Athletic trainers and other sports medicine professionals may become focused solely on the physical health and well-being of athletes, failing to view them as “whole” individuals with a spiritual aspect. However, for complete healing to occur, and to assist with injury and illness prevention, health care professionals should attempt to support the entire person rather than segmenting individuals into the physical and then everything else. According to Ledger,1 “The patient has a right to receive holistic care, which includes cultural, religious and/or spiritual care.” Ledger1(p220) contended that health care professionals “have a duty to recognize and respect the diversity of patients’ values, customs and beliefs, and provide appropriate care.” In other words, the mind, the body, and the spirit are inseparable, and what affects one, affects all.
In general, spirituality refers to an awareness of one’s inner self and a sense of connectedness or relatedness to a higher being or to something greater than oneself.2 In this sense, spirituality does not refer to religious practices, specific doctrines, or denominations but rather refers to the broader sense of its inclusion as part of the physical, emotional, intellectual, social, and spiritual part of the complete human being.
One of the major difficulties in the discussion of spiritual care is the actual definition of spirituality. O’Hara3 discussed spirituality as the context of a person’s life versus something that gets added onto life. For instance, is there a difference between spirituality and religion? Does it matter? Should it matter? One simple differentiation is that religion is the way individuals express their spirituality,4,5 whereas spirituality is something universal that all individuals have: it is innate.4,6 Therefore, individuals can be spiritual but may not be religious; however, the opposite cannot be true. Spirituality has a “greater depth and breadth” than religion and it affects a person’s health and illness.6 Narayanasamy7 discussed spirituality as being “inherent,” and described individuals as becoming more aware of their “life source” when dealing with spiritual issues. Pesut and Thorne8 described spiritual experiences as “phenomenological” and “subjective,” and religion more as external communal practices. Others may feel spirituality in a more humanistic or existential way, whereas to those who do not believe in any spiritual dimension at all, it may mean nothing.9 Speck10 described spirituality as dynamic and unique for each individual.
The themes used for spirituality definitions in occupational therapy in Canada included “meaning and purpose in life, the life force or integrating aspect of the person, and transcendence or connectedness unrelated to a belief in a higher being.”11(p10) Other definitions from the nursing literature as reported by Narayanasamy7(p387) included:
- A process and sacred journey.
- The essence or life principle of person.
- The experience of the radical truth of things.
- A belief that relates a person to the world.
- A life relationship or sense of connection with mystery, higher power, God, or universe.
One definition proposed by Murray and Zentner12, as cited by Narayanasamy,7(p387) was much more inclusive of a wider array of spiritual concepts: “A quality that goes beyond religious affiliation, that strives for inspirations, reverence, awe, meaning, and purpose, even in those who do not believe in God. The spiritual dimension tries to be in harmony with the universe, strives for answers about the infinite, and comes into focus when the person faces emotional stress, physical illness, or death.”
The definition used may be the choice of the individual or the institution. In any case, the definition should be the foundation on which to proceed with spiritual care.
Pesut and Thorne8 stated there is an ethical responsibility to pay attention to all dimensions of the person, including the spiritual dimension. However, when discussing ethical considerations, it is important to remember not everyone has spiritual needs that require attention from a health care professional.9 Even if there are needs present, patients’ needs may be met by friends, family, clergy, or any combination of these, or others. The key is to recognize whether there is a need, assess that need, and determine the intervention. If there is no need, health care professionals should move on, and if there is a need, health care professionals should take the necessary precautions and move forward.
Health care professionals must use caution regarding when to ask individuals about their spirituality. In some instances, such questions may seem intrusive.8 For example, are there others who may hear the conversation? Is the individual in the right state of mind for the discussion? Common sense might dictate the opening of the dialogue. In addition, the need and the direction that will be taken must be based on the individual’s definition of spirituality and not the health care professional’s definition.9 No moral judgment or criticism should be made regarding an individual’s spiritual and religious views, beliefs, or choices. This may be difficult, especially if a patient’s views are in conflict with the views of the health care professional. Health care professionals may find themselves walking a fine line of trying to support a patient’s “healthy” spiritual beliefs but wanting to change seemingly “unhealthy” ones. It becomes a dance between being supportive verses being coercive.8 Another potential problem is that of “objectifying” patients, which can occur if health care professionals see only with their perceptions, experiences, and world view of spirituality rather than listening to patients. Health care professionals must “defer to the experiences of the patient” and be “authentically engaged rather than impartial observers.”8(p401)
Treloar6 cited 2 studies in which patients said they desired health care providers to be involved in their spiritual care. The first study reported more than three-quarters of patients believed physicians should “consider” patients’ spiritual needs, and almost one-half of patients wanted their physician to pray for them. The second study found patients’ frequency of religious service attendance was a predictor of their acceptance of physician inquiry concerning spiritual practices and concerns. Narayanasamy and Owens13 reported patients appeared more “peaceful, relaxed and calm, and grateful” after spiritual care intervention. Nurses also reported that patients felt comforted and supported, and more able to cope. Families of patients also have been affected by patients receiving spiritual care and have reported feelings of gratitude, comfort, and happiness.
Initially, it may be challenging for both sports medicine professionals and athletes to embrace spiritual practices because adding the spiritual dimension to the healing process has not been a major topic of discussion in the field. Including spiritual practices begins with identifying one’s own spiritual beliefs and practices and then exploring the spiritual needs and desires of coworkers. This might be as straightforward as asking nonthreatening questions14,15 or taking a spiritual history,4 or it might be more complex and involve using a spiritual assessment tool. McSherry and Ross9 provide an excellent review of spiritual assessment tools. They break the tools down into 4 categories: direct questioning, indicator-based, audit, and value clarification tools. These assessments, which require good communication and trust between the health care professional and patient, may be used as part of the general assessment of an initial injury or as additional tools used as necessary.
The use of spiritual disciplines, a discipline being defined as any activity used to train or develop by instruction and exercise, as modalities may be a unique concept.16 However, if sports medicine professionals view these as additional tools toward the common goal of aiding in the healing process, it might be easier to view spiritual disciplines as modalities. By using the 2 definitions provided for spiritual and discipline, the definition for spiritual discipline emerges as an activity used to train or develop by instruction and exercise toward a greater awareness of one’s inner self and sense of connectedness or relatedness to a higher being or to something greater than oneself. For this specific purpose as a modality, the definition extends to include the use toward the goal of aiding in the healing process. Three specific classic healing disciplines include meditation and visualization, prayer, and celebration.
Meditation and Visualization
Meditation and visualization help to focus the mind on positive, pleasant thoughts, while physiologically decreasing blood pressure and heart rate, relaxing the muscles, and increasing the immune response. In addition, there is a subjective experience of decreased pain and stress. All of these positive responses allow patients to become compassionate witnesses to their own experiences, to avoid making premature decisions, and to be open to new possibilities, transformation, and healing.17 Studies have looked at meditation effects on sport injuries as well. Christakou and Zervas18 examined the effects of imagery on pain, edema, and range of motion in 9 athletes with grade II ankle sprains. Although there were no significant findings, they discussed their descriptive statistical results of a treatment effect in decreased pain in the first 4 measurements. These would have been on days 10 to 13 after injury, as the authors did not start data collection until day 9 after the injuries. These findings agree with those of Cupal and Brewer,19 who used guided imagery with 30 patients following arthroscopic anterior cruciate ligament reconstructive surgery. Their results indicated a significant decrease in pain and reinjury anxiety, and an increase in strength 24 weeks postsurgically compared with placebo and control groups. Hamson-Utley et al20 found certified athletic trainers and physical therapists held positive attitudes toward the use of mental imagery in the rehabilitation process.
Spiritual meditation does not means emptying the mind but opening the mind to the mind of God, Buddha, Allah, the universe, or another spiritual entity or belief.21 It also may include meditating on a selected scripture by repeating it in the mind. A single event, a parable, or a few verses are taken and allowed to stay in the mind. Individuals put themselves in the experience, allowing their senses to smell, hear, see, and breathe the scene. It is not a time to study the passage but to experience it.22
Although the application and procedures for meditation and visualization are relatively simple, it takes time and patience for individuals to learn and become comfortable with them. Application begins by first helping individuals clear their mind to focus on whatever is important at the time, including the actual healing process, to create emotional and spiritual space. The second step is helping individuals become open to discovering new ideas, or to hearing and following God’s or their higher power’s direction. Buddhist meditation uses visualization of the body of the Buddha, specifically his healing form.23 The third step is helping create a general sense of well-being, with the emphasis on “being” and not “doing.”18 For this intervention to become spiritual versus simply psychological, individuals may choose a spiritual phrase to repeat or picture to visualize that is important to them. The addition of the spiritual component has the ability to make the exercise more meaningful and therefore more useful for individuals.
One simple procedure for meditation and visualization is outlined in the Table. The procedure may be used during a modality treatment, a quiet time, or a ride in a car. Other meditation ideas and techniques can be found on the Free Meditations Web site.24
Table: Meditation and Visualization Technique
Prayer is the act of talking to a higher being.16 The literature has been varied in its evaluation of prayer and healing; however, it is agreed that more than 80% of Americans believe prayer can improve health or cure illness.25,26 Seventy-seven percent of Americans believe God can intervene to cure those with serious illness,26 and 44% of Americans have reported they experienced healing through prayer.3 Ameling27 also found 64% of respondents wanted physicians to pray with them. In general, prayer has been shown to decrease stress, increase coping, uplift the spirit, increase hopefulness, activate the immune system, decrease heart rate and blood pressure, and allow the body to heal.3,26
In a double-blind study in which coronary care patients did not know they were being prayed for (ie, intercessory prayer or distant healing), patients were 5 times less likely to need antibiotics after surgery, required less intubations and ventilation assistance, and had fewer cardiac complications than patients who were not prayed for.28 These findings suggest intercessory prayer had an impact on patient outcome. In contrast, Aviles et al29 found no significant influence of intercessory prayer in a study also using coronary care patients.
Astin et al30 conducted a systematic review of studies involved in distant healing and intercessory prayer. Five of the studies evaluated the healing effects of prayer as a distant healing intervention (ie, the patients did not know they were being prayed for); 2 of the trials showed a significant treatment effect for prayer, and the remaining 3 did not. In one of those that did not, Astin et al30 cited methodology as a potential problem in their outcome. Although it is difficult to clinically assess the effects (or lack thereof) of prayer, direct prayer (ie, when patients know they are being prayed for) has been found to decrease heart rate and blood pressure; activate the immune, hormonal, and cardiovascular systems, which are conducive to healing; reduce stress; and promote positive emotions. Thus, intercessory prayer (ie, distance healing) has been found to work in some studies but is inconclusive in other studies. With these different research findings on the ability of prayer to effect healing, it is up to clinicians and patients to decide what is best in each situation.
Farah and McColl31 proposed 4 guidelines before prayer is used in the health care setting. First, it should be determined whether there is a spiritual component to the problem. Is the patient struggling with themes such as meaning and purpose, despair, belief in God, or other theological issues? Second, the health care professional should be equipped to offer prayer. Can the health care professional offer the prayer in an authentic manner, believing what is offered? Third, it should be determined whether the patient would be receptive to prayer. Caution must be used to avoid assumptions about the patient’s needs or wants based on observations. In addition, a relationship should be established before prayer is offered. Fourth, it should be determined whether the workplace will support the use of prayer. Can the health care professional justify the use of prayer as a modality to his or her colleagues and superiors? Do the institutional policies proclaim a respect for spiritual health? After addressing these concerns, health care professionals should be able to determine more accurately whether prayer would be an appropriate modality for patients.
Narayanasamy and Narayanasamy26 discussed 4 types of prayer that might be used:
- Prayer of transaction (carrying out a dialogue).
- Prayer of petition (making a personal plea or request).
- Prayer of submission (submitting of self, injury, and illness).
- Prayer of intercession (praying with and for others).
Health care professionals may choose to pray alone or with others when appropriate. Prayer does not require any specific form or formula; individuals may choose what format to follow.
Celebration is widely regarded as a spiritual discipline.21,32 Foster22(p191) stated, “Celebration brings joy into life, and joy makes us strong…Celebration is central to all Spiritual Disciplines.” Celebration is not something that simply occurs but something that must be “chosen,” a way of life, a way of thinking and living. When one thinks this way, then healing and redemption will begin to occur in one’s lives and relationships. The ultimate result will be joy.22
Among the characteristics and activities that may be included in celebration are an optimistic or positive outlook, and humor or laughter. By definition, optimism is an inclination to put the most favorable construction on action and events, or to anticipate the best possible outcome.16 Optimism can act as a resource to preserve mental health and protect physical health,33 and positive emotions can block panic, foreboding, and depression that leads to damaged tissues.34 Dossey35 sees a natural link between optimism and the “Absolute” or “Divine.” This is because the word optimism comes from the “Latin words meaning highest or best, which is what we consider the Divine to be.” 35(p91) Dossey35(p91) further suggested that “optimism unanchored to the Absolute is hard to sustain” because if we do not believe in an afterlife, then life will come to an end and optimism would be “a worthless, pitiful Band-Aid.”
Application occurs when health care professionals help athletes recognize “negative self-talk” and encourage them to respond with positive statements. Health care professionals also can encourage positive thinking and help athletes discern their purposes outside sports and physical activities.
Celebration keeps one from taking oneself too seriously and adds a sense of joy to one’s lives.22 Humor is an important modality used by many traditional healers.36 As cited by Dossey,35(p89) Don Elijio Panti, a traditional Maya healer stated, “…a person’s spirit needs to be uplifted as much as the body needs to be healed. And without an uplifted spirit I don’t think there is enough energy within the body…for a person to properly and completely experience healing.”
Laughter brings an anesthetic effect and other changes in body chemistry including reduced blood pressure, lowered heart rate, stimulated circulation, decreased muscle tension, increased oxygen supply to muscles, and increased endorphins.33,37 In addition, evidence of activation of immune cells36,37 and a reversal of some of the effects of stress (eg, cortisol, dopamine, epinephrine elevation) has been reported.36 In a study of patients undergoing cardiac rehabilitation, patients whose rehabilitation included a 30-minute comedy video experienced decreased arrhythmias, had lower plasma and urinary catecholamines, and required fewer beta-blockers and nitroglycerins.36 Johnson38 noted many cancer patients found laughter to be “spiritually uplifting” when in a stressful or painful situation. In her study of breast cancer survivors, she found humor and spirituality were both instrumental in coping. In addition, Johnson38 reported humor and spirituality helped the women laugh at themselves and at life, see that God had a sense of humor, understand themselves better, aid as a step in recovery, and see a need for helping others; in other words, humor and spirituality helped the women see a purpose and meaning in their lives.
Carson39 stated humor has an incredible ability to heal body, mind, and spirit. In support of how humor is an element of spirituality, she stated, “Humor is transcendent—it momentarily removes one from an isolated personal state to join in surprise at the ludicrous situations of human beings…perhaps strength and inner resources can be measured by one’s appreciation of humor in life.”39(p198)
Seaward37 described 4 theories of humor from the literature:
- Release and relief.
Superiority, from Plato, is more emotionally based and is described as an outlet for aggression, which is socially acceptable at someone else’s expense, where the individual’s own self-esteem is elevated. Incongruity theory, more cognition-based, maintains laughter is “triggered by the connection of two or more concepts that seem absurd or incongruous.” 37(p67) In release and relief theory, posited by Freud, laughter is a “physical manifestation of repressed thoughts and feelings of taboos such as sex and death.”37(p68) The final, newest theory is the divinity theory that maintains humor is a gift from God. This theory proposes laughter has the ability to “make order out of chaos, promote unity and connectedness through shared laughter, uncover the naked truth of a situation and lift one’s spirit.”37(p68)
Seaward37 proposed 3 methods of using laughter or humor in the clinical setting. These include using humor as a diversionary tactic, as a therapeutic tool, and as a coping mechanism. As a diversionary tactic, humor may take the patient’s mind off the injury or illness,36,37 promoting more balance in emotions.37 As a therapeutic tool, laughter is used most frequently for the treatment of depression but may be used for other ailments as well. Laughter also is used to help strengthen the bond between clinicians and patients. Using humor or laughter as a coping mechanism is a positive tool to help alleviate and control both fear and anger. Fear and anger may be related to the unknown, including why the injury or illness occurred in the first place or why rehabilitation is not progressing as anticipated.
There is one caution to the use of humor. Humor can be both positive and negative, depending on how and when it is used.40,41 Humor can be used to hurt another person, reduce another person’s self-esteem, or bring another person to tears. In these cases, humor is considered unhealthy and should be avoided.40
Health care professionals can create an environment of appropriate humor and lightheartedness, as well as encouraging their athletes and clients to watch good, wholesome comedies.42 Other (non-wholesome) types of comedies may bring about laughter but would negate the idea of “celebration” in the spiritual sense it is intended. However, it should be cautioned there is a difference between laughing with patients and laughing at patients. Timing is also critical when using humor. There are times to be serious, for example, when first giving a difficult diagnosis. Health care professionals need to be aware of when and where humor belongs.
To implement spiritual disciplines in the sports medicine setting, health care professionals need the following: good rapport with patients, comfort in their personal faith, and knowledge of the disciplines and how to implement them. The use of spiritual disciplines may be challenging to implement at first because just like any other modality, it takes practice to become comfortable with these disciplines.
However, the disciplines should not be seen as an infringement on religious freedom or on any sort of “separation of church and state” issues. Sports medicine professionals are working with spirituality, not religion, with the patient’s permission and within parameters of solid medical research evidence. The nursing profession has been using these practices, and others, for years with positive effects in private and public settings. It is challenging, yet if health care professionals truly want to treat the whole person—body, mind, and spirit—and use every possible modality at their disposal, all health care professionals should consider the use of spiritual disciplines when appropriate.