April 2018 Article of the Month
Laures-Gore, J. S., Lambert, P. L., Kruger, A. C., Love, J. and Davis, D. E. Jr. "Spirituality and post-stroke aphasia recovery." Journal of Religion and Health (2018): published online ahead of print, March 15, 2018.
SUMMARY and COMMENT: "This study represents the first exploration of spirituality and its possible effects on recovery from post-stroke aphasia" [MS p. 10] and comes from Georgia State University's Department of Educational Psychology, Special Education, and Communication Disorders and Department of Counseling and Psychological Services. Co-author Don E. Davis, Jr. has published extensively on the psychological study of spirituality, and Jacqueline Laures-Gore has studied mindfulness meditation in aphasia. The article should be of interest to chaplains as an entreé to the topic of post-stroke aphasia, as a report of findings emphasizing the role of spiritual coping from the perspective of psychology, as a challenge to think about how to accomplish spirituality research with a communication-impaired population, and as a "foundation for future inquiry into the contribution of spirituality to post-stroke aphasia recovery" [MS p. 9]. Appendices conveniently provide the items for the study's questionnaire and semi-structured interview.
Noting that there has been "[l]imited empirical work...examin[ing] how an individual's spirituality is involved in the process of stroke recovery" [MS p. 1] and that "researchers have never examined spirituality in stroke survivors experiencing aphasia" [MS p. 2], Laures-Gore and her colleagues state:
...the purpose of the present study is to examine the spiritual experience of stroke survivors to clarify the direction of future inquiry and to better understand the role of one's spirituality in the aphasia recovery process. Specifically, we investigate whether these adults with aphasia view themselves as spiritual, what their characterization of spirituality is, and then, whether they attribute their aphasia recovery to spirituality. [MS p. 3]The definition of spirituality is given as: "a general feeling of closeness and connectedness to the Sacred," with the clarification that "[t]he Sacred is whatever a person considers central to their spirituality, such as God, nature, humanity, or the transcendent" [MS p. 2].
A convenience sample of seven men and six women with a current diagnosis of mild aphasia was recruited from the Georgia State University Speech-Language-Hearing Clinic and rehabilitation clinics in the Atlanta area. Three were African American and ten were Caucasian, aged 41 to 71 years, with a high education level (85% college-educated) and with a post-stroke range of 3 months to over 18 years. All completed a questionnaire based upon the Trait Sources of Spirituality Scale [--see Related Items of Interest, §I, below]. Subsequent 20-40-minute interviews where audiotaped at the Aphasia and Motor Speech Disorders Research Lab, at the individual's home, or "at a quiet location closer to the individual's home" [MS p. 4]. Four participants were accompanied by a spouse or caretaker for assistance with word-finding and details of past events.
Among the results:
These findings are discussed in light of the psychology of coping and meaning-making and connected to a "neuropsychobiology of stress framework"* [MS pp. 2 and 8; and see Related Items of Interest, §II, below]. For the six participants who indicated a view of a greater power in control of events and who reported only infrequently engaging in prayer or other practices, the authors write:
...this type of invocation of a higher power can be interpreted as attribution of control to forces outside the self and does not involve much personal activity or agency in relation to the power or to the recovery. This belief is most akin to God control or deferring control to God (a coping behavior) in which the locus of control of the events in one's life is external.... This coping behavior--if not appropriately paired with other coping strategies--could potentially have negative implications for the amount one is actively involved in his/her stroke recovery. [MS p. 8; and see Related Items of Interest, §III, below]In contrast, for the five participants who focused on a greater power as helper and who reported more frequent religious/spiritual practices:
For those who viewed the Sacred as a personal being, viewing the Sacred as a source of help aligns well with attachment theory.... Namely, the stressor causes existential distress, and this distress causes individuals to seek greater closeness to the Sacred for comfort and relational support. These proximity seeking behaviors might involve engaging a variety of spiritual resources to understanding the meaning of the stroke and aphasia. [MS p. 8]The authors say, "The idea that spirituality offers a form of coping for these adults is significant; it may be a resource for individuals with aphasia to use when enduring the life changes accompanying an event such as stroke" [MS p. 9].
Clinically, this is important because spirituality may be a helpful component to recovery, understanding, and acceptance of life changes associated with aphasia. Additionally, the results indicate that spiritual activities offer opportunities for adults with aphasia to practice using language and interacting with others which may contribute to positive outcomes. As one participant explained, spiritual activities provide ways for individuals with aphasia to communicate with others "instead of sitting at home watching television." [MS p. 11]Ultimately, they observe: "Making spiritual meaning, especially reworking a negative event into a more positive and redemptive story can be difficult, but participants were able to indicate that this can be done" [MS p. 10].
Limitations of the study are quite well lined out [--see MS pp. 9-10], including the low sample size, demographic characteristics, the US "Bible Belt" geographic context, the range of time since stroke, the presence of spouses or caretakers in some interviews, and possible confusion around conceptualizations of spirituality and religion. Constructive suggestions for future research accompany each limitation, along with the general acknowledgement of room for improvement of the questionnaire and interview items after this "first attempt at exploring this topic in a novel population" [MS p. 10].
The very undertaking of research into the experience of people with communication difficulties is methodologically daunting, which explains why patients with aphasia were excluded from earlier investigation into spirituality & stroke [--see MS p. 2]. Indeed, only people with mild aphasia were enrolled in the present study, "to ensure a functional level of auditory comprehension and ability to answer questions" [MS p. 3]. The allowance of spouses or caretakers to be present at some interviews is a nod to the need of assistance with communication even with this group, and even at the risk of influencing results [--see MS p. 10]. And yet, there is certainly demand for understanding the experience and role of spirituality in the lives of these and less communication-accessible individuals. Chaplains routinely work with patients struggling with communication barriers in acute and long-term settings, and we may be good partners with other providers for research with such populations. For patients with aphasia, chaplains could help explore the interplay between language and spirituality, how a problem with one may affect the other, and how not only might spirituality be a resource for coping with distress but how a condition like aphasia might be the means for a deepening sense of spiritual journey.
*NOTE: The text on MS p. 2 regarding the 2015 article includes the sentence: "Within this framework, spirituality could be one of a variety of individual factors that modules stress reactivity and the course of aphasia recovery." The word modules here is a typographic error, and the correct word should be modulates.
Suggestions for Use of the Article for Student Discussion:
This month's article might best be used with a group that has had enough clinical practice to have encountered patients with aphasia or at least patients with transient difficulties understanding or expressing speech. What has it been like being with such patients, how did you work with the communication difficulty, and what was your sense of patient spirituality? Did they find that these patients were intentionally using spirituality to cope? How did the patients' communication issues seem to affect them spiritually? Then, perhaps the group could turn to the article and general impressions of the study. Discussion could focus on the two themes of a greater power being in control or as helper. Do the students see the logic of the authors' explanation of these themes [--see MS p. 8], and what sense do they have of their own pastoral perspective in relation to the authors' psychological perspective? Is there some overlap, or tension, or just a different way of talking about the same thing? What do the students think about the statement, "...the spiritual experience typically occurs within the context of a community" [MS p. 8], in terms of social/community needs of patients for whom communication difficulty may be isolating? If they have visited with aphasia patients, did those individuals appear to think that problems of communication with other people extended to an impediment in communicating with God? If so, did the students -- in the role of chaplain -- somehow help the patient overcome that impediment? The group could also go over the illustrative quotes from study participants [--see Table 2, MS p. 6]. Finally, the group could look at the items from the questionnaire and especially the semi-structured interview, helpfully provided in the appendix [MS pp. 10-12], to see how the researchers sought to prompt participants for the most relevant information to address the research goals [MS p. 3, top paragraph].
Related Items of Interest:
I. The authors of this month’s featured article state that they used a "truncated variation" [MS p. 3] of the Trait Sources of Spirituality Scale for their questionnaire and also derived their interview items in part from the same source. Note that co-author Don E. Davis, Jr. is also a co-author on the referenced article for the scale.
II. Our authors point to a 2015 article that sets up a broad framework for thinking about stress and which may offer "a way of understanding how spirituality may influence the appraisal and coping process for adults with aphasia" [MS p. 2]. However, that article does not explicitly address spirituality.
III. Regarding the authors' reference to "deferring control to God" [MS p. 8] as a coping strategy, they mention a 2013 article: McLaughlin, B., et al., "It is out of my hands: how deferring control to God can decrease quality of life for breast cancer patients," which was our January 2014 Article-of-the-Month. See that previous feature for more on religious coping strategies/styles.
IV. Little has been written about spiritual care to people with aphasia in particular, but see especially:
V. The following research may be of interest, coming from outside of chaplaincy:
Also, a research project is currently underway through the Weston Area Health NHS Trust, UK, by Katharyn Mumby, PhD (firstname.lastname@example.org), a Speech Language Therapist: "A feasibility study to pilot an assessment of spiritual health ('SHALOM') and a Spirituality Toolkit ('WELLHEAD') with people with Aphasia." For more on the two resources noted in the title, see the website for WELLHEAD and the following articles regarding the SHALOM spiritual assessment: Fisher, J., "Development and application of a spiritual well-being questionnaire called SHALOM," Religions 1, no. 1 (2010): 105-121; Fisher, J., "Selecting the best version of SHALOM to assess spiritual well-being," Religions 7, no. 5 (2016): 45 [electronic journal article designation]; and Fisher, J., "You can't beat relating with God for spiritual well-being: comparing a generic version with the original spiritual well-being questionnaire called SHALOM," Religions 4, no. 3 (2013): 325-335.
VI. For more on aphasia per se, see the website of the National Aphasia Association. And for an overview of aphasia from a medical standpoint, see:
VII. A recent Wall Street Journal article briefly accounts the work of Julie Shulman, who advocates for the spiritual integration of people with aphasia who are adherents of speech-based faiths. See: Schuss, G. F., "Learning to pray when words fail," Wall Street Journal (March 15, 2018): online at www.wsj.com/articles/learning-to-pray-when-words-fail-1521153496.
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