Performing a spiritual assessment
Assessing S/R may appear to be complex and risky, but it is required when considering the cultural context of patients.15 Clinicians do not need to change their methodology as long as they remain sensitive to the spiritual and cultural differences of patients. In gauging the extent of a patient’s beliefs, the HOPE questions can help. This mnemonic systematically addresses 4 domains16:
• The sources of hope, strength, comfort, meaning, peace, love, and connection (H)
• The role of organized religion for the patient (O)
• Private spirituality and practices (P)
• The effects on medical care (E)
A more thorough investigation would also consider the S/R history, including family background, religious education, and life changes; the importance of S/R in the patient’s life; positive and negative S/R coping with the illness; explanatory models; and spiritual needs. Domains and examples of open-ended questions are described in the Table.
Mr H, 50-year-old man with schizoaffective disorder, hears voices and feels persecuted. He denies his illness, refuses medication, and relies only on Buddhist practices to cope with his symptoms. However, his S/R coping strategies are ineffective in preventing emotional distress, heteroaggressive behaviors, and social isolation.
Clinical and S/R assessment opened the door for psychotherapy that integrated Mr H’s S/R beliefs and practices. Indeed, he did not know if what he heard were people or demons. This doubt helped lead him to consider his beliefs as hypotheses about reality and to design experiments to test those hypotheses. Unable to find a definitive answer to the meaning of the voices, Mr H finally considered the medical and spiritual explanations as possible. His treatment combined psychiatric care (medication and psychotherapy) with more effective S/R strategies guided by a Buddhist monk in his religious community.