Vol. #15, No. 1
Welcome to start of our 15th year of publishing Tips and Topics. It is hard to believe there are now 14 years of back issues in the Archives at Tips & Topics.
David Mee-Lee M.D.
- A new “Cultural Formulation Interview” (CFI) among several proposals for further research.
- It is one of several assessment and monitoring tools “for which we determined that the scientific evidence is not yet available to support widespread clinical use” (p. 23f).
- The introduction to the CFI chapter explains, “Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems” (p. 749).
- Patients are assigned a spiritual counselor who is a member of their treatment team, and automatically scheduled for a formal spiritual interview, which typically occurs between the 3rd and 7th day of treatment (depending on availability and readiness, given the complexities of addiction withdrawal).
- The assessment interview is captured in an extended narrative that becomes a part of the patient’s medical record, and is frequently referred to by other members of the treatment team.
- Any action steps or interventions devised in the assessment are incorporated in relevant goal areas in their written treatment plan. Thus, the team and patient are engaged collaboratively in spiritual work as an integrated part of treatment goals.
- He or she provides lectures, small groups, specialty groups (e.g. grief and loss)
- May collaborate in these components with other disciplines.
- Patients with significant areas to explore that were identified in the initial assessment may benefit from an individual follow-up consultation if time and resources allow.
- The spiritual counselor is a partner in the dialogue as the team provides ongoing treatment plan updates and works to author a plan for next level of care.
For each assessment, a variety of tools are woven into a foundational portrait of the recovery process as narrative and journey.
- How can the individual and family move toward greater connectedness?
- What are the barriers that impede this movement?
Story or “narrative” plays an important role in theology, philosophy, and social psychology. One of the central resources in Caron’s spiritual care training program focuses on the work of Arthur Frank, and his text, “The Wounded Storyteller”. It may not be obvious to persons who are unfamiliar with this material, but Frank looks masterfully at the types of stories people use to navigate through illness, and emphasizes the role of an “epic” story style in circumstances of serious illness and personal or family crisis.
- It is not uncommon for people to adopt a “restorative” narrative, one that sees the treatment episode as brief and compartmentalized, a kind of ‘penalty box’ experience after which the ‘player’ returns to the ‘game’ of life.
- At other points, the sense of having a coherent narrative may fall away, leaving a person in a “chaos” or un-utterable phase – a time when no story seems to make sense.
- Ultimately, successful recovery is generally accompanied with a different kind of story, a story that often has classic features of epic narratives or “heroic” journey.
- The traveler embarks upon a quest, entering the ‘sick world’ where a combination of helps and challenges shape movement towards a new, hoped-for outcome.
- Connectedness, a fundamental aspect of spirituality, is central to every phase of the quest journey.
- What spiritual assessment and interventions may consist of
- Some of the models most useful for designing them
- How differing personal and cultural backgrounds are taken into account.
- Phil Rich’s formulation of grieving
- Judith Herman’s stages for trauma recovery
- James Fowler’s identification of five “stages of faith”
- Paul Pruyser’s work on ministerial diagnosis.
- To be mindful of learning styles and cultural and religious frameworks which inform the expectations and struggles of each person and family.
- Howard Gardner’s theory of multiple intelligences and the DSM’s CFI are key resources.
- Each spiritual care clinician has their own identity, formation, and belonging. They are accountable for understanding how this informs their experience of the spiritual care encounter, attending to projection, transference, and counter-transference as these occur.
- Identified spiritual care concerns may be mild, moderate, or severe.
- In certain instances, strengths are identified rather than areas of need or focus.
- While not equating to formal diagnoses of other disciplines, spiritual care findings often correlate with medical and psychological diagnoses identified by other practitioners – and should.
Exploring an individual’s past and current experiences of substance use and withdrawal.” The discipline of spiritual care attends to tremors, eye contact, and ability to focus, and even emotional elements of withdrawal like homesickness. Some patients will invite comment in this area; others merit no observation on Dimension 1. Consider a patient in early withdrawal, whose emotions are characterized by fear and loneliness, perhaps having “burned bridges” and sought treatment multiple times previously. This Dimension 1 lamentation, with aspects of fear and loneliness, constitutes an aspect of their spiritual assessment or “diagnosis.”
Exploring an individual’s health history and current physical condition.” Spiritual care attends to the chart and patient’s presentation, and explores how biomedical conditions contribute to the patient’s self-understanding and negotiation of the challenges of existence. A patient with chronic migraines sees their unrelenting pain not only as a medical affliction, but as a cause for despair. Other examples of particularly significant Dimension 2 presentations might include HIV positive status, an amputation, or a history of cancer.
Exploring an individual’s thoughts, emotions, and mental health issues.” What is the patient’s suffering? How does their suffering affect their connection to self, others, the natural world, and to the transcendent – the “God of their understanding?” Dimension 3 is often the most significant area of findings for spiritual assessment. Shame is a frequent challenge for those with use disorders in Dimension 3, and religion, culture, or spiritual outlook often layer this with a narrative of brokenness that seeks forgiveness or redemption. Grief, trauma, and life meaning or purpose are also central to this Dimension. Multiple keywords may apply, for example faith and trust, grief, or woundedness and healing (trauma). It is helpful not only to identify areas of focus but to provide insight into severity and staging.
Exploring an individual’s readiness and interest in changing.” The discipline of spiritual care explores change in varied terms including fear, developmental processes, ritual theory, religious or spiritual conversion, and 12 step recovery. Appropriate findings here are based on the data described in an interview summary and might include observation of patient’s difficulty with surrender in part or whole, fear in relation to specific issues like care planning, or an inability to conceive of a new paradigm.
Exploring an individual’s unique relationship with relapse or continued use or problems.” The spiritual counselor helps identify obstacles and risk factors for the achievement or maintenance of a sustained recovery. Apathy and self-reliance are frequent concerns. The patient’s cultural or religious context may contribute positively or as caution. This dimension may simply highlight findings in other areas, which present the greatest concern, but simple redundancy should be avoided.
Exploring an individual’s recovery or living situation, and the surrounding people, places, and things.” The discipline of spiritual care may be especially interested in the network of relationships or meaningful attachments and their status. Distrust, alienation, and resentment are frequent keywords. Examples would be marital discord, strained parent-child relations, hostility or risk in friendship and work settings, and the loss or reduction of any sense of “home” and “belonging.”
- Breathing and other mindfulness practices
- Specific readings from classic recovery texts
- Observance of customary faith practices (e.g. Sabbath)
- Grief processing is often aided by the writing of therapeutic letters
- Resentments in recovery are often processed through AA’s “fourth step” columnar exercises.
- While mindfulness exercises in the generic sense appeal to many, others may be interested in the meditation practices of their family of origin faith experience.
- A learning style limitation or preference may suggest music or collage as better methods over reading or letter-writing.
- Any follow-up intention or scheduling should be noted.
- The spiritual counselor is a regular attendee at treatment team meetings, so that progress towards the fulfillment of action plans and larger objectives can be assessed and the treatment plan updated on an ongoing basis.
- The treatment plan is then a ‘living’ document, rather than a snapshot, which may quickly lose relevance.
- “Heart” is what the staff on the United Airlines flight forgot about (or lacked) when Dr. David Dao didn’t want to give up his seat on the plane, concerned about getting back home to see his patients the next day. If you missed the video of his being dragged up the plane aisle: United Airlines and Dr. Dao
- “Heart” is what the flight attendant on American Airlines forgot about when he grabbed the stroller from the distraught and crying mother carrying 15-month-old twins.
- Discharged people for having a flare-up of addiction and drank alcohol or used other drugs.
- Heavily confronted clients with profane language, punishments and re-traumatizing practices to strip a person of their defenses.
- Blacklisted clients – barring them from treatment for months, after three poor outcomes in the program.
- Used physical restraints and leather straps to tie down psychiatric patients to their beds.