In all traditions, medicine is seen as a gift of the Divine or of a Divinity. The oath of Hippocrates already attests this. Medicine calls for a profound transformation of the sick person, anactual conversion, that is, the healing of the body. When thistakes place, it is in practice the consequence of the healing of the soul obtained through purification, a catharsis that may bemore or less long.In this therapeutic scenario the reestablishment of a spiritual relationship with the divine brings one back to normality, that is to health.

[2]Therefore, health and illness always referred to a precise vision of man: it is evident that the perspective of spirituality was an integral part of a person considered in his totality.

As an evolution took place over the centuries, even though at times in conflicting tendencies, this vision has always been present: in fact, in the Western tradition, medicine and religion have always been, even if more or less, strictlyrelated.

As the historical process of secularization began, the healer became less and less an expert in the salvation of the soul and more and more an expert in the health of the body, a dispenser or mediator of health that is considered less and less a gift of God and ever more a gift of science.

Alongside this mechanistic evolution of medicine, however, authoritative voices of disagreement have not been lacking in every age. For example, Sir William Osler and Richard Clarke Cabot, two famous doctors who contributed to the development of scientific medicine between the eighteenth and nineteenth centuries, strongly supported the importance of the patient and the consideration of spirituality in the field of care.

Cabot observed that he has not spent a week in a clinic as a medical practitioner without having been consulted on one or more problems and religious issues; not for intellectual speculation, but rather as questions of human suffering.[3]Therefore,for Cabot, it is important for a doctor to understand religious issues, since religion is important to a doctor's patient.

It is undeniable, however, that the rapid progress of medicine ended up in focusing its attention on the biophysical aspects, reaching a biomedical model, which identifies disease with respect to precise biological parameters, classifiable by signs and symptoms and analysable according to the rigorous canons of Evidence Based Medicine (EBM). A reductionist model though, because the psychological, social, and spiritual dimensions are not considered, since they are regarded as being outside biomedical control.

However, other approaches and clinical action models are now emerging, such as Narrative Medicine, Patient-Centred Medicine and others.Although they have various differentiations, they all call for the need to combine the doctor’s perspective with that of the patient’s values, experience, family and social group of reference.The narration of the disease is not just the description of a pathological process, but is an experience of a specific human being in a particular situation.[4]

It could also be noted that there is a growing interest in spirituality, as evidenced by doctors and health professionals themselves; interests that are similar tothe ones generally present in society.

In an article published in «Lancet» in 1997, it was stated that "spirituality is the forgotten factor in medicine andit is hoped, from various parts, that it would be included in the curriculum of studies of biomedical schools".[5] In these recent decades, there have been attempts to scientifically demonstrate the influence of spirituality on various pathologies. As early as 1987 two reviews presented a large picture taken from two hundred empirical studies published in the medical literature on the effects of spirituality on health,[6]^,[7] and on morbidity and mortality.

A recent systematic review based on a quantitative research of publications in peer-reviewed journals between the years 1872 and 2010, in order to present the quantitative and multiplicity of data concerning the relationship between spirituality and medicine, has subdivided the researches into 4 main areas: health physics, mental health, lifestyles, and clinical implications.[8]Likewise, these studies highlight specific contexts wherein these dimensions have had a particularly significant impact: the serious pathologies and the terminal phase.[9]For example, a study in the field of oncology emphasizes the importance of understanding spiritual care within the multidisciplinary team, resulting in the reduction of the risk of aggressive therapies, besides the improvement ofquality life.[10]

Other evidences reported by the studies are as follows:[11]

• Spirituality often gives a sense of well-being, improves quality of life, increases survival,[12]^,[13] provides psychosocial support.^[14],[15]
• Spiritual convictions can also have an influence on the decision-making process.^[16]
• Patients wish to talk to their physicians about spiritual needs and that spirituality be included also in care plans.^,[17],[18]

Limitations of the study

It is not easy to define the complexity and the different conceptual facets of religiosity and spirituality, just as it is not easy to reach a definition that is acceptable to all researchers. This lack of consensus makes it difficult to compare the results of the various studies.[19]

Until recently, religion and spirituality have always been considered as one and the same reality. With the advent of the twentieth century there has been a gradual distinction between religiosity and spirituality. It is claimed that spirituality includes religiosity, although they do not coincide.At the same time, spirituality may not necessarily be connected with a particular religious faith.The spiritual dimension can be delineated as the need for meaning, purpose, and realization that characterizes human life, beliefs, and faith.

Is it possible to "measure" the level of religiosity and/or spirituality? With whattools?Could the same results in terms of biological parameters, be actually dependent on other associated variables (changes in lifestyle, environment, etc.)?

For these reasons, we generally prefer to refer to the two terms considered together: there are numerous studies that highlight positive correlations between religiosity/spirituality and health.

The welfare implications

While fully agreeing that spiritual care must be part of the care process, one might ask: who should practice it and how should it be implemented?

A critical issue generally present in all care environments should be taken into consideration, that is, the scarcity of time to dedicate to each patient.How then could we translate what has been said so far in the daily assistance?

Many health professionals with a strong spiritual need are trying to "translate" this aspect of their personal life into professional work; perhaps, there may be some tested "strategies" that could be helpful.I refer to the spirituality of Chiara Lubich, whose purpose is universal brotherhood. This spiritualityentailsthat each one contributesto its fulfilment by accomplishing it in the relationship with the people he or she meets.

• Make assistance personalized

To make care personalized requires that each patient be treated as unique and should be made to feel so. One way is to consider the person in front of you as if he or she is the only person you are going to meet during the day. That is, without thinking about the previous patient or the next one waiting for you.To live the present moment free from haste and conditionings that could obscure decisions to be made.

A further step is to consider the patient as oneself: a significant reference for Christians is "love your neighbour as yourself", but the same imperative is required in other traditions as well.[20]For example, Gandhi said: "You and I are but one, I cannot hurt you without hurting me."

Such a consideration towards the patient implies then that I cannot make preferences or distinctions between collaborative and hypercritical patients, between those who have interesting pathologies and those who have trivial ones, which give poor satisfaction; I must begin from the assumption that all patients have the same right to my attention.

• Take the initiative in one’s relationship with the patient

This affirmation might seem obvious: it is generally the doctor or the operator who takes the first step towards the patient, but this is not always the case.It is difficult to approach those who address complaints, reproaches and the like, and it is even more difficult to go towards that person the next time around. Yet, the operator cannot expect the patient to be the first one to behave desirably, and to take into consideration the fatigue and stress of care work.It is up to us, the operator, to take the initiative in a relationship that would make the patient aware of our interest, esteem, trust, and sincere desire to help.

Such an attitude of the operator would facilitate a similar attitude in the patient for which reciprocity, a harmony of intent, "a therapeutic alliance" arises.

• “Make yourself one with the other person”

If all patients are deserving of the same attention, it is also true that each patient is different from the other. Therefore, it is necessary to try to understand the health situation and emotional state of the person, in order to establish an adequate relationship and an effective communication. In recent years, the term empathy has been used a lot: we have been talking more and more often about empathic relationships, "person-oriented" operators, etc. Sometimes there is the risk to trivialize or empty this term,and even to abuse it by limiting oneself to a friendly face with the patient or attitudes of camaraderie.

An effective expression could be 'make yourself one with the other person', which gives the sense of entering as deeply as possible into the soul of the other. That is, trying to get into his situation, putting yourself in his shoes, in his skin by truly understanding his problems and his needs. It means, taking full charge of his burdens and shouldering his needs, as well as his sufferings.[21]

• Listening

For this reason, it is necessary first of all to exercise the ability to listen, a capacity that goes beyond simply hearing.In fact, if hearing is carried out and exhausted at the physiological level of the auditory function, it may also be performed without or against the intention or will of the person. However, to listen means to perceive not only words, but also thoughts, mood, personal and more hidden meaning of the message that is transmitted to us.

In order to listen, one must be detached from one's own interests, from one's own thought and life patterns, in order to gradually and respectfully enter into the world of the other person.

The fertile ground on which a good listening capacity can grow is an attitude that we often find difficult to implement, even if it is an indispensable condition for listening, that is, setting judgment aside. This kind of attitude is a question ofrefraining from appraisals of approvals or disapprovals, and of making hasty conclusions. It means,therefore, the unconditional acceptance of the other person.

In addition to the silence of the listener, there must also be space for the patient's silence.Sometimes, through his or her silence, he or she wants to tell us that he/she needs to reflect, or intends to warn us that he/she feels stuck because of something he/she has perceived in us or in the environment. Sometimes, it may be an invitation for us to give them a hand, or to askthem a question.

The role of spirituality in the care team

Spirituality also affects the health operators’ person and the relationships among them.Attitudes towards patients must also be experienced towards colleagues. Today’s training process is still aimed at a more "autonomous" development of the profession. As a consequence, in various places of assistance, what is often more evident is the individualism, the esprit de corps or group spirit, the defense of one's role, the objective of the career, even at the expense of one’s colleagues.

On the other hand, team work cannot be improvised; it is not enough to find oneself interacting in the same work environment to create a team. Rather, it is necessary that the different operators actively pursue it.

In addition, the team should not be read only through the patient's perspective. Indeed, it should be read first of all within the operators' perspective, since it is the first place where one elaborates the psychological and spiritual burdens that assistive work may entail.The possibility of sharing one’s emotional involvement in facing a particularly painful situation, of comparing a difficult decision, or of asking for an opinion, is of fundamental help, moreso, it turns out to be "therapeutic" for the operator’s person itself.

In order for a multidisciplinary group to be effective, all members must accept the fact that there is no one who has all the answers to all the questions. Everyone, in one way or the other, is dependent on the culture and competence of others.Therefore, it is necessary to put oneself in an attitude of learning so as to discover what contribution, what enrichment could come from those who work with us.

The care environment will then be truly "therapeutic": for the patient, who would breathe in anatmosphere of serenity, attention, listening, and care in the most global sense of the term. On the other hand, the operators themselves would feel appreciated and valued for their work. While, those who are in the directional positionwould feel less the weight of responsibilities and decisions would be shared and participated.

This "climate", besides improving the doctor-patient relationship, would also contribute to increasing the therapeutic impact of interventions.

Conclusion

In this perspective, every healthcare professional can and must pay attention to spiritual care. It can be implemented if one would keep in mind, besides the necessary scientific competence, the true meaning of one’s profession and the meaning of the illness for the patient and hisor her family.

If it is important to include spirituality in the formation of health professionals, the next step would be to put it into practice, that is, to "translate" spirituality into concrete gestures in everyday care.

In this way, real reciprocity is achieved in which patients and operators can feel "healed" or restored" in care relationships, in sharing moments of suspensions, of pains, and of new hopes, which help to refocus the essential aspects, not only of the profession, but also of the authentic meaning of our life.

Flavia Caretta [1]

[1] Centro di Ricerca per la Promozione e lo Sviluppo dell’Assistenza Geriatrica, Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia “Agostino Gemelli”, Roma

[2] Andrès G., La Medicina Tradizionale, Mediterranee, Roma 1997 

[3]Cabot R.C., Training and rewards of the physician, J.B.Lippincott, Philadelphia 1918

[4]Weizsäcker von V.,Filosofia della medicina. Guerini e Associati, Milano 1996, p. 103

[5]Firshein J., Spirituality in medicine gains support in the USA. «Lancet» 1997;349:1300.

[6]Levin J.S., Schiller P.L., Is there a religious factor in health?Journal Religion Health 1987;26(1):9-36

[7]Jarvis G.K., Northcutt H.C., Religion and differences in morbidity and mortality. Soc Sci Med. 1987;25:813–24

[8]Koenig H.G., Religion, Spirituality, and Health: The Research and Clinical Implications. International Scholarly 10Research Network ISRN Psychiatry). 2012, Dec 16;2012:278730. doi: 10.5402/2012/278730

[9]Candy B, Jones L, VaragunamM, Speck P, Tookman A, King M., Spiritual and religious interventions for well-being of adults in the terminal phase of disease. The Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD007544.DOI: 10.1002/14651858.CD007544.pub2.

[10]Balboni T.A. et al., Provision of Spiritual Care to Patients With Advanced Cancer: Associations With Medical Care and Quality of Life Near Death. Journal of Clinical Oncology 2010;28(3):445-452

[11]Puchalski C.M., Post S.G, Sloan R.P., Physicians and Patients’ Spirituality. VirtualMentor.American Medical Association. JournalofEthics. 2009;11(10): 804-815

[12]Sawatzky R., Ratner P.A., Chiu L., A meta-analysis of the relationship between spirituality and quality of life. Social Indicators Research 2005;72:153-188.

[13]Chida Y, Steptoe A, Powell L.H., Religiosity/spirituality and mortality. A systematic quantitative review. Psychotherapy and Psychosomatics 2009;78:81-90.

[14]Cohen SR, Mount BM, Tomas JJ, Mount LF. Existential well-being is an important determinant of quality of life. Evidence from the McGill Quality of Life Questionnaire. Cancer. 1996;77(3):576-586.

[15]Burgener SC. Predicting quality of life in caregivers of Alzheimer’s patients: the role of support from and involvement with the religious community. Journal of Pastoral Care. 1999;53(4):433-446.

[16]Silvestri GA, Knittig S, Zoller JS, Nietert PJ. Importance of faith on medical decisions regarding cancer care.Journal of Clinical Oncology 2003;21(7):1379-1382.

[17]Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill?Archives of Internal Medicine. 1999;159(15):1803-1806.

[18]McCord G, Gilchrist VJ, Grossman SD, et al. Discussing spirituality with patients: a rational and ethical approach. Annals of Family Medicine 2004;2(4):356-361.

[19]Lucchetti G, Lucchetti A.L.G., Vallada H.P., Measuring spirituality and religiosity in clinical research: a systematic review of instruments (available in the Portuguese language). Sao Paulo Medical Journal 2013;131: 112–122. 

[20]Lubich C. L’arte di amare. Città Nuova, Roma 2005

[21] Cfr. AA.VV., Per una sanità di comunione. Il carisma dell’unità e la medicina, Associazione Culturale Medicina Dialogo Comunione, Roma 2004, p. 42