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.

The example of Prophet Muhammad, upon him be peace, is explicitly commended in the Qur’an as the best pattern for believers to follow. Therefore, the practice and precepts of the Prophet have been a source of legal judgements and general guidance in the affairs of Muslims since the earliest days of Islam, a source which supplements and is second only to the Qur’an. Since health is so important a part of human well-being, it is not surprising that Muslims over the centuries devoted so much effort to recording and reflecting upon what the Prophet taught about maintaining good health, preventing and curing diseases and ailments.

The most widespread book on ‘Prophetic Medicine’ was that written by Ibn Qayim al-Jawziyiah (691-751AH / 1293-1351). But there are scores of manuscripts on the subject in world libraries and museums. After a preliminary study, I found references to some forty different books (some published, most manuscripts, some lost) with the title ‘Prophetic Medicine’. In his 1985 paper on Islamic heritage, S. Abdullah al-Habashi of Yemen mentioned 23 monographs by different authors on plagues and infectious diseases – I could add a further 16 on the same subject. He went on to write a book on infectious diseases as related to Prophetic Medicine, with a Foreword by the late Sheikh al-Azhar. ‘Abd al-Halim Mahmud.

Recently, the number of publications on Prophetic Medicine as a whole or on different areas of it has been growing rapidly. There are many books and articles, referenced with ahadith (sayings) of the Prophet on the curative properties of honey, black seed (Nigella Sativa), senna (Casiacutifolia), henna (Lawsonia Inermis), aloes (Aloe Vera), garlic and onions, olive oil, etc.; on the positive health benefits of breast feeding, and of the Islamic practices of fasting, prayers, ablution, cleaning the teeth and mouth, etc. Doctors in particular have been very active in elucidating the relevant ahadith and their importance to health promotion and disease prevention. Papers are published almost weekly on Islamic teachings related to health concerns, for example on food and drink (prohibition of excess, of pork, blood, and intoxicant drugs like alcohol), on circumcision, on sexuality and marriage (particularly with regard to the spread of sexually transmitted diseases such as AIDS).

There is growing interest, too, reflected in the volume of publications, in spiritual medicine which treats psychological ailments believed to be produced by evil jinn (evil spirits). Die treatment usually includes reciting particular chapters or verses of the Qur’an, certain supplications attributed to the Prophet, and making incantations.

Current issues in medical ethics from an Islamic perspective have also received a great deal of attention in recent times. There are literally hundreds of articles, books and doctoral dissertations on organ transplantation, brain death, new methods of procreation including test-tube babies and surrogacy, abortion, contraception, cloning and genetic engineering.

Traditional Medicine

As lbn KHaldun observes in his famous Muqaddimah, the pre – Islamic Arabs used a sort of folk medicine based on herbs and plants tested by experience and handed down. At the time of Prophet Muhammad, there were surgeons adept at treating wounds, abscesses and other minor operations, and also some renowned physicians like al-Harith ibn Kalada of Ta’if who had travelled to Jundishapur (near Ahwaz in Iran) to gain more knowledge. The Prophet asked his cousin Sa’d ibn Abi Waqqas to consult al-Harith when Sa’d fell ill after the conquest of Makkah in 8AH(630).

Cupping, venesection and cautery were all common pre-Islamic treatments endorsed by the Prophet with some reservation against cautery. Cupping with blood-letting was definitely encouraged by him and there are tens of ahadith related to this procedure. It is interesting to note that cupping and cautery are still widely practised in Arab countries, especially among villagers and Bedouins.

Recently, Dr. Mansoor Suliman of the medicine faculty of King Abdul Aziz University, Jeddah, published a paper on ‘The myth and reality of treatment by cautery’ in Alternative Medicine (1986, 1(3), pp.237-40). He studied 500 patients treated with cautery and modern techniques for different ailments. He found that cautery was useful in treating diarrhoe where 45% of those cauterized showed marked improvement. Cautery was useless for jaundice, haemolytie blood diseases, respiratory diseases, other infectious diseases and cancers, though it was helpful in stopping bleeding. Diathermy (cautery) is also used in modern medicine to treat epistaxis, cervical erosion, to stop bleeding during operations, and to remove warts and other skin tumours. There are also different types of modern heat therapy e.g. infrared and laser therapy.

Cupping and blood-letting were used widely in the past to treat different ailments e.g. hypertension, polycythemia, and even heart failure. Modern medicine rarely, if ever, resorts to such measures.

The pre-Islamic Arabs believed in supernatural forces such as evil spirits, the evil eye and so on, and sought to counter them with spells, amulets, talismans and other animistic practices. The Qur’an (see 72.6) deplored all such rituals of seeking refuge from evil spirits as a pseudo-worship and therefore a sort of polytheism. The Prophet Muhammad scorned superstitious beliefs. Al-Bukhari records his saying: ‘There is no Adwa (i.e. contagion) [except by the will of Allah]; no Safar [the pagan Arabs believed that Safar, the last month in the lunar calendar, can cause malady. Safar could also refer to huge ‘snakes’ that dwell in the abdomen of some people and cause serious disease]; no Ha’ma [i. e, vengeful ghosts of the dead that hover around the living].’ And Tirmidhi records the Prophet saying: ‘Whoever wears an amulet has relapsed into shirk (polytheism). Whoever goes to a fortuneteller or a divine and asks him about anything, his prayers extending for four nights will not be accepted.’ In another hadith, he said: ‘Magic spells, amulets and the like are shirk.’ Polytheism is considered in Islam the worst of sins, the one that will never be pardoned by God until the person repudiates all forms of polytheism and reverts to pure, original monotheism. The Muslim should have faith in God alone, in whose control lie the causes of health and disease, life and death, in fact of all things, small or large.

Diseases and ailments are considered in Islam as a type of tribulation which expiates sin. Those stoics who forbear to complain and endure in dignity are rewarded in this world and on the Day of Judgement. Al-Bukhari, Muslim and Ibn Hanbal record the Prophet’s saying: ‘Never a believer is stricken with discomfort, hardship, illness, grief or even anxiety but that his sins are expiated.’ However, the Prophet also always urged Muslims to seek remedies for their ailments: ‘O servants of God, seek medical treatment, for God has established a remedy for every malady, clear to whoever knows it and unclear to whoever does not know it’ (recorded by Ahmad ibn Hanbal). In another hadith (in al – Bukhari),he said: ‘0 servants of God! seek remedy for He who established the malady has already created its cure and remedy.’

Muslims are thus encouraged by their religion to search for cures and new modalities of treatment, and apply them if they prove successful. Islam exhorts Muslims to keep healthy as health is one of God’s most precious gifts. Islamic teachings which prohibit alcohol, intoxicants, fornication, adultery and consumption of pork, blood or carrion, and which, at the same time, command cleanliness by frequent ablutions and baths with water, frequent daily cleaning of teeth, physical exercise, are all most beneficial to the maintenance of individual and public health.

The teachings of the Prophet Muhammad radically changed the mode of life, beliefs and customs of the pre-Islamic Arabs. The Muslim became a shining pearl in the jahiliyya community, as lie was chaste and clean inside and outside. Islam inspired Muslims to search for knowledge and wisdom. The Prophet said: ‘Search for knowledge and wisdom even as far as in China’, as China was the farthest country known to Arabs.

Once Islam became established as a civilization and empire, the medical sciences and wisdom of different nations were translated into Arabic and then incorporated in the traditional medicine.

Greek medicine, most notably the works of Hippocrates and Galen, received great attention. They were translated mainly during the rule of the ‘Abbasid Caliph al-Ma’mun (late 8th and early 9th century). The four humours were at that time accepted as the basis of medical theory. Both theory and practice flourished and were developed enormously not least in the area of the design and administration of hospitals – by some of the greatest figures In medical history, such as al-Razi (in the West known as Rhazes, d.925), Ibn Sina (Avicenna, d. 1037), at-Zahrawi (Abuleasis, d. 1013), Ibn al-Nafis (d.1288), ‘Ali ibn al-’Abbas al-Majusi (Haly Abbas, d.994) among many others. Within the same inclusive Islamic civilization, there were also many non-Muslims who achieved eminence for their encyclopaedic learning and skill as physicians, the best known being the Jewish philosopher, Musa ibn Maimun (Maimonides), the Christians Bakhtishisha who worked for the Caliph Harun al-Rashid, and Hunayn ibn Ishaq who worked for Caliph al-Mutawakkil and had been the chief translator of Galen, Hippocrates, Plato and others.

The Muslim and non-Muslim physicians, pharmacists, surgeons, opthalmologists etc. wrote huge works in Arabic and added their wisdom, knowledge gained by experience and experimental procedures, to the previous knowledge gained from the ancient Greeks and other peoples.

Although some of the original works are no longer extant, a huge amount of this Islamic medical knowledge contained in books and manuscripts is still accessible in many libraries and museums. Also, many of the original works were translated into Latin and thence into European vernaculars and provided the basis of modern medicine after the intellectual renaissance of Europe: the Latin texts of Arabic originals can still be read.

The Islamic world suffered from internal feuds and wars resulting in its weakness and gradual disintegration. The Mongols and Tartars (under Genghis Khan and Hulagu) dealt crushing blows to Islamic civilization in the eastern part of the empire from Samarkand to Baghdad and beyond towards Egypt. In the western domains of Islam, Christian Spaniards not only rebelled against Muslim overlords, they set about systematically removing Muslims and their civilization front the Iberian peninsula despite eight centuries of mutual tolerance between Muslims, Jews and Christians under Islamic rule: Granada fell in 1492.

The Islamic world became intellectually stale and very little innovative scientific work was produced. Even the great medical works such as those of lbn Sina, al-Zahrawi, lbn al-Nafis etc. were not kept alive except in isolated centres. Exceptionally, in the Indian subcontinent lbn Sina’s al-Qanun (Canon) continued to be the standard text for physicians with additions front ancient Hindu medicine. This style of healing is still active in India and Pakistan and known as Unani medicine, its practitioners being known as hakims rather than doctors.

In the Arabic-speaking world, by contrast, only a few people could read and understand al-Qanun or other great works, the later physicians depended on the Tazkarat Dawud of Dawud al-Antaki, a work quite inferior to the writings of Ibn Sina or al-Mansuri or al-Razi. With further passage of time, many of the traditional healers and physicians were unable to read and understand even Tazkarat Dawud. Many reverted back to animistic practices including the prescription of amulets, charms and talismans which are all prohibited in Islam.

The growing interest over the last two decades in herbal medicine has made it a profitable subject area for publishers. Some of them have begun to publish abridged versions of the works of Ibn Sina. Indeed, there are almost weekly additions to the popular literature on herbal medicine, most of it containing nothing new. However, there are a few physicians (mostly Western-educated) both in Arab countries and else where who have published the results of modern researches in pharmacology and biochemistry. The work of Dr Hassan Shamsi Pasha in this field is a good example. Also, many centres have sprung up in the Arab world for the study of traditional and Islamic medicine which organize conferences and symposia to encourage and enable new research in this field.

Conclusion

A lot of work has been going on to revive both traditional herbal medicine and Prophetic medicine in many Arab and Islamic countries. There is, however, a great need to improve on traditional medicine and integrate it with the national medical system. The majority of physicians and pharmacists, trained in Western medicine, lack even rudimentary knowledge of traditional medicine and are therefore hostile towards it. This negative attitude will not disappear unless the medical curricula in universities include training in traditional and Prophetic medicine. Equally, there is a need to educate herbalists and practitioners of traditional medicine to improve their standards of understanding and their techniques in preparing and prescribing traditional remedies.