Healthcare Research on spirituality and medicine every year called Spirituality, Culture, and End-of-Life Care that I have co-chaired. Having the AAMC support work in this area gives it more credibility, too. I think the most important part is that, as a profession, we are beginning to recognize that the patient-centered approach is vital. Attending to patients’ meanings and life purposes fits into the patient-centered model of care.

Among physicians, do you see a trend as to particular disciplines finding this work appealing? Who attends your workshops or these types of conferences?

Oncologists, primary care doctors, those in family practice, internal medicine, geriatrics, and pediatrics are the most interested. Some orthopedic surgeons, plastic surgeons, and quite a number of neurosurgeons also have participated in workshops. It varies, but I don’t find a huge percentage of the more technical and more specialized disciplines at the talks. Palliative care doctors and pulmonary specialists and others who deal with a lot of terminal illness are especially drawn to this work.

Do you have any idea how many people you’ve trained so far?

I’ve directly trained roughly 4,000 people to do the spiritual history. It is a train-the–trainer model as these people then take the tool back to their settings and they may train others. In addition, many of the courses at medical schools are using the spiritual history (FICA) tool, so it's hard to make an exact estimate.

Are you evaluating your efforts in any way?

We are now. I’m doing a study where I’m looking at whether the FICA assessment itself makes differences in the things people say it does, like the patient-doctor relationship and some patient outcomes. I’m looking at depression as well as a spirituality index.

How are you measuring these outcomes?

I have different instruments for each of those. I have a patient satisfaction instrument; a depression scale, the Brief Depression Inventory, and the Spirituality Index is a 12-item part of FACT/SP, it’s a subscale of the FACT quality of life measurement scale. And we’re using a five-item religiosity scale. We’re just beginning these studies, though.

Are you going to be doing any interviewing? If you’re talking about meaning it would seem that in-depth interviews would be a good way to assess patients’ or physicians’ understandings of the quality of the patient-doctor relationship.

Absolutely. I’m changing the study a little bit because I found that these instruments weren’t sufficient to measure what I’m interested in. So, we are going to do some focus groups. People want to share stories much more than they want to give a specific answer to a forced choice question.

What kind of feedback have you gotten about the usefulness or the effects of this training?

Some people say that they’ve been addressing spiritual issues all along, but that this simple set of questions has made it easier. Part of the problem is that people don’t know what’s spiritual and what isn’t. What the FICA does, albeit it’s a little simplified, is to clarify the topic. I’ve heard people say, "This makes it approachable. This makes sense."

At the American Academy of Hospice and Palliative Medicine meeting in Utah this past summer, I was particularly moved because the people shared their own personal experience. When reporting on doing the spiritual history in pairs for example, someone said, "When I did the spiritual history, I found myself remembering when my mother died and my feelings about her death resurfaced." Someone else said, "I got in touch with my spirituality today, I didn’t realize I had such strong spiritual beliefs." Another person said, "This is great. I’m definitely going to try this with my patients. It certainly isn’t time-consuming." Just last week I gave a presentation, and someone said at the very beginning, "This is fine, but I bet it’s going to be too long to do." And afterwards, he said, "You mentioned you could do it in a short amount of time, and I was really surprised, but when I did it here, I can see that I could do it in two minutes. I could raise these topics in a couple minutes, and then obviously, just like anything else, if there are issues, you deal with it."

This tool is geared to a time-constrained setting. I wanted to create something doctors or others could use at the beginning of the exam, something that wouldn’t be so constrained that patients could really lead in to any area that was important to them. I see the spiritual assessment as opening up the conversation and making it permissible for patients and health care providers to include this domain in the medical interview. That really was the focus behind this. There are a lot of spiritual assessment tools out there, particularly that chaplains use, that are very in-depth, but they take 40 minutes sometimes, or an hour, and there are some psychosocial instruments that may include some spiritual dimensions, but those take a long time, too. The FICA tool serves a different purpose.

Have you gotten any feedback from psychiatrists or psychologists in terms of how they feel this dovetails with what they do?

Actually, a lot of psychiatrists are involved in this themselves. At the National Institute for Health Care Research, we give awards to psychiatry residency training programs for developing spirituality in medicine curricula. These programs have felt that it’s very useful. I’ve also spoken at the American Psychiatric Association (APA) several times, and each year they keep accepting the workshop. In fact, when I first presented at the APA, I had some trepidation, because I thought, "They’re doing this already. This is going to be oversimplified for them." But in fact, it wasn’t, and they found this short tool quite useful because it’s not that easy to bring spiritual beliefs up in that context. Some psychiatrists have the luxury of time to go into these things in a lot greater depth, so they might use this to open up the conversation, and then they have other kinds of things they use to address spiritual beliefs in more detail, related to psychodynamic issues.

Do you think this tool would be applicable internationally or cross-culturally?

Yes, because the principles are general. You don’t have to use the exact words in the assessment tool. The first question is an open-ended question, asking the person if they consider themselves spiritual or religious. And respect for the patient’s belief system is integral to doing a spiritual history. You don’t impose your own belief or culture on it. The patient is really educating you.

Here is a twist on your question: Some health care providers have modified the FICA spiritual assessment tool to do a cultural assessment. So instead of the first question being, "What is your faith or belief or Do you consider yourself spiritual or religious?" they have transformed it to, "What’s your cultural background? Tell me about it." The second question then becomes "How important is it? How does it influence you?" So the tool seems quite flexible and adaptable to other domains such as cultural identity.

On the other hand, if someone were to say something like, "Do you have a specific religion? How many times do you go to church?", that would be a misreading of my tool. Those kinds of questions could lead the clinician to miss out a wide range of beliefs. That’s why I specifically kept the spiritual assessment rather open-ended.

It also sounds as though your spiritual history tool can address people who have concerns about the meaning and purpose of their lives, but wouldn’t necessarily label those concerns as "spiritual" themselves.

Exactly.

Do you have any examples of international implementation of your work?

Just last week I gave the presentation at the APA meeting in Toronto, and there were some Canadians as well as Europeans there. I’ve also trained a few people from South America — a couple of people in Brazil, and one person in Chile.

What are sort of the lessons you’ve learned so far? Where are you going with this?

One thing I’d also like to get involved in is defining spirituality better. What does spiritual care mean? Talking to practitioners about what they mean by spiritual care. What are the different types of spiritual care that one can offer? Right now off the top of my head I can list a few things: listening would be one; being present to the person; allowing the time and space for ritual, guided imagery, prayer, meditation and including referral to chaplains as an acceptable part of care.

I think we need to assess what we’re doing. In addition to looking at patient outcomes, I'm starting to do follow-up surveys with people who have attended my conference. I think we need to get a little bit more analytical, even though I resist being analytical about spirituality because I think some things just can’t be measured. I really do. Having been a researcher in the past I think that there are some aspects of the spiritual interaction between the physician and the patient that maybe cannot be measured. You can measure denomination; you can measure church/temple/mosque attendance, but certainly the intensity of a person’s own spirituality, I think, is very difficult to measure. I think that’s one of the things people are having trouble with.

Can you say anything more about your own spirituality, which you clearly bring to this, but which you haven’t articulated up to this point?

Well, I think I have been very fortunate to have very spiritual parents, who themselves are from Europe and both of them experienced World War II in very powerful ways including a lot of losses. I grew up with people who have used their own spiritual beliefs to help them cope with difficult things and to find meaning in life. Although they have a religion (they are Catholic), it wasn’t really the focus on the religion ever, it was really a focus on a much broader concept. There’s a real focus, at least my upbringing was on broader principles. I was never raised with "There’s only one God and the Catholic one is the right one." Never. My parents have given me great role modeling on the role of spirituality and have allowed me to search extensively. I was going to convert to Judaism, so I explored that for a while. My dad and I went to Hindu temples together; we explored that faith. You know, I learned Eastern meditation by myself and with him, so I’ve done lots of different things. I was involved in a Tibetan Buddhist monastery throughout my 20’s, so I’ve explored many different religious and spiritual beliefs and practices, and have throughout the course of my life been with people of many different beliefs. Some are religious, some are not, and I’ve just always been very interested in spirituality. So based on those experiences, as well as several major deaths of significant people in my life — all of these experiences are part of the background of my interest in integrating a spiritual history into the medical interview.

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