She has conducted research on the psychology of meditation for over 25 years, including investigations on the effects of meditation on heart rate control, general well-being, spirituality, psoriasis and anxiety disorders. Her other (but related) line of research is investigating the role of spirituality in adjustment to serious medical illness. A recently published randomized intervention study documented benefits of a very brief physician-delivered spirituality intervention offered to cancer patients on quality of life, emotional well-being, and satisfaction with care. Current work is investigating how religious and spiritual resources, from the patient's perspective, may help in adjusting to cancer. Matter&Beyond spoke with her on her research.
Matter&Beyond: Dr. Kristeller, you are doing research on the spirituality of cancer patients. You also developed an intervention technique called OASIS that could benefit the patients who are going through spiritual struggles. What was your starting point for this project?
The OASIS Project stands for Oncology Assisted Spirituality and Intervention Study. In this project, we were exploring how individuals draw on their spiritual and religious resources to deal with having a cancer diagnosis. The other question was how physicians perceived that aspect of their patients' resources and whether they felt it was appropriate to bring it up in the medical environment. First we went out and actually asked physicians what they thought about the role of patients' spirituality in dealing with cancer. We actually got back a very positive response. Substantial proportion of the physicians actually felt that it was helpful to their patients; it was something that was valuable to engage within the medical environment.
M&B: Were they able to address the spiritual dimensions of the patients?
What we found out was that they didn't know how to do that. They were afraid if they brought it up, their patients might get upset with them and they'd be triggering off a reaction perhaps that would require so much time and effort on their part to explore with their patients that it just wasn't practical. So when we found that out from the physicians we decided that we would systematically look at that from that patient's side.
What we heard from patients was that they also wished to bring it up in the medical environment but they felt that the physicians wouldn't want to and that they would bring it up if the physicians asked about it first, and the physicians were saying they'd talk about it if the patients brought it up first. So nobody was bringing it up.
So we moved this onto the next step. What if we taught the physicians a particular approach to bringing up this issue with their patients because we couldn't sit down and teach the patients how to do it. We decided to take a risk and teach physicians how to bring this up to their patients in a very simple way. And we found a few very brave oncologists who were willing to work with us around this and we designed literally a 5-minute patient centered way of introducing this concept.
M&B: How did you design this approach and what were its characteristics?
In a way, we're guided by previous research on how physicians can talk to their patients about difficult topics. This is actually research that I had done previously in relation to other difficult topics like smoking and alcohol use. And what we did in those cases was we taught the physician a very neutral, gentle supportive way to introduce those issues with their patients and then we took a look at how we could use that with introducing the questions about spiritual resources. So a physician may say something like “Many patients draw on their spiritual or religious resources to deal with something like finding out they have cancer. As your physician I would like to hear more about whether that is true for you, it may or may not be, how do you feel about that?” And that very gentle open way of introducing it feels very comfortable to the physicians and it feels very comfortable to patients. And what we find again is most of the patients respond very positively to that.
M&B: What if the answer is no and they are not interested in talking about spirituality?
We also taught physicians that if the response they get back from a patient is something like “oh no, I'm not religious or I don't want to talk about that,” how they should respond to that. They should say something like “really what I'm concerned about is how you're dealing with this and I'd like to hear more about that. Is that ok?” And that shifts it just a little bit. But for about 90% of the patients, they really open up and they are responsive and they start to talk about it and if they are a little hesitant we then teach the physicians how to draw them out a little bit more. Very simply saying, “Tell me more about that. I'd like to hear more about that. Are there any problems you're having around that? Who else can you talk to about this?” It's very important. So being encouraging and thanking them for having the courage to share their feelings with the physician. Asking them a little bit more about how they draw on a sense of inner meaning and peace, because we've identified that in research as one of the key elements for moving to a different level of coping with cancer.
To our surprise this actually worked very, very well. What we found was that patients have appreciated it. Over 50% of them actually told us after the fact that they had found that conversation helpful to them in dealing better. And about a month after this very brief exploration, they actually said that they were feeling less depressed and they were coping better in comparison to patients from the very same physicians who didn't get this, who just go their usual appointment. So we've been continuing to work on this line of research to deepen it and to expand it at this point.
M&B: You also discuss that a small number of patients are coping in a negative way with spirituality. How does it happen?
Our research and research from some other groups, for example Harold Koenig's work at Duke, is systematically coming up with a pattern that shows that individuals who feel angry at God, who feel that they're being punished by having cancer are not doing very well.
Most people feel that at some point. But what I'm talking about is a sort of enduring ongoing struggle around this. And what we find is individuals who are really caught in that struggle in fact are doing very poorly. They are more depressed, and their relationships are not going as well. We don't have any evidence at this point to show that it actually affects the course of their disease. That would be a challenging kind of study to take on and we haven't been able to do that. But certainly it's affecting their inner struggle and their inner well-being. What we encourage physicians to do if they realize that one of their patients is struggling at that level is to encourage the individual to find somebody else to talk to, maybe a Chaplain for example from the medical environment. We really encourage them to look to that and to try to provide those resources and not take that on themselves.
M&B: Maybe it is difficult to estimate how the constant spiritual struggles affect recovery time, but maybe it is easier to estimate how it affects the quality of life.
The individuals caught up in that struggle have a poorer quality of life in general and the research again is pretty consistent in that. And of course it would be naïve to say that you just turn that off. If somebody is struggling in these deep personal issues, they deserve to be recognized and I think we have to assist the individual to find some way to talk to people in their own personal circle of friends, family, religious community about how to deal with them.
M&B: Regarding spiritual intervention, what is the general opinion of the medical community? Is there a growing interest?
I think we are just shedding some light on this. Given how positively the patients respond to even just 5 minutes, I think that there is a growing awareness that there can be a role for this. Within the care of the whole patient, when you shift into the perspective that the spiritual and religious resources people bring to a medical crisis are actually tremendously valuable, and the more they can bring those to the crisis the better they're going to be doing then. I feel that that defines within the medical environment in a different way.
One of the issues that often physicians would bring up with us is “I don't know if I have the same beliefs as my patient does” and “if I don't have the same beliefs maybe it's not appropriate to bring this up.” And one of the things we do in our training is to work with them around that. Saying you know it isn't about the beliefs that you have and whether they match your patients. It's about listening to your patient; it's about hearing the underlying feelings and meaning that the patient has.
M&B: In terms of spiritual response to cancer, do you see people going through a spiritual transformation?
Let me give you a little bit of frame on that. We're funded on the Spiritual Transformation Project. When you think of spiritual transformation you're actually thinking about a real shift in people's beliefs and people's sense of themselves as a religious or spiritual person, their relationship to God, or their sense of relationship to God. We've compared our data to data that's been collected on AIDS patients in Miami. Something like half of the AIDS patients communicated that spiritual transformation happened to them. We had 2 out of 100 cancer patients relate that level of change occurred.
M&B: Fifty percent compared to two percent. That is a huge difference. What is your explanation for that?
A couple of reasons I think, one is that even though cancer is a very frightening disease, it's nowhere near as frightening as AIDS. The prognosis is much better in truth. The other is that the AIDS patients were really people who were struggling with their lives in general. Most of our cancer patients have really quite well-functioning lives. They're already members of religious community. They don't need a transformation. They just need to deepen or engage that religious support more fully or the spiritual side of themselves. So, one of the issues is that transformation isn't necessary, it isn't needed for this. Engagement though is what we're talking about.
M&B: What are the fundamental difficulties in doing research on spirituality?
One of the things that is so challenging about this area is trying to measure, trying to capture very elusive concepts and do it in a way where we can systematically identify them, where we can frankly put some numbers to them. So we can compare individuals, so we can look at the effect, for example, of a stressful life event on something like spirituality. So, one of the other lines of work we've been doing here is to develop the framework for measuring what we call religious and spiritual engagement, and it's very challenging to do that. Within Psychology, there's a long tradition of trying to capture these psychological processes, something like depression or fear. And we have lots of different measuring tools.
M&B: Is there a widely accepted measure of spirituality and religious participation among the healthcare and medical research community?
When we started working in this area, what we discovered were a couple of hundred different scales to measure what people called religious and spiritual involvement. But most of them had been developed in very small groups of individuals, they hadn't been put into a larger theoretical model and we knew there were probably not hundreds of different dimensions but we didn't know whether there were 2 or 4 or 5 or 10 and one of the projects we've done here is to identify using a group of these measures that seem to capture different aspects of spiritual and religious involvement like belief, compassion, like sense of growing within oneself. As in mystical experiences, we've had several of these projects where we've given this set of measures actually over almost a couple of thousand people at this point.
Another dimension is interestingly their willingness to tolerate questions about their beliefs and their spiritual well being. Tolerating those questions seems to be a separate and important element that is linked into doing better, to growing more. Mystical experience is a separate dimension so someone who has a mystical experience may or may not be strong in their belief system. Having that may shift that strength but it's somewhat separate.
We focused on several dimensions. One of the 5 or 6 dimensions is what we call spiritual struggle and that is a separate dimension and again people might be high or low on their strength of their beliefs. If that dimension is strong or high, you do see a lot of distress not only in that part of the person's life but often in other areas of their life.
M&B: People often think that hope, love, and compassion are the indicators of spirituality. But you are giving other dimensions as toleration to questions or having a mystical experience etc. Do you choose them because they are easier to analyze?
That's a very good question. It's very important to include as a part of someone's total spiritual well being their ability to feel compassion towards others; their ability to feel hope. One of the challenges now in this area is to understand those dimensions in and of themselves and I see them more as overlapping with spirituality rather than defining it. And I say that partly because there are many people who feel that they are not religious or spiritual perhaps, but they certainly have the ability to feel hope and they have the ability to be compassionate toward other people in their lives. From the perspective of Psychology, we don't have the answers to this yet but we're applying tools out of Psychology that we've used in other areas of understanding human emotions, personality, and patterns to try to apply them within this arena of understanding something as complex as religion and spirituality.
M&B: You are using tools from both religion and psychology. Are psychologists generally interested in spiritual experiences?
Well. William James who is considered one of the founders of Contemporary Psychology in the 1800s wrote the Varieties of Religious Experience. And he wrote that from a very sophisticated perspective where he said we really do need to look at some of the universal aspects of religious or spiritual experience. At the time he didn't really have the tools to do that but he introduced the discourse around the value of doing that, the value of understanding those very human experiences from a psychological perspective. And it began with a respect for those experiences rather than discounting them. And I think that that is a very important distinction.
In contrast, when some of the thinking that came out of the Psychoanalytic Schools and particularly Freudian theory tended to pathologize those experiences considering them as an anomaly or like a sickness. In fact one of the differences between Freudian thinking and Jungian thinking was the discounting of those experiences as regressive and pathological. It is an aspect of human experience that could tremendously contribute to the best in human nature. And if understood and cultivated in appropriate ways, this could tremendously increase people's ability to engage with their fellow human beings to act ethically.