August 2017 Article of the Month
Kestenbaum, A., Shields, M., James, J., Hocker, W., Morgan, S., Karve, S., Rabow, M. W. and Dunn, L. B. "What impact do chaplains have? A pilot study of Spiritual AIM for advanced cancer patients in outpatient palliative care." Journal of Pain & Symptom Management 54, no. 5 (November 2017): 707-714. [This article was originally featured ahead-of-print.]
SUMMARY and COMMENT: Spiritual AIM (Spiritual Assessment & Intervention Model) is a "brief, chaplain-delivered spiritual care intervention" [p. 710] that "was developed through 25 years of clinical practice and supervision" [p. 708]. Here, a research team that included three chaplains, four physicians and a Social Worker, sought to evaluate its "feasibility and tolerability" and its "impact on...spiritual well-being, religious and cancers-specific coping, and physical and psychological symptoms" [p. 708]. The study not only speaks to the potential value of Spiritual AIM and the important process of empirical testing of a spiritual care model but, along the way, also provides insights into a conceptualization of fatalism found in the health care literature.
The model is described succinctly:
Spiritual AIM posits that every human being, by virtue of being human, has three fundamental or "core" spiritual needs: for meaning and direction (referred to in Spiritual AIM "shorthand" as "Meaning and Direction"); for self-worth and belonging to community ("Self-Worth"); and to love and be loved, often facilitated through seeking reconciliation when relationships are broken ("Reconciliation"). Spiritual AIM asserts that in a crisis -- such as facing one's mortality -- one of three core spiritual needs emerges most strongly, influencing the patient's subjective thoughts and feelings as well as affecting their observable words and behaviors. In Spiritual AIM, the chaplain's pastoral encounter requires diagnosing an individual's primary unmet spiritual need, devising and implementing a plan for addressing this need, and evaluating desired and actual outcomes of the intervention. [p. 708]A full explanation has been published elsewhere [--see Related Items of Interest, §I, below].
The three chaplain co-authors conducted the intervention with 31 advanced cancer patients being treated at an outpatient palliative care service of an urban, academic, comprehensive cancer center. Three 45-60 minute sessions were audiotaped and transcribed: one followed the patient's completion of baseline measures, and two subsequently were conducted either in person or by phone, two to three weeks apart. "All chaplains met weekly with researchers to promote consistency in assessment and interventions" [p. 709]. Participants completed eight self-report measures, including the FACIT-Sp-12, Brief RCOPE, and the Mini-Mental Adjustment to Cancer scale (Mini-MAC) with five subscales: Fatalism, Fighting Spirit, Anxious Preoccupation, Helplessness/Hopelessness, and Cognitive Avoidance --also calculated as two higher-order coping constructs, i.e., Adaptive Coping (Fighting Spirit, Cognitive Avoidance, Fatalism) and Maladaptive Coping (Helplessness/Hopelessness, Anxious Preoccupation) [--see p. 709].
Among the results:
On the FACIT-Sp-12, compared to a large sample of adult cancer survivors, our sample scored approximately one standard deviation below the mean on each subscale at baseline. Post-Spiritual AIM, a significant increase was observed only on the Faith subscale of the FACIT-Sp-12.Also, participants were assessed as fairly evenly distributed in terms of the Spiritual AIM categories: 11 with the core spiritual need of Meaning and Direction; 11 with the need of Self-Worth; and 9 with the need of Reconciliation. A table of Examples of Assessments, Interventions and Outcomes for Each Core Spiritual Need in Spiritual AIM [p. 711] gives a nice picture of how the intervention was used by the chaplains and received by the patients, with illustrative quotes.
The authors conclude: "This study provides preliminary evidence for feasibility and acceptability of Spiritual AIM..." [p. 710] and "suggest[s] that Spiritual AIM may hold promise as a brief, chaplain-led spiritual care intervention for patients with serious or life-limiting illnesses" [p. 712]. However, what may be as important for chaplain readers as the findings per se is the authors' perceptively critical discussion of their methodology and the challenge of how to capture change in patients receiving such an intervention. Regarding the FACIT-Sp-12 and the Brief RCOPE (which are two of the most popular instruments in the spirituality & health literature), they admit that "...it is difficult to know whether these measures are the most appropriate or sensitive to any impact of the intervention..." but that "[i]t is possible that the FACIT-Sp-12 and the Brief RCOPE, which both have some parallels to Spiritual AIM, are more sensitive to the kinds of effects that Spiritual AIM is hypothesized to exert" [p. 712]. Here they venture into the issue of conceptualizations behind measures that -- at least in this reader's opinion -- is too often overlooked in the literature. The Discussion section should be instructive to all chaplains contemplating tests of their own interventions.
Of particular interest to chaplain readers may be the discussion of the finding that there was a trend toward an increase on the Fatalism subscale of the Mini-MAC. The authors note: "Importantly, the 'Fatalism' construct of the Mini-MAC may be conceptualized (or even better, relabeled) as gratitude or active surrender, as reflected by the items comprising the scale (e.g., 'I've put myself in the hands of God;' 'I count my blessings;' 'I've had a good life, what's left is a bonus')" [p. 712]. [See also, Related Items of Interest, §IV, below, regarding fatalism.] There is a cautionary adage that the use of any measure is as much a window on the measure itself as on the thing being measured, and our article's authors engage the spirit of such a caution here very well. They present their findings as a step in a scientific process that builds on "intriguing" [p. 712] results and sets the ground for further study. For any chaplain readers who are new to the research literature and who may become impatient with articles that do not conclude with grand claims, this month's article may implicitly champion the value of carefulness. Our authors state: "The unique work of chaplains deserves both careful elucidation and close examination" [p. 710], and the test of their model of spiritual intervention seems a kind of model itself of research-mindedness for chaplaincy.
One final note: our authors write, "Spiritual AIM is one of the few spiritual assessment models that articulates assessments, interventions, and outcomes, and that has been empirically studied" [p. 708], and they indicate two endnotes in relation to that statement. Those two citations are for articles by Stefanie Monod, et al., regarding the Spiritual Distress Assessment Tool, and they are pertinent in this regard only as examples of research testing of an assessment model; there is no direct connection between the Spiritual Distress Assessment Tool and Spiritual AIM.
Suggestions for Use of the Article for Student Discussion:
This somewhat brief article could be especially useful for students who have had some exposure to the research literature and are at the point of contemplating how research might validate and guide chaplaincy interventions. It best would be paired with (or follow a separate reading and discussion of) Shields, M., Kestenbaum, A. and Dunn, L. B., "Spiritual AIM and the work of the chaplain: a model for assessing spiritual needs and outcomes in relationship," Palliative & Supportive Care 13, no. 1 (February 2015): 75-89 [--see Related Items of Interest, §I, below]. The group could focus on the present article's Discussion section, which walks the reader through the authors' thinking about how to interpret the findings. Copies of the FACIT-Sp-12, the Brief RCOPE, and/or the Mini MAC could be useful, so that students can see how the data were derived from specific questions on the measures. [See Related Items of Interest, §II and §III, for sources and for a conceptual break-down of the Brief RCOPE.] The group could also muse specifically about how the concept of fatalism might be trickier than at first glance. Additionally, the table of Examples of Assessments, Interventions and Outcomes for each Core Spiritual Need in Spiritual AIM could be discussed as real-world illustrations of the intervention in practice. Does this intervention interest students, and why? Finally, how does the article give insight into the difficulty of capturing the effect of a spiritual intervention?
Related Items of Interest:
I. Spiritual AIM was the subject of a workshop at the Second Caring for the Human Spirit Conference (April 20-22, 2015, Orlando, FL), and a slide presentation by three of our featured article's authors is available online from the HealthCare Chaplaincy Network. For a full explanation of the model, see:
II. The FACIT-Sp and Brief RCOPE are two of the most widely used measures in the spirituality & health research literature. For more about the FACIT-Sp, see our October 2015 Newsletter, which includes a link to facit.org for versions of the questionnaire. And, for more on the Brief RCOPE, see Pargament, K., Feuille, M. and Burdzy, D., "The Brief RCOPE: current psychometric status of a short measure of religious coping," Religions 2, no. 1 (2011): 51-76; which is an Open Access article. Also, for a tabular summary of the Brief RCOPE's 14 items, pairing religious coping methods and key religious functions, click HERE.
III. The Mini-MAC was developed in 1994 as a 29-item measure, refined from an original 40-item Mental Adjustment to Cancer scale [i.e.: Watson, M., Law, M., Santos, M., Greer, S., Baruch, J. and Bliss, J., "The Mini-MAC: further development of mental adjustment to cancer scale," Journal of Psychosocial Oncology 12, no. 3 (1994): 33-46; and Watson, M., Greer, S., Young, Q., Burgess, C. and Robertson, B. F., "Development of a questionnaire measure of adjustment to cancer: the MAC scale," Psychological Medicine 18, no. 1 (1988): 203-209; both of which may be slightly difficult to obtain]. Much of the research on the scale and its use has since been done with Greek, Italian, Chinese, and Portuguese populations; but the measure's 29 items are listed (in English) according to the five subscales in:
IV. Fatalism: Our featured authors question whether certain items in the Mini-MAC should be labeled as fatalism [--see p. 712]. The conceptualization of fatalism in measures may indeed deserve some rethinking, especially in the context of spirituality & health research. It's possible that some particular items on instruments meant to detect fatalism may not simply indicate a person's sense of an unchangeable destiny and an attitude of passiveness toward medical treatment. Couldn't a cancer patient who agrees with a statement like, "I've put myself in the hands of God" (from the Mini-MAC), be asserting a basic tenet of faith while still working (and praying) for healing? Moreover, even when patients respond to a situation with fatalism as a form of coping, would it necessarily have to be a form of coping that is dysfunctional to their health? Researchers for a 2013 study of Chinese breast cancer survivors have observed, for instance: "Although past studies suggest that cancer patients used a fatalistic attitude as a mode of coping with cancer that was associated with poor psychosocial adjustment, more recent studies' interpretations indicate that fatalism appears to promote healthy behaviors among survivors" [--see p. 237 of Cheng, et al., cited below]. Chaplains may be in a good position to comprehend the intersection of religion/spirituality, health, and what the literature and various instruments have called "fatalism." The following are just a few articles that speak to the complexity of fatalism as a concept in health care research.
V. Lead author, Allison Kestenbaum (ACPE Certified Educator) noted the Spiritual AIM intervention in a "Reflection on Research" for our Spring-Summer 2013 Newsletter (Item #3). For more on Spiritual AIM in the context of chaplains conducting research, see:
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