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CHAPTER 25 Faith and Prayer
Prayer indeed is good, but while calling on the gods a man should himself lend a hand. Hippocrates
“You’re being religious when you believe in Jesus or Buddha or any other truly holy being, but wow, you’re being spiritual when you become the loving compassionate, caring being they all inspire you to be.”
by Robert Thurman.
Health care sciences have begun to demonstrate that spirituality, faith, and religious commitment may play a role in promoting health and reducing illness. Nurse clinicians and researchers, as well as others, are becoming more interested in the connection between religious faith and survival. Increasingly, people are beginning to recognize that faith is good medicine. Spirituality is that part of individuals that deals with relationships and values and addresses questions of purpose and meaning in life. Spirituality unites people and is inclusive in nature, not exclusive. It is not loyal to one group, continent, or religion. Although spirituality is not a religion, being involved in a particular religion is a way some people enhance their spirituality. Yet, people can be very spiritual and not religious. Spirituality involves individuals, family, friends, and community. Individual aspects are the development of moral values and beliefs about the meaning and purpose of life and death. The development of spirituality pro- vides a grounding sense of identity and contributes to self-esteem. Spiritual aspects relating to family and friends include the search for meaning through relationships and the feeling of being connected with others and with an external power, often identified as God or a Supreme Being. Community aspects of spirituality can be under- stood as a common humanity and a belief in the fundamental sacredness and unity of all life. It is that which motivates people toward truth and a sense of fairness and justice toward all members of society. Spiritual health is expressed through humor, com- passion, faith, forgiveness, courage, and creativity. Spirituality enables people to develop healthy relationships based on acceptance, respect, and compassion.
Religion can be described in a number of ways. The definition chosen for this text is one developed by Mickley, Carson, and Soeken (1995), three nursing researchers. They believe that religion develops and changes over time and is composed of people’s beliefs, attitudes, and patterns of behavior that relate to the supernatural God, the Divine One, the Great Spirit, Creator, and so forth. Religion usually includes a group of people who hold similar beliefs, have sacred texts, share religious symbols, and participate in shared traditions or rituals. Many people may say they are spiritual but not religious, while most religious people also identify themselves as spiritual (Carson & Koenig, 2008; Young & Koopsen, 2011).
Faith refers to one’s beliefs and expectations about life, oneself, and others. In a religious context, faith refers to a belief in a Supreme Being who listens and responds to people and who cares about their well-being. In a spiritual context, faith is thought of as the power to accept the nature of life as it is and live in the present moment. It is a sense of letting go of the need to control while trusting and waiting for the moment when answers come (Carson & Koenig, 2008). Prayer is most often defined simply as a form of communication and fellowship with the Deity or Creator. The universality of prayer is evidenced in all cultures’ having some form of prayer. The Hindus speak of the thousand names of God, and surely there are a hundred ways to pray. Imagine a circle or wheel with many spokes leading to the center or Supreme Being. Each spoke is a different religion with different prayers, but they all lead to the center. Prayer has been and continues to be used in times of difficulty and illness, even in the most secular societies. Prayer for self and prayer for others are the most frequently used forms of alternative therapies (Young & Koopsen, 2011). A common image of prayer in the United States is something like this: “Prayer is talking aloud to yourself, to a white, male, cosmic parent figure, who prefers to be addressed in English” (Dossey, 1997, p. 10). This cultural view of prayer fails to encompass how prayer is regarded by many other people throughout the world. For some, prayer is more a state of being than of doing; for others, prayer is silence rather than words; for some, prayer is a thought or a desire of the heart; others pray to a female Goddess or a Divine Being who looks like they do. Buddhists do not believe in a personal God as creator and ruler of the world, yet prayers offered to the universe are central to the Buddhist tradition. Prayer may be simply being still and knowing that God is God. Prayer is part of many religious traditions and rituals and may be individual or communal, public or private (Young & Koopsen, 2011). Larry Dossey (1997) provides a broad definition of prayer: “Prayer is communication with the Absolute. This definition is inclusive, not exclusive; it affirms religious tolerance; and it invites people to define for them- selves what ‘communication’ is, and who or what ‘the Absolute’ may be” (p. 11). According to a Sufi saying, prayer is when you talk to God, and meditation is when God talks to you. In this definition, meditation is thought of as passive and receptive, and prayer as active and engaging. The boundaries between meditation and prayer, however, are often blurred.
BACKGROUND
Until approximately two hundred years ago, medicine and religion were so thoroughly united that healers and priests were often the same individuals. The first hospitals were founded in monasteries by physicians who were usually monks. Today, many cultures throughout the world continue to regard their healers as a source for guidance in matters of faith and wellness. In the West, religion and medicine were fused until the end of the Middle Ages in the mid-1400s. Philosophers such as Descartes (1596–1650), Locke (1632–1704), and Hume (1711–1776) promoted the scientific basis of knowledge, believing that truth could be realized only through the examination of empirical data and the rational, scientific method. Centuries later, Western societies continue to experience the consequences of this split between religion and medicine. Western physicians are educated to think primarily in terms of what can be empirically proven in the laboratory. Discussions of spirituality and religion are considered by many physicians to be “off limits,” with such discussion relegated to spiritual or religious leaders. In the past, when arguments arose between religion and medicine, religion usually did not fare well. As nurses such as M. Dossey, Carson, Burkhardt, Nagai-Jacobson, Taylor, Winslow, Treloar, Koerner, Goertz, and Holt-Ashley and physicians such as B. M. Dossey, Matthews, Koenig, and Benson research and write more about the blending of religion and health care, the practice of their professions will evolve to, once again, include the forgotten “faith factor” in health care. In some situations, religion may have a negative impact on people’s lives. Religious participation can lead to more, not fewer, problems when unscrupulous leaders coerce or manipulate others to give up all personal autonomy. Problems also occur when religion fosters excessive guilt or shame or encourages people to avoid dealing with life’s problems. Some religious groups urge their members to avoid all conventional medical care, which can lead to life-threatening situations (Wachholtz & Pearce, 2009).
CONCEPTS
Universality of Faith
Throughout history and around the world, people have called on a Divine Being to sustain them. People are nourished by life-affirming beliefs and phi- losophies. They meditate and say prayers that elicit physiologic calm and a sense of peacefulness, both of which contribute to longer survival. Benson (1997) believes that a genetic blueprint makes believing in the Great Mystery part of people’s nature. Through the process of natural selection, mutating genes retain the impulses of faith, hope, and love, and faith is a natural physio- logic reaction to the threats to mortality that everyone faces. Benson (1997) went on to say that “according to my investigations, it does not matter which God you worship, nor which theology you adopt as your own. Spiritual life, in general, is very healthy” (p. 212).
Spiritual Crises
Serious illness presents a spiritual crisis. As long as people are well, they maintain their autonomy and their ability to function at home, work, or school. Their feelings of self-worth are supported as they find meaning and purpose in their many activities. Once serious illness occurs, some of these things change. Ill people may have to depend on others for personal care, and they may experience other radical lifestyle changes. Body concept changes may threaten self-esteem. In these situations, most people are forced to reevaluate life’s meaning and purpose. Religious people draw heavily on their resources of faith to see them through difficult situations like serious illness.
Positive religious coping involves such beliefs as “God will care for me.” One research study asked 345 patients with advanced cancer which of the two interventions they would prefer:
(1) interventions to extend life even though that would mean more pain or
(2) interventions to relieve pain even though it would mean they would not live as long.
There was a positive correlation between greater use of positive religious coping and wanting more aggressive end-of-life care near the time of death (Phelps et al., 2009).
Twelve Remedies Numerous studies demonstrate that religious involvement promotes health. It appears at this time that a number of religious “ingredients” promote health and well-being. Although some may be found in nonreligious settings, they are more commonly found operating together in religious organizations. Matthews and Clark (1998) termed these “religious remedies,” a listing of which appears in Box 25.1.
Religious Remedies
1. Relaxation response
2. Healthful living
3. Aesthetics of worship
4. Whole-being worship
5. Confession and absolution
6. Support network
7. Shared beliefs
8. Ritual
9. Purpose in life
10. Turning over to a Higher Power
11. Positive expectations
12. Love for self and others
The first remedy is the relaxation response, which can be evoked with meditation and prayer (Matthews & Clark, 1998). The relaxation response buffers stress by clearing the mind and freeing the body from everyday tension. Practiced regularly, the relaxation response decreases heart rate, lowers metabolic rate, decreases respirations, and slows brain waves. In addition, it enhances measures of immunity. Benson (1997) found that when religious beliefs were added to relaxation response activities, worries and fears were significantly reduced compared with the relaxation response alone. Most worship services provide time for silent prayer or meditation and help people take time out from busy schedules. With regular practice of the relaxation response, people report experiencing an increase in spirituality. They often describe the presence of an energy, a power, or God, that is beyond themselves. Those who feel this presence often experience the greatest medical benefits (Benson, 1997).
The second remedy is one of healthful living (Matthews & Clark, 1998). Some religious groups actively promote a healthy lifestyle as part of their doctrine. Religious prescriptions may include dietary moderation, rules about sexual behavior, and regulations regarding hygiene as well as avoidance of tobacco, alcohol, and drugs.
Remedy three is the aesthetics of worship, which taps into a universal appreciation for beauty. Visual symbols of faith are reassuring and calming images. Stained-glass windows, beautiful architecture, and floral arrangements all provide an experience of harmony and balance. Sacred music uses audible beauty to communicate the splendor of God. The smell of incense may evoke a deep sense of peace and quietude (Matthews & Clark, 1998).
The fourth remedy is whole-being worship. Christians who sing familiar hymns, Jews who sing “Torah Ora” when the Torah scroll is presented, and Buddhists who chant their prayers all participate in whole-being worship through music. This combination of physical activity (singing), cognitive activity (reading the words), and spiritual activity (prayer through song) evokes a sense of peace. Movements such as kneeling, standing, bowing heads, folding hands, or even dancing engage people on all levels of being. As people worship with body, mind, and spirit, they undergo a unifying experience that is as good for them as it feels (Matthews & Clark, 1998).
Remedy number five is confession and absolution. Harboring guilty feelings can literally make people sick. In many religions, people are
encouraged to confess their sins and repent, after which they are given assurance of forgiveness and absolution. This process allows individuals to review their mistakes, share their personal pain, learn from their errors, and move on rather than becoming preoccupied with personal shortcomings (Matthews & Clark, 1998).
The sixth remedy is one’s support network those family members and friends who offer practical help, emotional support, and spiritual
encouragement in times of need. People are social beings whose health often deteriorates when they become isolated and lonely. Lack of human companionship has been linked to depression of the immune system and a lowered production of endorphins, the neurotransmitter that produces feeling of well-being. Religious organizations often provide many opportunities for social
interaction, from religious services to sacred study groups; to youth, women’s, and men’s groups; and to community outreach groups. Koenig (2008) describes some of the benefits of group interaction: it offers a sense of partnership, helps with coping, creates a sense of community and safety, encourages a cooperative approach to problem solving, helps change behaviors and thoughts, sup- ports taking control, and encourages personal action.
Remedy seven is shared beliefs. Most people prefer to associate with individuals who share similar beliefs and points of view. Great things can be achieved when groups are unified around common values. Religious traditions are opportunities for people to share common beliefs. Individuals who feel they are part of a group find they are not alone and gain strength from the power of shared beliefs. Participation in regular worship not only helps people feel connected and helps them rise above their differences, but it also is an antidote to the alienation often prevalent in Western society (Matthews & Clark, 1998).
The eighth remedy is ritual. Ceremony and ritual are ways of creating sacred space and time, when normal ways of relating are put aside, and people can listen and pray with an open heart to their Divine Being. Religious ritual is a powerful healing mechanism that has soothing and calming effects. Rituals provide people a link with tradition and give them a sense of security (Matthews & Clark, 1998). As Benson (1997) stated:
There is something very influential about invoking a ritual that you may first have practiced in childhood, about regenerating the neural pathways that were formed in your youthful experience of faith. . . . Even if you experience the ritual from an entirely different perspective of maturity and life history, the words you read, the songs you sing, and the prayers you invoke will soothe you in the same way they did in what was perhaps a simpler time in your life. (p. 177)
The ninth remedy is that of finding a purpose in life (Matthews & Clark, 1998). Victor Frankl (1984) described people’s search for meaning as being the primary motivation in their lives. This search for meaning becomes more intense during periods of illness as people struggle with age- old questions such as, Why me? Why now? Did I do something to deserve this?
Religion and worship attendance provide a framework of meaning, a sense of purpose in life, and a meaningful interpretation for difficult times. People who are dying often seem to arrive at a sense of life’s purpose. As they tell it, the purpose of life is to grow in wisdom and to learn to love bet- ter. They discover that health is not an end but rather a means. In other words, health enables people to serve a purpose in life, but health is not the purpose of life.
Remedy 10 is turning one’s life over to the Great Mystery or God. It is an acknowledgment that no one has total control over her or his life. Religion provides an avenue for asking for guidance, intervention, and strength. Faith in a God who is loving and caring provides comfort for those going through difficult times. Worship services often leave people feeling less burdened and anxious, as well as more peaceful (Matthews & Clark, 1998).
The 11th remedy is that of positive expectations. During a time of illness or distress, religion often provides a sense of hope and the strength to endure that which has happened. The expectancy of help from the Divine Source works in the same way as does the expectancy of help from a medication, procedure, or caregiver. Various holy writings promise health and healing to the faithful, and researchers are beginning to document the effect of this expectation on the outcome of disease (Matthews & Clark, 1998). Gregg Braden (2008) wrote about the role of belief in both creating illness and healing from illness on personal, community, and worldwide levels.
The 12th, and last, remedy is love for self and others. All religions focus on loving God and other people. This love includes helping others— strangers as well as family and friends (Matthews & Clark, 1998). When people love and help others, they often experience better health than those who do not. These 12 religious remedies can be found outside of religious organizations. Frequent religious participation, however, provides many of these remedies in one context.
Research is demonstrating that religious participation is an important factor in the prevention of disease, achievement of well- being, healing from illness, and extension of life span. One mystery that remains, however, is why some people are cured and others are not. One can be very spiritual and still get sick and die. It must be remembered that religious participation and spirituality are no guarantee for physical health. Failure to recognize this basic reality can result in inappropriate self-blame (Matthews & Clark, 1998).
How Prayer Works No one knows how praying for others works. Skeptics say it cannot happen because no accepted scientific theory explains it. In the development of theories, however, empirical facts often lead to the development of an explanatory theory. For example, it was well known that penicillin worked before anyone discovered how it worked. The debate has now shifted from whether prayer works to how prayer works.
Larry Dossey (1993), Joellen Goertz Koerner (2011), and Gregg Braden (2008) have proposed that prayer is “nonlocal,” an idea derived from the field of quantum physics. The word local means that something is present in the here and now; each of us exists here and not somewhere else, and now and not at some other time. The word nonlocal means that something is not confined by place or time. All the major theistic (belief in a personal God as creator) religions agree on the nonlocal nature of God; that He or She is everywhere, is not con- fined by space and location, and exists throughout time. According to the concept of nonlocality, consciousness cannot be localized or confined to one’s brain or body, nor can it be confined to the present moment. Consciousness is basic to the universe, perhaps similar to matter and energy. According to this theory, neither energy nor information travels from one mind to another, because the two minds are not separate but rather interconnected and omniscient. Dossey, Koerner, and Braden have proposed that consciousness-mediated events such as prayer, telepathy, precognition, and clairvoyance may become explainable with continuing developments in quantum physics. Like any other new theory, the nonlocal theory raises more questions than it answers. Evidence exists that prayer works, even though the exact mechanism is unknown at this time.
TREATMENT
Some people seek nurses, doctors, counselors, and therapists who focus on spiritual concerns as well as physical and emotional concerns. This focus is especially helpful for those who are dealing with issues related to meaning and purpose in life.
Alternatively, people may seek the help of religious leaders who include healing practices in their religious practice. Faith healing has not been scientifically proven but remains a popular option for many. Some people go to specific places for healing. The Catholic Church has documented 36 “miracles” at Lourdes, for example. A variety of spiritually focused healing groups are also available. People with addictive disorders benefit from 12-step programs, which rely on both group support and the specific invocation of a Higher Power. Two different types of prayer are directed and nondirected. In directed prayer, the praying person asks for a specific outcome, such as for the cancer to go away or for the baby to be born healthy. In contrast, in nondirected prayer, no specific outcome is asked. The praying person simply asks for the best thing to occur in a given situation. Studies show that both approaches are effective in promoting health. Prayer can also be described according to form.
Colloquial prayer is an informal talk with God, as if one were talking to a good friend. Petitional prayer or intercessory prayer is asking God for things for oneself or others. The focus is on what God can provide.
Intercessory prayer is simply praying for someone else.
Ritual prayer is the use of formal prayers or rituals such as prayers from a prayer book or from the Jewish siddur, or the Catholic practice of saying the rosary.
Meditative prayer, also known as contemplative prayer, is similar to meditation and is a process of focusing the mind on an aspect of God for a period of time.
RESEARCH
It is difficult to compare studies on faith and prayer when researchers do not agree on conceptual models with operational definitions. Different opinions exist on what should be included in the research studies. This is a hurdle that must be overcome before a systematic review is possible. The following is a small sample of studies related to spirituality, religious practice, and prayer:
• A study of intercessory prayer added to normal cancer treatment randomized 999 participants to either an intervention group or a control group. An external group was asked to offer Christian intercessory prayer for those in the study group. The people praying were given nonidentifying details about the recipients. The intervention group showed significantly greater improvements in spiritual, emotional, and functional well-being compared with the control group (Olver & Dutney, 2012).
• A 1-year follow-up was completed on women with depression and anxiety who had undergone 6 weekly 1-hour person-to-person prayer sessions. Evaluations at 1 year showed significantly less depression and anxiety, more optimism, and greater levels of spiritual experience than did the baseline (preprayer) measures (Boelens, Reeves, Replogle, & Koenig, 2012).
• A qualitative study exploring the meaning of spirituality was done with 19 Jordanian Muslim men living with coronary artery disease. The data provided four themes. The subjects said that faith facilitated their acceptance of illness and enhanced their coping strategies; that seeking medical treatment did not conflict with their belief in fate; that spirituality enhanced their inner strength, hope, and acceptance of self-responsibility; and that their faith helped them find meaning and purpose in their lives (Nabolsi & Carson, 2011).
• A study examined changes in religious faith among homeless people enrolled in a supported housing program. A total of 582 clients were separated into three groups based on whether they reported a decrease, an increase, or no change in their religiosity scores at 1-year follow-up. Those who gained faith reported doing more volunteer work, being more engaged in community activities, and having a higher quality of life than those who lost faith. Subjects who reported a large gain in faith had better mental health ratings than those who reported a large loss in faith (Tsai & Rosenheck, 2011). INTEGRATED NURSING PRACTICE Every serious illness is a spiritual crisis because it is a confrontation with one’s own mortality. Every nurse, regardless of personal belief, must recognize that religion or spirituality or both are often an essential part of the lives of those entrusted to her or his care. To avoid these issues is to fail to truly be a nurse healer because the nurse’s task is to address the physical, psychological, and spiritual needs of clients.
As a nurse, you can incorporate faith and prayer issues in your care of clients, regardless of your own personal religious beliefs or worldviews. When you remember that people are spiritual beings, you will be more alert to spiritual concerns. It is important that you promote an atmosphere that accepts and encourages many forms of spiritual expression.
The International Code of Ethics for Nurses, the ANA Code of Ethics, and the Joint Commission on Accreditation of Healthcare Organizations all state that nurses must assess clients’ spiritual needs. Why is it, then, that some nurses do not incorporate faith and prayer into their professional practice? Some nurses are unaware of the research data regarding the faith factor. That situation is beginning to change as schools of nursing develop courses to teach students about the faith health connection. Some nurses have been told specifically that they are not to mix nursing and faith. This recommendation was made out of a concern that nurses might blur the professional–personal boundaries and cause harm to their clients. Some nurses believe they do not have enough time, while others are unfamiliar with spiritual assessment tools. As research continues to be documented, nurses are reexamining the relationship between nursing and faith (Balboni et al., 2011; Dunn, Handley, & Dunkin, 2009). Taylor, Mamier, Bahjri, Anton, and Petersen (2009) examined a self-study program designed to help nurses learn to speak with patients regarding religion and spirituality. They found significant differences in pre- and posttest responses.
Faith and prayer can be explored effectively with people of most age groups. The depth and focus of the conversation will vary based on the cognitive and developmental ability of the individual or family. Health maintenance visits provide an opportunity to explore spiritual beliefs and practices in the context of an overall assessment of lifestyle, risks, and resources. Doors can be opened in a nonthreatening, nonurgent fashion, and the topic can be validated for future discussion. See Chapter 2 for a list of nursing spirituality assessment tools. In the face of major illness, terminal disease, or dying, the discussion of faith and prayer is even more relevant. Clearly though, discussion of this topic should not be restricted to these types of client encounters. Box 25.2 provides an example of a nursing assessment regarding faith and prayer. Respecting people’s beliefs and experiences also means that nurses do not force spiritual issues on clients, push religion on them, or attempt to con- vert them to a particular faith. Prayer should never be imposed on patients or used as a substitute for high-quality nursing care. Nor should prayer be used as an invocation of magic. Doing so violates the trust that is basic to the nurse client relationship. Promoting the benefits of faith and prayer includes respecting clients’ choices about doctrine, denomination, beliefs, and traditions (Carson & Koenig, 2008; Young & Koopsen, 2011).
Of course, some nurses and physicians do incorporate faith and prayer into their care. Dr. Alijani, a faculty member at Georgetown University Medical School and a well-known surgeon, believes that faith plays a significant role in his patient’s well-being. He sees prayer as the literal lifeline between health and spirituality: “Just as my body needs water, carbohydrates, protein, and lipids, my mind needs Allah, and the only way to receive Allah is to pray” (Matthews & Clark, 1998, p. 73).
Health care practitioners are not meant to replace clergy; the roles are distinct. Although many clients may want their spiritual needs addressed by nurses and physicians, others do not, preferring to have these issues addressed by clergy. The practitioner needs to consider, however, where and how the client’s belief enters into the healing process. Nor should health care practitioners be forced against their wishes into participating in clients’ religious practices. In the best of worlds, health care professionals and clergy work closely together to provide meaningful holistic care. Although intercessory prayer is guided by beliefs, experiences, and faith traditions, you can provide clients with some basic guidelines on how to incorporate the benefits of intercessory prayer into their lives (Matthews & Clark, 1998):
• If you are ill, ask specifically for people’s prayers for healing. It may involve clergy, members of a congregation, adding your name to a prayer list, or asking family and friends to pray for you on a regular basis.
• Pray for your own healing.
• Seek out healing services. Many churches and synagogues offer opportunities to participate in a prayer service or healing service.
• Pray persistently. Keep praying regardless of apparent results. Continuing prayer is an expression of faith and hope.
• Pray for others who are suffering
As a nurse, you can also teach yourself and others to take time out to count blessings and say “thanks” for the good things in life. Paying attention to what you already have and what is going right helps alleviate stress, anxiety, and depression. An act of gratitude often restores a sense of balance and perspective. You can make the following suggestions:
• Remember to say “thank you.” Make it a habit whenever someone helps you out, gives you a compliment, or gives you a gift.
• Create rituals of thanks, for example, saying grace before meals or daily prayers. Practice them until they become a habit.
• Every night before you go to bed, make a list of five things for which you are grateful. It will help take the focus off the stresses in your life.
• Take the time to give back. Look for opportunities to help others and recycle the good fortune you have in your life.
• Once a day, strike a grateful pose, for example, kneeling in prayer or standing with your arms extended joyfully to the sky.
• Take 10 minutes each day to be grateful. Go outside into nature, meditate, or pray. Whatever you do, take the time to appreciate all that you have right now. As nurses, you must educate yourselves about the clinical relevance of faith and prayer for your clients. The time has come to give more than lip ser- vice to the spiritual aspects of nursing care. It is important that you let your clients know that you will do everything you can do scientifically but that science and technology have their limitations. Perhaps it is appropriate also to let them know that you may pray for guidance in providing competent and compassionate care.
Faith and Prayer Assessment
Do you consider yourself a spiritual or religious person?
What does your faith mean to you?
Has it changed during your illness?
What is the importance of this faith in your daily life?
Do your beliefs influence the way you think about your health or look at your illness? How important is your religious identification?
Do you belong to an organized group?
Tell me about your religious practices, such as worship, prayer, or meditation. How important is prayer for you now?
What type of prayer would feel comfortable to you now?
What aspects of your faith would you like me to keep in mind as I care for you?
Would you like to discuss religious implications of your care?
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