Healing and spirituality

Healing and spirituality David Aldridge Collected Papers

David Aldridge

Collected neurology papers

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REVIEW ARTICLE

Spirituality, healing and medicine DAVID ALDRIDGE

SUMMARY The natural science base of modern medicine influences the way in which medicine is delivered and may ignore the spiritual factors associated with illness. The history of spirituality in healing presented here reflects the growth of scientific knowledge, demands for religious renewal, and the shift in the understanding of the concept of health within a broader cultural context. General practitioners have been willing to entertain the idea of spiritual healing and include it in their daily practice, or referral network. Recognizing patients' beliefs in the face of suffering is an important factor in health care practice.

interest in complementary medicine. There are also spiritual healing groups who have no church or religious affiliation who only exist to pursue spiritual healing. In the United Kingdom these spiritual healing organizations and some religious groups, have formed themselves into the Confederation of Healing Organizations, to practise in hospitals and take referrals from physicians.

This confederation issues strict guidelines for practice and conduct which have been worked out with the British Medical Association and various royal colleges (Confederation of Healing Organizations, personal communication, 1990). The code of conduct covers legal obligations and emphasizes full cooperation with medical authorities. Healers must disclaim any ability to cure but offer to attempt to heal in some measure. The confederation has several clinical controlled trials in progress including a randomized double blind trial protocol (Benor D, personal communication, 1990).

Introduction 'On our own, o r in our most intimate groups, we devise more personal and idiosyncratic beliefs, rituals and protocols to ward off the potential storms or deserts of uncertaintgl

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N modern medicine the overriding concern of medical decisions is for correct diagnosis. Health becomes defined in anatomical or physiological terms, and problems of living are translated into physical descriptions, and more importantly submitted to physical interventions. Rarely d o we find a diagnosis which includes the relationship between the patient and his or her god. Patience, grace, prayer, meditation, forgiveness and fellowship are as important in many of our health initiatives as medication, hospitalization or surgery. In the face of suffering our spirituality may help us to find purpose, meaning and hopee2 Christian healing survived under Roman persecution by inspiring followers with acts of healing. As christianity became accepted and established, christian healing, which depended upon individuals being inspired by the spirit as opposed to being licensed by law, was seen as a threat to the hierarchy of the church. Furthermore, physicians began to organize themselves into guilds, and medicine began to form itself into a body of knowledge replicable in universities throughout Europe.

Metaphysics became increasingly idiosyncratic and open to individual interpretation. Christianity surrendered its sole authority to speak of life, birth and death to a materialistic science which verified human life in the same way in which it verified the physical universe.' The belief that the human body could be organized by subtle forces which represented the presence of a higher intelligence in the universe was a b a n d ~ n e d . ~ In spite of the growth of scientific knowledge in medicine, spiritual healing has survived throughout western Europe, and continues to flourish. During this century some church groups have called for a revival of spiritual healing. Within the last decade this has culminated in a recognition of the christian churches' healing ministry, albeit contentiously. Spiritual healing is often associated with an holistic approach and with a general D Aldridge, p m , research consultant, Faculty of Medicine, Witten Herdecke University, Germany.

Submitted: l6 January 1991; accepted: 23 April 1991.

C3 Brilish Journal of General Practice,

1991, 41, 425-427.

Explanations of healing There are various explanations for how spiritual healing works, including metaphysical, magnetic, psychological and social processes. Most spiritual healers maintain that there are divine energies which are transformed from the spiritual level by the healer and which produce a beneficial effect upon the energy field of the patient. The notion of the energy field is a source of disagreement between orthodox researchers5v6and spiritual healers, since researchers argue that if such a field exists then it should be possible to measure by physical means. However, the explanation of the energy field is as yet unsubstantiated by scientific research.

Spiritual healing exists throughout western and occurs in two different ways. The first involves hands on contact, or near contact, between the healer and the patient, similar to the church ritual of the laying on of hands. The second is distant healing, where a healer or group of healers pray or meditate for the absent patient. Healers emphasize that a special state of mind is required by them for this influence to occur. An altered state of mind in the healer is a feature common to spiritual healing and prehistoric forms of healing.

Older shamanistic techniques of healing have mainly died out in Europe except for remote rural areas in northern E ~ r o p e . ~ Shamans, present in most tribal cultures throughout the world, were an elite who used techniques of ecstasy (dream and trance) to cure people, to guard the soul of the community and to direct its religious life.I0 While trances were used to cure, they were also a means of transporting souls to other worlds and mediating between humans and gods. The recruitment of such healers was by inheritance or spiritual vocation, entailing an arduous apprenticeship, and an initiatory crisis which involved the novice shaman being cured of a sickness.

While the state of mind necessary for healing has been elusive to scientific research, there has been extensive research into the physical sequelae of spiritual healing, which has included investigations using controlled tria1s.I' The effect of spiritual healing on cells and lower organisms, including bacteria, fungus and yeasts; on human cells in vitro; on the motility of simple organisms and plants; on animals; and on human illnesses have been investigated.l1.l2While spiritual healing is often dismissed as a placebo response, the evidence from studies of lower organisms and cells would indicate that there is direct inf l ~ e n c e . Even ~ ~ J ~if we introduce the idea of expectancy effects as an influence on experimental data we still have a body of

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knowledge which begs understanding. The explanations of placebo and expectancy are no less metaphysical than those given for healing phenomena.

Clinical experience General practitioners have been willing to entertain the idea of spiritual healing and incorporate it into their daily practice, or as part of their referral network.I3-l5The demand for an holistic approach to care has been adopted by some nursing groups who remind us that in caring for the patient there is a need to include spiritual needs and to allow for the expression of those needs.I6-Is Within these approaches there is a core of opinion which accepts that suffering and pain are part of a larger life experience, and that they can have meaning for the patient and for the carers.lg The counselling methods incorporated in these medical approaches place emphasis upon the person's concept of god, his or her sources of strength and hope, and the significance of religious practices and rituals for that person. l 7 Doctors, nurses and the clergy have worked together in caring for the d ~ i n g , ~ O and - ~ * a community approach which includes the family of the patient and his or her friends appears ~ , ~principal ~ benefits for the patient to be b e n e f i ~ i a l . ~The include a lessening of anxiety, feelings of well-being and an increasing spiritual awareness, regardless of sex, marital status, age or diagnosk2j Comprehensive treatment programmes for people with the acquired immune deficiency syndrome (AIDS), recommend that the spiritual welfare of the patient is a~knowledged.~~.~~ Prayer may be a valuable part of care for the elderly across . ~ ~ ~ ~medical ~ help and prayer are not several c ~ l t u r e s Seeking mutually exclusive actions, as prayer is considered to be an active coping response in. the face of stressful medical problem^.'^ A study of 160 physicians found that physicians believe that religion has a positive effect on physical health, that religious issues should be addressed and that older patients may ask the physician to pray with them.33The belief system of the practitioner may influence the willingness of the patient to talk about their religious beliefs.

Although initial clinical research into the benefits of prayer more recent studies from a broader was inconclusive,34~36 medical perspective and with larger study populations have shown that intercessory prayer is beneficial. In one study in a coronary care unit, patients in the prayer group had an overall better outcome, requiring less antibiotics, less diuretics and had a lower incidence of intubation/ventilation than the control group.j7 For renal patients, prayer and looking at the problem objectively were used most in coping with stress.j8 It is interesting to see that for the patient, prayer and looking at the problem objectively are not exclusive but complementary activities in a patient's belief system.

The treatment of alcoholism has historically included spiritual consideration^.^^ Such treatments for alcohol abuse were often composite packages using physical methods of relaxation, psychological methods of suggestion and autosuggestion, social methods of group support and service to the community, and spiritual techniques of prayer. Such procedures are still in use today and have been extended into the realm of chemical dependencyd0 and substance a b ~ s e . ~ '

Health beliefs While the number of people claiming active membership of a religious institution in the UK is very low, many people report that they have had a religious experience at some time or

another.42 While it may not be usual to bring the sacred into the medical consultation, secular knowledge is found to be wanting at particular critical moments in those consultations. For the patient it is vital to make sense of experience. There is a need to search for meaning in the face of chaos, loss, hopelessness and suffering. New efforts for lay involvement in medicine and in the church, and a call for spiritual (or holistic) understanding of illness are the expressions of individual calls for such meaning according to patient beliefs.

It is at the level of health beliefs that perhaps the most acceptable explanations of healing take place. ln one research study of black American women with AIDS,27prevention and prayer were included in a treatment programme which incorporated womens' traditional beliefs. This incorporation of modern and traditional health beliefs has been used in treating patients throughout the world.43-46Patients are concerned about the origin and meaning of symptoms and about the way in which they may be healed.

For patients, symbolic meaning plays a part in disease classification, in the cognitive management of illness and in therapy.47 It provides a bridge between cultural and physiological phenomena. Symbolic meanings are the loci of power whereby illness is explained and controlled. Griffith and Mahyd8describe a church-based healing clinic which had both orthodox modern medi6ine and spiritual healing. Not only were there differences in what counted as evidence of healing, but also differences in rituals and in hierarchies of practitioners.

While different rituals may exist in parallel, it may be difficult for them to work together. Some authors see such a unity as diluting the richness of the culture, in that marginal practices will be medicalized and lose some of their vitality.49 It is the change in an individual's meaning of life \\hich appears to characterize many healing rituals. Marginalized individuals - the sick, the poor, the lonely and the elderly - are brought into a group. For some participants, this offers a way of self expression and fulfilment within a social context, thereby .~~ ritually affirming the social worth of the i n d i v i d ~ a l Thus, some church-based healing groups are more concerned with lifestyle approaches than physical pathologies. Sickness, when placed in the hands of a divine authority, releases the patients to a new form of living and integration within a community.

This is the significance of the sacrament of the laying on of hands as a sacred reality5' which should not be equated with the therapeutic touch of the doctor as a secular reality.

Discussion Important changes have been taking place both within the church and within medicine. Issues relating to health and well-being have questioned the fundamental practices of these two institutions.

Principally, these issues are about the definition of health and who is to be involved in healing. It is the contention of this paper that such issues are raised at times of transformation when the old order, whether it be in the church or in medicine, is being challenged.

From the community there is a growing demand for involvement in health issues and for initiatives promoting a healthy lifestyle. Within the church too there are demands by the laity to be actively involved in the life of the church, and for lay ministries to be recognized. Communities are eager to make decisions about matters which affect their daily lives and are no longer willing to abdicate decision making to licensed and expert professionals who may be far removed from them in terms of educational background, social class and experience. This does not mean that there is a revolt by individuals against care by health professionals or clergy men; it is proposed that these British Journal of General Practice, October 1991

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health experts become facilitators and informed advisers.

Both medicine and spiritual healing can bring about the conditions under which healing can occur. While we know of the social implications of healing such as an individual's integration into the community, and the maintainance of a pool of labour, and the psychological implications of healing such as it is far more happier, contented patients51 relieved of distre~s,~' difficult in modern society to articulate the spiritual implications of healing. While doctors may be initially sceptical of the claims of spiritual healers, it is possible to include the spiritual healer in patient management,13xs4given that registered spiritual healers in the UK acknowledge the central position of the medical practitioner in patient care, and that there are existing models for teamwork in primary health care23-55and the church.56Spiritual healing appears to be of particular benefit when it is at the request of the patient and family, and for the elderly, the chronically ill and the dying. Recognizing a pa~ient's beliefs, and facilitating health care practice which takes into account those beliefs appears to be an important initiative in the management of suffering and loss.

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2. Hiatt J. Spirituality, medicine, and healing. Soufh Med J 1986; 79: 736-743.

3. Needleman J. A sense of the cosmos. London: Arkana, 1988.

4. Nasr SH. Man a n d nature: the spiritual crisis in modern man.

London: Unwin, 1990.

5. Jacobs S. A philosophy of energy. ffolisfic M e d 1989; 4: 95-111.

6. Wood C. The physical nature of energy in the human organism. Holisfic A4ed 1989; 4: 63-66.

7. Visser J. Alternative medicine in the Netherlands.

Coniplemenfary Med Res 1990; 4: 28-31.

8. Sermeus G. Alfernafive medicine in Europe: a quanfifafive comparison of alternafi~~e medicine a n d pafienf profiles in nine European countries. Brussels: Belgian Consumers' Association, 1987.

9. Vaskilampi T. The role of alternative medicine: the Finnish experience. Coniplemenfary M e d Res 1990; 4: 23-27.

10. Eliade M. Shama~isin:archaic techniques of ecsfasy London: Arkana, 1989.

11. Benor D. Survey of spiritual healing. Coniplemenfary Med Res 199@ 4: 9-33.

12. Solfin J. Mental healing. In: Grippner S (ed.). Advances in parapsychological research. Jefferson, NC: McFarland, 1984.

13. Brown C, Sheldon M. Spiritual healing in general practice [letter]. J R Coll Gen Pract 1989; 39: 476-477.

14. Cohen J. Spiritual healing in a medical context. Pracfifioner 1989; 233: 1056-1057.

15. Pietroni PC. Spiritual interventions in a general practice setting. Holisfic Med 1986; l: 253-262.

16. Boutell K, Bozett F. Nurses' assessment of patients' spirituality: continuing education implications. J Confin Educ Nurs 1990; 21: 172.176.

17. Soeken K, Carson V. Responding to the spiritual needs of the chronically ill. Nurs Clin Norfh A J 1987; ~ 22: 603-61 I. 18. Labun E. Spiritual care: an element in nursing care planning. J Adv Nurs 1988; 13: 314-320.

19. Jacobson MN, Burkhardt M. Spirituality: cornerstone of holistic nursing practice. Holis/ic Nurs Prac/ 1989; 3: 18-26, 20. Roche J. Spirituality and the ALS patient. Rehabilifafion Nursing 1989; 14: 139-141.

21. Conrad N. Spiritual support for the dying. Nurs Clin Nor111 A177 1985; 20: 415-426.

22. Reed P. Spirituality and well-being in terminally ill hospitalized adults. Res Nurs Healfli 1987; 10: 335-344.

23. Aldridge D. A team approach to terminal care: personal implications for patients and practitioners. J R Coll Gen Pracf 1987; 37: 364.

24. Aldridge D. Families, cancer and dying. Funi Pruc/ 1987; 4: 212-218.

25. Kaczorowski J. Spiritual well-being and anxiety in adults diagnosed with cancer. Hosp J 1989; 5: 105-116.

26. Belcher A, Dettmore D, Holzemer S. Spirituality and sense of well-being in persons with AIDS. Holis~icNurs Pracf 1989; 3: 16-25.

27. Flaskerud J, Rush C. AIDS and traditional health beliefs and practices of black women. Nurs Res 1989; 38: 210-215.

28. Gutterman L. A day treatment program for persons with AIDS. A m J Occup Ther 1990; 44: 234-237.

29. Ribble D. Psychosocial support groups for people with HIV infection and AIDS. Holisfic Nurs Pracf 1989; 3: 52-62.

30. Chatters L, Taylor R. Age differences in religious participation among black adults. J Geronfol 1989; 44: 183-189.

31. Markides K. Aging, religiosity, and adjustment: a longitudinal analysis. J Geronfol 1983; 38: 621-625.

32. B e a r o ~L, Koenig H. Religious cognitions and use of prayer in health and illness. Geronfologisf 1990; m 249-253.

33. Koenig H, Bearon L, Dayringer R. Physician perspectives on the role of religion in the physician, older patient relationship.

J Fam Pract 1989; 28: 441-448.

34. Joyce C, Welldon R. The efficacy of prayer: a double-blind clinical trial. J Chronic Dis 1965; 18: 367-377.

35. Rosner F. The efficacy of prayer: scientific versus religious evidence. J Religion Health 1975; 14: 294-298.

36. Collipp P. The efficacy of prayer: a triple blind study. Med Times 1969; 97: 201-204.

37. Byrd R. Positive therapeutic effects of intercessory prayer in a coronary care unit population:South Med J 1988; 81: 826-829.

38. Sutton T, Murphy S. Stressors and patterns of coping in renal transplant patients. Nurs Res 1989; 38: 46-49.

39. McCarthy K. Early alcoholism treatment: the Emmanuel movement and Richard Peabody. J Sfud Alcohol 1984; 45: 59-74.

40. Buxton M, Smith D, Seymour R. Spirituality and other points of resistance to the 12-step recovery process. J Psychoacfive Drugs 1987; 19: 275-286.

41. Prezioso F. Spirituality in the recovery process. J Subs1 Abuse Treat 1987; 4: 233-238.

42. Hay D, Morisy A. Secular society, religious meanings: a contemporary paradox. Rev Religious Res 1985; 26: 213-227.

43. Dillon MC. Mutumwa Nchimi healers and wizardry beliefs in Zambia. Soc Sci M e d 1988; 26: 1159-1172.

44. Durie M. A Maori perspective of health. Soc Sci Med 1985; 20: 483-486.

45. Loudou J, Frankenburg R. Social anthropology and medicine.

ASAC Monograph 1976; 13: 223-258.

46. Roman0 0. Charismatic medicine, folk healing, and folk sainthood. Am Anfhropol 1965; 67: 1151-1173.

47. Kleinman AM. Medicine's symbolic reality. On a central problem in the philosophy of medicine. Inquiry 1973; 16: -206-21 - - - - -7 .

48. Griffith E, Mahy G. Psychological benefits of spiritual baptist 'mourning'. A m J Psychiatry 1984; 141: 769-773.

49. Glik D. Symbolic, ritual and social dynamics of spiritual healing. Soc Sci Med 1988; 27: 1197-1206.

50. Griffith E, Mahy G, Young J. Psychological benefits of spiritual baptist 'mourning', 2: an empirical assessment. Am J Psychiafry 1986; 143: 226-229.

51. Csordas T. The rhetoric of transformation in ritual healing.

Cult M e d Psychiafry 1983; 7: 333-375.

52. Fehring R, Brennan P, Keller M. Psychological and spiritual well-being in college students. Res Nurs Hea/fh 1987; 10: 391-398.

53. Malatesta V, Chambless D, Pollack M, Cantor A. Widowhood, sexuality and aging: a life span analysis. J Sex Murifal Ther 1988; 14: 49-62.

54. Robertson J. A week in the working life of a provincial GP. Holisfic Med 1990; 5: 141-149.

55. Lamberts H, Riphagen F. %'orking together in a team for primary health care - a guide to dangerous country. J R Coll Gen Procl 1975; 25: 745-752.

56. Aldridge D. One bodv: a guide f o healing in flie Church.

London: SPCK, 1987.

Address for correspondence Dr Da\lid Aldridge, Medizinische Fakultat, Universitat W'itten Herdecke, Beckweg 4, D-5804 Herdecke Brd, Gernlany.

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IS THERE EVIDENCE FOR SPIRITUAL HEALING?

Is There Evidence for Spiritual Healing?

David Aldridge

M y intent here is t o offer some evidence t o show that spirituality is a viable idea even within modern medical practice and that it is definitely an issue worthy of study.

David Aldridge, Ph.D., is associate professor of clinical research in the Faculty of Medicine at the University of Witten Herdecke in Germany, and the European editor for the journal The Arts in Psychotherapy. He contributed "The Music of the Body: Music Therapy in Medical Settings" to the Winter 1993 Advances.

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David Aldridge

The natural science base of modern medicine that, in turn, influences the way in which modern medicine is delivered, often ignores the spiritual factors associated with health. Health invariably is defined in anatomical or physiological, psychological, or social terms. Rarely d o we find diagnoses that include the spiritual concerns of oatients.

The descriptions we invoke as clinicians or researchers to characterize disease have implications for the treatment strategies we suggest and for the ways we believe people can be encouraged to become healthy or maintain the state w e regard as "health." We need to recognize that patience, grace, prayer, meditation, hope, forgiveness, and fellowship are as important in many of our health initiatives as medication, hospitalization, incarceration, or surgery. The spiritual elements of experience help us to rise above the matters at hand such that in the face of suffering we can find purpose, meaning, and hope (Hiatt 1986).

Desuite the attitude of modern scientific medicine, spiritual healing continues to exist, renewing itself with successive generations.

My intent here is to offer some evidence from a variety of sources to show that spirituality is a viable idea even within modern medical practice and that it is definitely an issue worthy of debate.

Two examples will illustrate the way this issue expresses itself in daily practice.

A 59-year-old woman, recently widowed, was referred to my practice after having taken an overdose of her prescribed pain medication.

At the time, as a research psychologist, I was seeing all patients within a given area of South westEngland as ii part of aresearch project attempting to understand why people attempted suicide (Aldridge 1984; Aldridge & Rossiter 1983; Aldridge & Rossiter 1984). This woman had a historyof chronic pain. A clinically significant point was reached when, after extensive tests and repeated therapeutic interventions, no organic grounds for her pain were found and her specialist consultants declared that her problem was "psychological" in origin.

She was then referred to a psychiatrist. At this point she overdosed with pain medication.

During our initial conversation, after I elicited the previous history, she described her problem as "being abandoned by God."

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ALDRIDGE The reader can perhaps understand my embarrassment at the time. Either I was faced with what appeared to be a psychiatric problem, for which I could find no grounds from the rest of her conversation, or a problem completely out of my therapeutic range. Yet I could recognize that her life was, indeed, one lacking in hope, one lived in isolation and perpetual suffering. Her religion made little sense to her anymore, and her priest could not comfort her.

Moreover, her family doctor, and confidant, had passed her on to a psychiatrist, an act in her eyes that condemned her as mad.

T h e case reflects a growing problem in our current society. People are suffering, often alone. They are without hope, and feel abandoned. when pain is expressed in this way, it has no simple causal reality (Morris 1992).One of the ways in which people express their suffering is by contacting a general practitioner or family doctor. When this contact fails, or they are stigmatized by the suggestion that their problem is psychiatric, they are further alienated-alienated in a system of organized care that is set u p to them.

Another example. A priest contacted me on behalf of one of his a professional man in his late thirties. Married with two children, he had been treated with a marrow transplant for leukeniia. There was little evidence of success. The patient was in increasing pain, and his blood status was causing concern.

His wife had become withdrawn. His oncologist, when asked what the next step was, had suggested that they pray. Nothing more, it appeared, could be done for the man.

The basic situation resembles that of the first case. A man, this time with his family, is suffering. The family is faced with a loss of hope. Its plans for the future no longer have any meaning. The medical initiatives have been exhausted. In both examples the patients were asking, "Why me, what have I done to deserve this?"

It is with regard to such exan~ples,by no means extraordinary, that we are asked to practice modern medicine. I shall argue that the issues of abandonment, suffering, loss of hope and meaning evident in such cases, and the transitions from living to dying are essentially spiritual, and clearly not solely physiological, psychological, or social.

What Is Spirituality?

Spirit, spiritual, spirituality, spiritual healing are terms with many shades of meaning and

The issues of abandonment, suffering, and loss of hope and meaning, and the transitions from living t o dying are essentially spiritual, and not solely physiological, psychological, or social. interpretation. We begin, therefore, with some definitions (see Figure 1 on page 6).

Benor, an American psychiatrist now a resident in England who has made a detailed study of healing initiatives (Benor 1991), offers a definition of healing that succinctly combines most of the modern concepts found in spiritual healing. Benor writes, healing is "the intentional influence of one or more persons upon a living system without using known physical means of intervention." Thus, spiritual healing is predominantly an activity of the mind as it impinges on matter.

H i a t t (1986), a psychiatrist, offers an understanding of the spiritual in medicine as it is understood in psychological terms. "Spirit refers to that noncorporeal and nonmental dimension of the person that is the source of unity and meaning, and spirituality refers to the concepts, attitudes, and behaviors that derive from one's experience of that dimension. Spirit can be addressed only indirectly and inferentially, while spirituality can be understood and worked with in psychologic terms." Hiatt suggests that by taking such a psychological framework we can discuss and use spiritual healing "within a modified Western framework" (p.

742). Thus healing, in Hiatt's perspective, is predominantly an activity of the spirit upon the mind.

In recent years the word spiritual has appeared increasingly in the nursing literature (Emblen 1992; Reed 1987) where spiritual needs have been differentiated from religious needs.

The difference between religion and spirituality centers on the idea of transcendence. Religious care is seen as helping people maintain their belief systems and worship practices, while spiritual care is seen as helping people to maintain personal relationships and a relationship to a higher authority as defined by an individual (God or life force, for example), to identify meaning and purpose in life and, to transcend a given moment. This idea of transcendence, the ability to extend the self beyond the immediate con-text to achieve new perspectives, is seen as especially important in the last phases

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IS THERE EVIDENCE FOR SPIRITUAL HEALING? P

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P

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Figure 1 Definitions of Spiritualit1 Spiritual Healing, and Spiritual Well-Being From Literature Cited in the Text --

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Author

Description

Benor D. 1990

"Healing is the direct influence of one or more persons upon another living system without using known physical means of interventions."

Cohen J. 1989

"Spiritual healers believe they can influence the course of an illness by 'spiritual' or nonphysical means. Healing can be offered in person or at a distance, and does not require religious acceptance or belief by either party. It is a complement, not an alternative, to orthodox medicine."

Csordas T. 1983

"Four kinds of healing are practiced by charismatics. Physical healing is the one most widely known in American religious culture, and is associated with popular evangelists. Spiritual healing treats the soul that has been injured by sin. The Healing of the Memories, also called Inner Healing, treats en~otional hurts or scars. Deliverance is the form of healing in which the adverse effects of demons or spirits on a person's behavior and personality are removed by expulsion of the spirits p d g e d to be responsible."

Ellis J. 1991

"Spiritual well-being is the affirmation of life in a relationship with God, self, community, and environment that nurtures and celebrates wholeness."

Emblen J. 1992

"Spiritual care includes helping people to identify meaning and purpose in their lives, maintain personal relationships, and transcend a given moment."

Fehring R. 1987

"Spiritual well-being is a personality attribute conceived of having one vertical dimension connoting one's perception of a relationship with God, and one horizontal dimension connoting one's perception of life-meaning or purpose or satisfaction with one's existence."

Glik D. 1988

"In regards to healing, rituals, symbols, and myths serve to shift focus from self to the collectivity, from the particular to the whole, from one series of life events to the whole life, from the unique to the archetypal."

Griffith E. 1983

"Healing is a natural ministry of the church and a church-based clinic could help people move toward a mature faith in God which, in turn, could influence bodily reactions in the direction of greater health."

Kuhn C. 1988

"Spiritual elements are those capacities that enable a human being to rise above or transcend any experience at hand. They are characterized by the capacity to seek meaning and purpose, to have faith, to love, to forgive, to pray, to meditate, to worship, and to see beyond present circumstances."

Hiatt J. 1986

"The spiritual dimension, then, is that aspect of the person concerned with meaning and the search for absolute reality that underlies the world of the senses and the mind and, as such, is distinct from adherence to a religious system."

Reed P. 1987

"Spirituality is defined in terms of personal views and behaviors that express a sense of relatedness to a transcendental dimension or to something greater than the self."

Smyth P. 1988

"Spiritual awareness is when others speak of the conviction that life has a purpose, of the search for meaning, of the attempt to interpret their personal illness in a way that makes sense of their worldview."

Solfin J. 1984

"Mental healing is the practice of treating illness without a known physical curative agent. It is also known as psychic healing, spiritual healing, nonmedical healing, sharnanic healing, prayer healing, miracle healing, laying on of hands, paranormal healing, and magnetizing, although these terms are not interchangeable."

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ALDRIDGE of life where dying patients are encouraged to maintain a sense of well-being in the face of imminent biological and social loss.

Generally, spiritual healing is discussed in three contexts. One involves clinical experience and the effects of spirituality on the wellbeing of patients. Well-being in this context mostly means an inner state of being; in a few instances spirituality in this context has implications for physiological change. A second context involves the communal and social benefits that spiritual healing brings. The third context involves physiological changes as a result of spiritual healing-sometimes in this sense called "mental healing." In this paper, I shall offer examoles from each context and then examine the historical and social sources of spiritual healing.

I t must be emohasized that in manv instances all three contexts, psychological, social, and physiological, are interlinked. For example, a lonely widow with a chronic illness may be invited to join the healing group of her local church for fellowship and the laying on of hands. The social context of the fellowship (belonging to a group) sets the context for her psychological well-being (acceptance, feeling wanted) which may have implications for her physical state (the relief of symptoms). All these may contribute to her spiritual state of transcendence (rising above thenutters at hand, feeling a new sense of purpose in life). Such considerations would seemingly belong to the biopsychosocial model suggested by Engel (1977). As clinicians and researchers, then, we are being asked to consider spiritual healing from the perspectives of social medicine, psychological medicine, and biological medicine.

The difficulty which arises when we try to discuss "spiritual" healing is that we are mixing a number of differing languages according to our own differing scientific, as well as religious, belief systems. he same discordant process can occur in medical consultations when we discuss symptoms with a patient who comes from a different ethnic or even religious group. Our explanations as practitioners also often differ from lay explanations. Some readers may readily accept that belonging to a social group will help a particular person feel well. Others may accept that feeling well has significant implications for physiological change which can be incorporated into medical practice. Another group may argue that it is not the physiological change that is important, or belonging to a group, but the very experience of transcendence which is all important for healing to take place.

The challenge for u s as practitioners is to make ADVANCES, The Journal of Mind-Body Health

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Table 1 Assessments b y Patients and Healers of the Benefits of Spiritual Healing* Response

Patients (N:44)

Healers -

p -

A great deal better

5

4

A good deal better

16

18

A lot better

9

10

A bit better

5

6

No different

9

6

'After Cohen 1989

The 44 patients in this study, with a range of problems common to general n~edicalpractice, were referred to a group of healers over a period of20 weeks by a doctor in London. Both patients and healers then assessed the benefits of the treatment.

sense of these ideas for ourselves and to understand how they make sense for our patients, and if they d o make sense, perhaps incorporate these ideas into our daily practice or referral network.

Spirituality and the Well-Being of Patients At the level of daily practice, a small but vocal number of general practitioners have been willing to entertain the idea of spiritual healing as a positive source of patient well-being and to incorporate spiritual healing into their practice (by laying on of hands, or praying with patients), or to include spiritual healers as part of their referral network (Brown & Sheldon 1989; Cohen 1989; Pietroni 1986). Cohen (1989) emphasizes the value of touch, time, and compassion that a healer can offer, and the benefits of referring patients to spiritual healers (see Table 1). In such practices, spiritual healers are included in the referral network of practitioners.

T h e demand for so-called "whole person" treatment has been strenuously adopted by some nursing groups who believe that in caring for the patient there is a need to include spiritual needs and to allow for the expression of those needs (Boutell & Bozett 1990; Burkhardt 1989; Clark et al. 1991; Grasser & Craft 1984; Labun 1988; Soeken & Carson 1987; Stuart, Deckro & Mandle 1989). Within these approaches, there is a core of opinion which Fain993

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IS THERE EVIDENCE FOR SPIRITUAL HEALING?

Figure 2 Coping W i t h the Effects of Terminal Illness on Family Life* Class of Change

Example of Change

Coping with physical changes

Anticipation of pain Management of pain Management of the physical sequelae of illness (nausea, incontinence) and change in the physical appearance Management of the physical sequelae of treatment

Coping with personal changes

Loss of hope, fitness, and identity Anxiety and depression about the future Loss of role in family and in employment Frustration and helplessness

Coping with family and marital changes

Resolution of conflict Change in parental roles Anxiety about future welfare (emotional and financial) Anticipated hospital contacts and treatment Anticipated loss of a family member ~lanni-ngthe future Social isolation Changes in family boundary, and of family and marital en~otionaldistance Negotiation of dependence/independence Saying "goodbye" and talking about dying Handling the above personal and physical changes Loss of sexual activity

Coping with spiritual changes

Feelings of loss, alienation, and abandonment Understanding suffering Accepting dependency Handling anger and frustration Forgiving others Discovering peace Discussing death Grieving Planning the funeral Discovering the value of living

*Aldridge 1987b,p. 214

The terminal illness of a family member raises many challenges for a family, which must deal with the physical changes in the patient and with changes in the family itselfpersonal changes, changes in intimate relationships, changes in family role and organization, and spiritual changes. Some changes have ramifications through the interconnected systen~s.

For example, personal changes have implications for family and co1111n1t11ity members.

accepts suffering and pain as part of a larger life experience, maintaining that they can have meaning for the patient and also for the people providing care (Nagai Jacobson & ~ u r k h a r d i 1989). The emphasis is upon the person's concept of God and his or her sources of strength and hope, and on the significance of religious practices and rituals in the patient's belief system (Soeken & Carson 1987).Some of the nursing community have argued that spiritual well-being is a hedge against suicide, providing 8

David Aldridge

some people with a reason for living (Ellis & Smith 1991), and that it alleviates depression (Fehring, Brennan & Keller 1987).

I n caring for dying patients, doctors and nurses sometimes work together with the clergy (Conrad 1985; Reed 1987; Roche 1989). A community approach that includes the family and friends of the patient appears to be beneficial (Aldridge 1987a, 1987b, 1987c, 1987d-also see Figure 2). The principal benefits of both ap-

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ALDRIDGE preaches include a lessening of state anxiety, improved general feelings of well-being, and an increasing spiritual awareness for the dying person regardless of gender, marital status, age, o r diagnosis (Kaczorowski 1989). In addition, comprehensive treatment programs for people with AIDS recommend that attention be paid to the spiritual welfare of the patient and its influence on the patient's well-being (Belcher, Dettmore & Holzemer 1989; Flaskerud & Rush 1989; Gutterman 1990; Ribble 1989).

Reed (1987), in a study of spirituality and well-being in terminally ill hospitalized patients, hypothesized that terminally ill patients would have a significantly greater spiritual perspective than either nonterminally ill hospitalized adults (with problems that were not typically life-threatening), or healthy nonhospitalized adults. The hospitalized patients were recruited from the same hospitals. To assess the extent to which spirituality played a meaningful role in the life of the patient, based on the patient's own understanding of spirituality, Reed used a spiritual perspective scale that she had developed (Reed 1986). To measure the participant's satisfaction with life, she used the Index of Well-Being developed by Campbell, Converse & Rodgers (19761, who incorporated both cognitive and affective dimensions of general well-being. Both instruments had been previously examined for reliability and validity and were found to be acceptable for the health groups studied.

R e e d found that for the terminally ill patients there was indeed a shift toward greater spirituality as indicated by a stronger faith and increased prayer. Adults who become increasingly aware of their own mortality appear to develop a greater need for the spiritual dimension of life. Reed found that the well-being scores were similar for all three groups, and she hypothesizes that an awareness of spirituality is a source of well-being for the terminally ill.

It is not only for the dying that spirituality plays a role. For the widow who must adapt to the loss of a partner, the ability to express her spirituality can, along with other criteria, play an important role in enhancing well-being.

In a study of widows between the ages of 40 and 89 (Malatesta et al. 1988), women over 49-years-old rated physical exercise, churchgroup activities, expressing spirituality, and interacting wit11 friends and relatives as similar in their effectiveness. For young and old groups of widows, attention tospiritual needs, physical exercise, and a willinp~essto be selfindulgent all contributed to satisfy emotional and sexual needs.

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Spirituality and religion, then, appear to be mediating factors for coping with an impending loss of life, and appear to be positive factors for maintaining well-being, particularly in older patients.

Prayer and Well-Being Prayer is, of course, a spiritual practice, and there is sufficient data on prayer and the wellbeing of patients to examine these data by themselves. A number of authors, across several cultures, have described prayer as a valuable activity for elderly patients (Chatters & Taylor 1989; Garrett 1991; Gorham 1989; Koenig, Bearon & Dayringer 1989; Markides 1983; Reed 1987; Taylor & Chatters 1991). Seeking medical helpand utilizing prayer are not mutually exclusive activities, since patients consider prayer an active coping response in the face of stressful medical problems (Bearon & Koenig 1990).

F o r example, in a recent study, Saudia and colleagues (1991) examined the relationship between a sense of control over one's own health and the helpfulness of prayer as a directaction coping mechanism in patients about to have cardiac surgery. The Multidimensional Health Locus of Control Scales and the investigator-developed Helpfulness of Prayer Scale were issued to 100 subjects one day before cardiac surgery. Ninety-six subjects indicated that they used prayer as a coping mechanism in dealing with the stress of surgery, and 70 of these patients gave prayer the highest possible rating on the Helpfulness of Prayer Scale.

Prayer was perceived as a helpful, directionaction coping mechanism, and according to these patients warranted support by health personnel.

Prayer as a coping mechanism for stress was also discoveredin another patient group.

Less than 4 years after a kidney transplant, 40 patients rated the severity of 35 potential stressors (Sutton & Murphy 1989). Patients then rated the extent to which they used each of 40 coping strategies to deal with stress. The most stressful items were monetary costs and fear of kidney rejection; the least stressful was fear of not being accepted by family and friends.

Prayer and looking at the problem objectively were used most often in cooine" with stress.

Drug and alcohol abuse and blaming others for problen~swere used least often. At the pragmatic level of the patient, prayer and looking at the problem objectively are considered conipleme&ary activities.

In treatment of alcoholism, there has been a historical tradition of including spiritual 1

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IS THERE EVIDENCE FOR SPIRITUAL HEALING?

Table 2 Positive Therapeutic Effects of Intercesso ry Prayer in a Coronary Care Unit Population* New problems and therapeutic events

Intercessory prayer group % (No.)

Control group % (No.)

P

Congestive heart failure

4(8)

lO(20)

<0.03

Diuretics Cardiopulmonarv arrest

3(5) 2(3)

805) 7(14)

<0.05 <0.02

Pneumonia

2(3)

703)

<0.03

Antibiotics

2(3)

907)

~0.005

Taken from Byrd 1988

When comparing patients who received intercessory prayer with patients who received the usual hospital treatment, a study found that a smaller percentage of the patients in the prayer group experienced new problems or needed additional therapeiitic interventions.

considerations in treatment plans (McCarthy 19841, apart from the temperance movement.

Such treatments for alcohol abuse are often composite packages using physical methods of relaxation, psychological methods of suggestion and auto-suggestion, social methods of group support and service to the community, and spiritual techniques of prayer. These approaches have been extended into the treatment of chemical dependency (Buxton, Smith & Seymour 1987) and substance abuse (Prezioso 1987).

A study of 160 family physicians and general practitioners in Illinois found that most physicians also believe that religion has a positive effect on physical health, that religious issues should be addressed, and that the older patient may ask the physician for prayer (Koenig, Bearon & Dayringer 1989). The physicians also reported that patients claimed that in times of great emotional and personal distress they would like their physician to pray with them and that religious faith was an important influence in their lives. While some physicians advocated active prayer with the patient, physicians were more likely to support more passive and less intimate forms of religiousinteraction, and patients were more likely to mention such issues if the initiative was taken by the doctor. An influential factor in requesting prayer is the belief system of the physician, which may influence, in turn, the willingness of the patient to talk about such matters. In terms of clinical effects, the expression by patients of their religious beliefs appears to be a deterrent for affective disorders such as depression, a factor in promoting 10

David Aldridge

health-seeking behavior, and a promotor of compliance with medical initiatives.

In a further paper, one of the authors of the above study, Koenig (1989), admits that spirituality is a sensitive topic in the primary care of the patient both for patient and practitioner. The older practitioner is likely to have been trained in the medical model that proscribes religion and personal concerns as part of the treatment plan. Younger colleagues, perhaps aware of the biopsychosocial model, may be more willing to consider religious beliefs which they include as "psychosocia~concerns."

Although " initial clinical research into the physiological benefits of prayer has been inconclusive (Collipp 1969; Joyce & Welldon 1965; Rosner 1975), at least one study indicates that intercessory prayer may have benefits.

In a study of a coronary care unit, Byrd (1988) found that the group receiving intercessory prayer had an overall better outcome, requiring less antibiotics, diuretics, and intubation/ventilation than the control group (see Table 2).

B y r d evaluated the effects of prayer using a prospective randomized double blind protocol. Over 10 months, 393 patients admitted to a coronary care unit were randomized (after signing informed consent) to an intercessory prayer group (192 patients) or to a control group (201 patients). While hospitalized, the first group received daily prayer from participating Christians, praying outside the hospital; the control group did not. The aims of the prayers were for a rapid recovery, the prevention of complications and death, and any other improvements that were beneficial.

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ALDRIDGE At entry, the groups were statistically identical. After entry, all patients had a clinical follow-up for the remainder of the admission.

Throughout the study, the investigator, doctors, and nursing staff remained "blind" to the group to which a patient was allocated. To avoid any bias, the investigator did not contact the patients after they were assigned to a group.

Each patient in the prayer group was assigned three to seven "intercessors"-those who would pray for them (intercede with God).

The intercessors knew the patient's first name, knew the medical diagnosis and general condition of the patient, and were informed of any changes in the patients' general condition.

Based on clinical events after entering the hospital, the group receiving prayer had a significantly lower "severity score." The control patients more frequently required ventilatory assistance, antibiotics, and diuretics than did patients in the prayer group.

In general, patients were said to have a good course of events when no new diagnoses, problems, or therapies were recorded. Patients with a higher level of morbidity and a moderate risk of death were said to have an intermediate course. Patients with the highest morbidity risk, or who died during the study, were considered to have had a bad course. Eighty-five percent of the prayer group were considered to have had a good hospital course as compared to 73 percent in the control group; an intermediate course was observed in 1 percent of the prayer group and 5 percent of the control group; and 14 percent of the prayer group had a bad course compared with 22 percent of the control group.

ically requested ~ h r i s t i a nScience treatment when he became ill, despite advice during his illness to seek medical

Health Beliefs and Social Explanations People claiming active membership in a religious institution in England is very low, yet many British citizens report that they have had a spiritual experience at some time or another (Hay & Morisy 1985). When given the chance, these people will talk freely about such seemingly common experiences. The point is that spirituality is not usually mentioned in medical dialogues with the physician because it does not appear to be pertinent to the physiciannot because it lacks pertinence to patients. New efforts for lay involvement in medicine and a call by the nursing profession for spiritual (or holistic) understandings of illness are efforts to bring into medical discourse the meanings that patients ascribe to illness and health that often involve notions of spirituality. For the patient, it ADVANCES, The Journal of Mind-Body Health

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IS THERE EVIDENCE FOR SPIRITUAL HEALING?

A small but vocal number of general practitioners have been willing t o entertain the idea of spiritual healing as a positive source of patient well-being and t o incorporate healing into their practices. is vital to make sense of the experience of being sick. Patients search for meaning in the face of stress, chaos, loss, loneliness, hopelessness, and impending or current suffering.

It is at the level of health beliefs that an individual's particular healing explanations . seem most acceptable to u s in the profession of medicine. For example, black American women with AIDS (Flaskerud & Rush 1989) described the sources of their illness and their remedies in two broad categories, natural and supernatural.

A treatment program based on the understandi n g of ~ the women themselves included prayer and spirituality as well as prevention. This incorporation of modern and traditional beliefs and practices has also been used in treating various ethnic groups throughout the world (Conway 1985; Dillon 1988; Durie 1985; Griffith 1983; Loudou & Frankenberg 1976; Roman0 1965; Viens 1983).

W h a t is important to learn from these experiences is that patients have beliefs about the origins and meanings of their symptoms, that these meanings are important for the pa: tients, that the meanings are mixed, and that they have implications for the way in which patients believe they may be healed (Helman 1984). It is as important to recognize and respect the meanings and worldview of the person being treated as it is to use the meanings incorporated in modern scientific medicine.

For both patient and doctor, syn~bolic meaning plays a n active part in disease formation, the classification of diseases, the cognitive management of illness, and in therapy (Kleinman 1978; Kleinman & Sung 1979; Kleinman 1973). Symbolic meaning provides a bridge between cultural and physiological phenomena, and is a means by which illness is explained, treatment negotiated, and recovery understood (Helman 1984).

Symbolic meanings are often contained within particular ritual practices. Hence the prohibition that spiritual healers cannot wear white coats in English hospitals. If such healers 12

David Aldridge

did wear white coats, there would be a blurring of symbolic realities and hierarchies belonging to particular rituals of orthodox medicine.

Griffith & Mahy (1984) describe such cultural differences in a church-based healing clinic that mixed orthodox modern medicine and spiritual healing. Not only were there differences in describing the healing processes in the clinic, there were understandable differences in the use of healing rituals-laying on of hands and prayer versus consultation and injections, and also differences in the hierarchies of practitioners. While practitioners from differing traditions may work in parallel, as in such a clinic, it is another gigantic step to ask that they work in unison. Some authors see danger in such unity in that so-called marginal healing practices may be "n~edicalized"and lose some of their vitality (Glik 1988).

A change in the meaning of life appears to characterize many reports of healing rituals.

Marginalized individuals-the sick, the poor, the lonely, and the elderly-are brought into a group context where they are cared for and accepted. For some participants, this process offers a way of self-expression and self-fulfillment within a communal context, thereby ritually affirming an individual's social worth (Griffith & Mahy 1984; Griffith, Mahy & Young 1986). Thus, some church-based healing groups are more concerned with lifestyle approaches than with physical pathologies. From this perspective, sickness, when placed in the hands of a divine authority, releases the patients to a new form of living and to integration within a community. This is the significance of the sacrament of the laying on of hands as a sacred reality (Csordas 1983)-placing the sickness in the hands of God. It is not to be equated, as some writers do, with the therapeutic touch of the doctor, which is a secular reality.

We have seen earlier that for widows, contact with others, combined with the ability to express spiritual needs, contributes to a feeling of well-being. If w e consider the plight of widows throughout the world, and the trends in suicide among the elderly (Mao et al.

1990; Pinto & Koelmeyer 1991; Schmidtke & Weinacker 1991; Sverre 1991), we may wish to ponder how seemingly unconventional approaches like prayer and encouraging the social activity of belonging to a church group might alleviate the problems of living alone, social isolation, and hopelessness. Increasing home care, as opposed to institutionalized care, for the elderly appears to be a valuable practice.

However, when a partner dies, and an elderly widow lives alone, then home care can lead to

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ALDRIDGE home isolation. While medical practitioners cannot be held responsible for the disintegration of the social network, they can initiate activities for a widow, for example, that put her in touch with people who may stimulate her reason for living and bring her into contact with a social group that would support her.

Church healing groups appear to fulfil1 this function for some elderly patients. While evidence for such a suggestion is scattered among the literature, it seems a matter of common sense to encourage family practitioners to try and incorporate such practice as social medicine, even if they cannot accept the spiritual explanations that are offered.

Healing, Energy, and Mental Healing

Isolation cannot be treated with medication. It is a sad reflection on our medical understanding~of the elderly that the medication that is prescribed for the relief of their problems sometimes is the agent of their deaths. In Norway, where suicide has increased in the elderly, sedatives are the toxic agents in 56 percent of the cases of attempted suicide (Ekeberg & Aargaard 1991). We must be aware that elderly individuals present their problems as somatic complaints to their physicians (Eisenberg 1992), but these complaints must not be taken at face e~ be understood as value. ~ a t h e r , t h should expressions of distress that may be psychological, social and, like my patient described at the beginning of this paper, spiritual. Expressing distress as sleeplessness and chronic pain can be understood in the context of isolation and loneliness. While prayer and church-going are not a panacea for all ills, for some patients they would surely set the appropriate social and psychological context for the delivery of medical initiatives and encourage the compliance on which such initiatives depend.

It should be noted that the poor, the lonely, and the isolated are prey to abuse by so-called spiritual healers. Television healers who appeal to the public for money are often preying on the sympathies and needs of people who have little hope and whose primary contact with a caring attitude is through television.

Apart from being an indictment of our uncaring society, this situation is an obvious reminder that spiritual healing in the name of evangelism can be usurped for material purposes. In biblical times healers, as evangelists, were not allowed to receive material or monetary gain for their endeavors. They had to earn their living by means of a trade. St. Paul was a tent maker, for example. Such a coarse yardstick may be applied today: if spiritual healing costs money or is followed by a request for a donation, then it should be treated with suspicion.

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We turn now to a concern that is completely different from the previous clinical examples and psychosocial descriptions, neither of which inferred any causal mechanisms: spiritual healing and physical change.

How the influence of spiritual healing on physical change is demonstrated, how evidence for it is presented, and how it is to be explained raises a number of problems. First, that which is of the "spiritu-that which is nonmaterialis not readily accessible to demonstration and explanation within the limits of a physicalist science, although the effects of healing are often expected to be shown in material change.

Second, the words that are used for describing different forms of healing come from varyingtraditions and have different meanings.

Explanations for how spiritual healing works are paraphysical, energetic, or magnetic.

The leading explanatory principle is that there are divine energies that are transformed from the spiritual level through the agency of the healer to produce a beneficial influence upon the "energy field" of the patient. This notion of "energy field" is the sticking point between orthodox researchers (Jacobs 1989; Wood 1989) and spiritual practitioners. If such a field exists, researchers ;aintain, then it should be possible means, which no one to measure it by. physical - has yet done to the satisfaction of modern scientific medicine.

The problem probably lies in the use of the word "energy," which has a broader meaning in spiritual healing than it does in physical science, and is likened to organizing principles of vitalism and life force that bring about a harmonizing of the whole person. The source of the word energy in Greek is ergon, meaning to work in a physical sense, and it is this meaning that is used by modern scientists. The alternative sense of the word-to be active or possessed by a demon-is more often meant by spiritual healers. With the prefix en, the word becomes energio-to be in action. Modern spiritual healers use energy in this sense to suggest dynamic forces that are channeled or set in motion by the healer, or the patient.

While the state of mind necessary for healing has been elusive to research, there has been extensive research into physical effects of spiritual healing, including investigations that use controlled trials. The effects of healing on enzymes, body chemicals, and human tissue Fall 1993

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IS THERE EVIDENCE FOR SPIRITUAL HEALING? cells have been studied in test tubes, as have the effects on cells and lower organisms (including bacteria, fungus, and yeasts), on the motility of simple organisms and plants, on animals, and even on human physical problems (Benor 1990a, 1990b, 1991; Solfin 1984).

While spiritual healing is often dismissed as purely a placebo response-a response "to please" the researcher-the evidence from studies of lower organisms and cells would indicate that there is direct influence. We must ask ourselves why a single-celled organism responding to spiritual healing would want to please a human. This way of thinking is surely an unacceptable form of anthropomorphism.

Gregory Bateson has pointed out that "a dormitive principle" w a s once used by scientists to describe the effects of morphine (Bateson 1972).

Such a principle in reality did not exist; it was a pseudoscientism adopted for the purposes of explanation. We may assume that in some cases "placebo" is invoked when in reality we should say that w e d o not understand what is happening. Even if w e introduce the idea of "expectancyeffectsUas an influence on experimental data, we are still left with a body of knowledge that begs understanding (Solfin 1984). In fact, the explanations of "placebo response," "spontaneous regression," and "expectancy effect" are no less metaphysical than those usually given for healing phenomena.

G r a d , Cadoret & Paul (1961) worked with a recognized "healer," the retired Hungarian army officer Oskar Estebany. Estebany became the source of a variety of successful and elegant healing experiments with plants and mice, some of which were replicated (Solfin 1984). These experiments were carefully controlled and hastened growth or healing.

Smith (1972), a Franciscan nun and biochemist, worked with Estebany and other healers to test the hypothesis that any healing force channeled through, or made active by, the hands of a "paranormal" healer must affect enzyme activity. At first she con~paredthe effects of laying on of hands by Estebany on the activity of the enzyme trypsin. Solutions of trypsin (500 p g per m1 in 0.001 N HC,, pH3) were divided into four samples. One sample was an unaltered control state. A second sample was treated by Estebany with the laying on of hands in much the same way he treated patients: he put his hands around a stoppered flask containing the enzyme solution for a maximum of 75 minutes, 3nd portions being pipetted out after 15,30,45, and 60 minutes.

Another sample w a s exposed to ultraviolet light (2537 Angstrom) for sufficient time to reduce 14

David Aldridge

the activity of the enzyme 68 to 80 percent.

(Grad, in the previously mentioned study had suggested that Estebany treat an "unhealthy" enzyme in future studies.) The fourth sample was exposed to a high magnetic field (8-13,000 gauss) for hourly increments of u p to three hours.

The qualitative effect of the high magnetic field and the treatment by Estebany were similar in that enzyme activity increased u p to one hour of exposure. Smith, while warning against drawing too close a parallel between magnetic field effects and treatment effects from a healer, suggests that both forces bring about a change in the organization of hydrogen bonding in the molecules leading to higher enzymic activity and that such a reorganization could be the basis of the healing principle.

Smith then repeated this work with three people who claimed to have no healing powers and with three who did. None of these subjects had any positive effect on the enzymes. Nor did Estebany when Smith attempted to replicate the experiment with him. His failure was attributed to his state of mind at the time, it presumably not being conducive to healing.

However, at a later date Smith found that three recognized healers were able to alter the enzyme (according to a spectro-photometric analysis) in the way that Estebany had done.

The quantitative effect varied daily according to the physical or emotional state of the healer.

Further experiments with two other enzymes, nicotinamide-adenine-dinucleotide and amylase-amylose, resulted in a decrease in activity or an inability to influence activity. Smith argues that for the amylose this was a good sign, in that a change in the amylase-amylose balance would not be conducive to healing. In all, Smith believes that the effect of laying on of hands on enzymes contributes to the healing process.

A nurse researcher, Krieger (1979), taking u p the challenge to demonstrate healing by laying on of hands, made a series of before and after studies on human subjects. Like Smith before her, she was influenced by the work of Grad and Estebany. As the dependent variable, she took hemoglobin values which had appeared to respond to Estebany in the initial experiments. Krieger used a small group of nurses whom she had trained in the art of laying on of hands (she called it "therapeutic touch"). The hemoglobin values of the patients did change after the laying on of hands. There is also anecdotal evidence that the general well-being of the patients improved.

Other authors (Benor 1990b; Solfin 1984) have searched the available literature and pre-

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ALDRIDGE sented the variable results of healing initiatives.

Most of the studies have fallen by the wayside because of poor research design. Nonetheless, there appears to be material evidence from the aforementioned studies for an intentional healing effect. At the same time it must be said that the energetic correlate of that effect remains elusive to measurement in both the laboratory and the clinic. Much of this difficulty seems to be caused by the literal expectation of a material energy and the need for a materialistic causal explanation. The Byrd coronary care study (1988) mentioned earlier highlights the difficulty of understanding what was going on. There was no physical contact between the patients in the study and the intercessory healers. Indeed the patients were blind to the knowledge of whether anyone was praying for them or not.

Furthermore, the praying was being done from a distance, not by laying on of hands, and if energies were involved they were not responding to the usual laws of energy which demand that as distance increases then energy diminishes incrementally. However, material benefits appeared to result from the prayer activity.

But there may be other ways to look at this issue.

A Historical Perspective on Healing Medicine has a system of explanations for what it does. These explanations are predominantly scientific, and it was the coherence of this system of explanation that was influential historically in separating scientific medicine from the influence of the church and metaphysical notions of healing.

Historically, ideas regarding healing fell into two main schools-ritualistic healine. ". whereby people fall ill and are restored to health through psychic or spiritual forces; and mechanistic healing, where people become ill from overindulgence, sitting in damp places, or changes in the weather, and are restored to health by purges, diet, and the physical unblocking of energies.

The sacred disease "epilepsy," which included hysteria and demonic possession, was once believed to be caused by the entry of the gods into mortal bodies to serve divine purposes. This explanation was challenged in the fifth century (Inglis 1979) when some argued that the invocation of divine elements masked the inability to provide effective treatment. With the questioning of spiritual causation, material causes were sought:~he result was the theory

of the "four humors," all of which must be balanced to maintain the status of health within the body. These theories eventually led to modern physiology and allopathic remedies. s o m e 2,000 years ago, Christian healing, reviving vitalist theories and shifting away from Greek concepts of hygiene, survived under the threat of Roman persecution by inspiring followers with acts of healing and other inspirational gifts. Christ's injunction to his disciples was to heal the sick. Sickness was said to be caused bv sin. or loss of faith: and the restoration of faith through acts of repentance and the sacrament of healing could restore the person to health. In the early accounts of Christian healing, body and soul were not separate. A soul restored to holiness (wholeness)-the root word of health and healing-was also a healthy body. In these terms, wholeness means a return to unity with God and is achieved by the action of the spirit. Thus, healing as a restoration of souls in their unity with God became an important element in the early evangelical endeavor.

Such an ecological understanding is not far from modern (w)holistic understandings (Bateson 1991) but is far removed from humoral or physiological explanations.

As Christianity gradually became accepted, the establishment of spiritual healing, which depended on healers who were inspired by the spirit as opposed to being licensed by law, was seen as a threat to the hierarchy (the law) of the church. Eventually, in the twelfth century, Pope Alexander banned spiritual healing as a suspect activity inspired by the devil to seduce unwitting clergy to deal with matters of the flesh and all its temotations. Such material concerns were best left, the church admonished, to physicians.

About thii time, physicians began to organize themselves into guilds, and medicine began to form itself into a b o d y of knowledge replicable in university centers throughout Europe. Metaphysics became increasingly idiosyncratic and open to individual interpretation and sentimentality. Christianity thus surrendered the sole authority to speak of life, birth, and death to a materialistic science that verified human life in the same way in which it verified the physical universe (Needleman 1988).

Understandings of the body and its relation to illness were then transformed in the seventeenth century by the ability to dissect corpses (Foucault 1989), which led to a new classification for disease. Supernatural explanations and causative forces were rejected in favor of theories within the realm of material phenomena as seen in the status of the internal

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IS THERE EVIDENCE FOR SPIRITUAL HEALING? Figure 3 The Action of Pneuma (Breath) in the Body in A y u v e d i c and Unani Medicine* Type

Location

Functions

Vital pneuma

Formed in the heart and conveyed through the arteries

All vital activities

Animal pneuma

Located in the brain and transported by the nerves

Intellect, sensation, dynamic, and movement

Natural pneuma

Located in the liver and transported by the veins

Sensual desire, nutrition, and blood formation

Ă&#x201A;ÂĽSeVerma R. & Keswani N. 1974

organs. However, what was missing from such observations of the dead were the vital forces necessary for living. Academic medicine in the universities was similarly separated from the empirical practice of clinicians observing the effects of their ministrations. Any understanding that the human body could be organized by subtle forces, and represented the presence of a higher intelligence in the universe, was abandoned (Hossein Nasr 1990).

I n this brief survey, it is helpful to look at some older conceptions of energy, spirit, and healing. Ancient systems of healing were based on the dynamic notion of energy (Leskowitz 1992) as such a life force. Fire energy brought warmth through the principle of motion. Hidden energy, as air, was the sustaining energy and the activator of fire energy, which used as its vehicle the blood stream, thereby maintaining the chemistry of life and conveying the vital energies of the body. In addition, there were three forms of energy distribution-through the seven energy centers that served as points of reception and distribution throughout the physical body, through the seven major glands of the endocrine system, and through the nervous system. Restriction or inhibition of the free flow of these energies was seen to create an imbalance or disharn~onyin the other energies.

Health could be restored by either releasing the cause of the blockages or through the application of specific musical tones, to restore the flow of energy.

In traditional Indian forms of medicine, Aryuveda and Unani (Greco-Arabian), we see a vitalist epistemology based on the physician as the activator of the seven natural principles that administer the body (called elements, temperaments, humors, members, vital breaths, faculties, and functions) (Verma & Keswani 1974).

The proposition of Hippocrates is to the point:

"Nature heals; the physician is nature's assistant.''

Breath is an important factor in activating the patient in the early systems of healing.

Vitality itself derives from viva, as in "Let him live." Such a living force is carried by the breath. Breath and spirit share the same root, in Latin spirare, which later becomes spiritus, life breathed as the Holy Spirit. Life has the quality of inspiration and is heard in biblical texts as "1 a m the Breath of Life." Similarly, the Greek anemos and the Latin animu are translated as wind and breath. Thus, we have the ideas of vitality and animation being achieved through the inspiration of the breath, or pneuma in Unani medicine, which is the conveyor of the spirit and activates, dependent on its location (see Figure 3), particular systems of the body.

Today, Aryuvedic medicine and yoga use the regulation of breathing as an important factor in healing.

If

we consider the roots of the everyday words that we use in medicine, then we see that spiritual considerations, as they relate to meaning, hope, and purpose, are not strange.

"Patient" is derived from the Latin pati, which is to suffer and patiently endure. "Doctor" is the teacher who discerns, from the La tin docilitas.

"Therapy," from the Greek therapeutikos, is attentive support. Therapist and doctor accompany the patient in his or her suffering. The responsibility of the healing practitioner is to reach out to the patient, and the responsibility of the doctor is to discern and to teach. Such a stance is not solely concerned with cure. There are also the possibilities of relief from suffering and comfort for the sick.

"Medicine," from the Latin root medicus, is the measure of illness and injury, and shares a derivation from the Latin metiri, to measure.

This medical measurement was based on nat-

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ALDRIDGE

Figure 4 Differences Among Health Practitioners, Modern Spiritual Healers, and Traditional Shamans Health Practitioner

Modern Spiritual Healer

Traditional Shaman

Becomes caregiver by self-selection to a professional group

Becomes caregiver by self-selection often to a group, o r by nomination within a hierarchy

Becomes caregiver by selection through crisis or inheritance

No initiatory crisis, and pathological crisis a hindrance to vocational training

No initiatory crisis necessary, but concept of "wounded healer" plays an important role

Initiatory crisis sign of vocation, and pathological crisis necessary for vocation

Personal quest acceptable

Personal quest valued

Personal quest devalued or irrelevant

Institutional training

No institutional training necessary

No institutional training

No arduous mental and physical ordeal

No arduous mental and physical ordeal

Arduous mental and physical ordeal

Limited apprenticeship

Brief apprenticeship

Long apprenticeship

Legitimacy bestowed by institution on behalf of the community (licensing)

Legitimacy bestowed by community

Legitimacy bestowed by community

No kinship ties

No kinship ties

Kinship ties

Variable status in community

Low status in community

High status in comn~unity

Patient removed from environment, often treated behind closed doors, with the focus on individuals or dyads (rarely as family or social groups)

Patient removed from environment, often treated behind closed doors, with the focus on individuals or dyads (rarely as family or social groups)

Patient treated within the con~munityas public phenomenon

Patient is the agent of his or her own healing and responsible for it

Spiritual forces or energy channeled by the healer is the agency of healing; patient responsible

The shaman is the agent of cure and responsible for the results

The patient takes the drugs

The patient receives the healing

The shaman takes the drugs

Time restraints to consultation

Flexible time restraints to consultation

No time restraints to consultation

Treatment provided for the material or personal gain of the therapist

Treatment provided for the material, personal, or spiritual benefit of the therapist

Treatment seen as a sacred event for the community with no personal benefit for the shaman

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IS THERE EVIDENCE FOR SPIRITUAL HEALING? ural cycles and measures. To attend medically, in Latin mederi, also supports the Latin word meditari, from which we have the modern "meditation," which is the measuring of an idea in thought. The task of the healer in this meditative sense is to direct the attention of the patient, through the value of suffering, to a solution that is beyond the problem itself-the idea of transcendence, as mentioned at the beginning of the paper. In this sense, the healer has the power to change the sign of the patient's suffering from negative to positive.

Shamans, present in most tribal cultures throughout the world, were also a spiritual healing elite who used techniques of ecstasy (dream and trance) to cure people, to guard the soul of the community, and to direct communal religious life (Eliade 1989). While trances were used to cure, they were also a means of transporting souls to other worlds and of mediating between humans and gods. Shaman healers were "recruited" by inheritance or spiritual vocation, underwent an arduous apprenticeship and then an initiatory crisis often involving the novice shaman being cured of a sickness.

Some modem-day healers like to think of themselves as caretakers of this legacy of the shaman. However, any such notion is a rather misguided romantic fantasy, revealing more about the modern-day healers' need for power and reward than the acceptable role of healers in present-day culture. Modern medical practice with its long initiatory training and its rigid hierarchy, the family expectations that sons and daughters follow parents into medicine, the veneration accorded doctors by the community, and the abuse of alcohol and drugs by medical practitioners has far more in common with shamanic practice (Figure 4, page 17).

Spiritual, Mental, and Energetic Healing Today While older "shamanistic techniques" of healing have all but died out in Europe except for remote rural areas in Northern Europe (Vaskilampi 1990), spiritual healing still exists throughout Western Europe (Sermeus 1987; Visser 1990), and occurs in two main forms.

The first involves hand contact, or near contact, from the healer to the patient. This form of healing is seen in the church ritual of the laying on of hands. The second form is healing at a distance where a healer or group of healers pray or meditate for the patient who is absent from their presence as we saw earlier in the Byrd study (1988). Patients can be far removed

18

David Aldridge

physically from the healing group. Healers of this practice emphasize that a special state of mind is required for it to occur.

D u r i n g this century some church groups have called for a healing revival. This has culminated within the last decade with a recognition in some Christian churches of a healing ministry. Such a healing ministry is often associated with a general interest in complementary medical initiatives that call for treating the "whole person." There are also spiritual healing groups who have no church or religious affiliation and whose sole existence is the pursuit of spiritual healing.

In England, various spiritual healing organizations and some religious groups have formed themselves into a confederation of healing organizations so that they can practice in hospitals and take referrals from physicians.

This confederation issues strict guidelines for practice and conduct ("Confederation of Healing Organization," 1990), which have been worked out with the help of the British Medical Association and the varying Royal Colleges.

The code of conduct covers legal obligations, encourages the patient to seek appropriate medical treatment, and emphasizes full cooperation with medical authorities. There are clear guidelines for healers visiting hospitals, which include instructions about not wearing white coats, how to behave on the ward, and how to obtain permission from the nursing officer.

Unlike doctors, healers must disclaim an ability to cure but can offer to attempt to heal in somemeasure, without any promise of recovery. (If healing should take place in such stringent conditions of psychological pessimism, then criticisms that these methods rely on "patient suggestibility" must surely be found wanting.) The above federation of healers now has several clinicallv controlled trials and a randomized double blind trial protocol under way for clinicians who are willing to cooperate (Benor 1990a).

Conclusion Clearly, in our modern culture several belief systems operate in parallel, and can coexist.

Patients have begun to demand that their understanding~about health play a role in their care, and practitioners, too, are seeking complementary understandings. As researchers and clinicians, we must act as anthropologists in the search for meanings to understand behavior.

Neither of the orthodox traditions, be it church or medicine, can explain how healing

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ALDRIDGE occurs. Nor will either be able to d o so until we begin to accept that our knowledge is wanting and our searching is misguided. Our spiritual understanding of the intention of healing is largely lost. While we may know the social implications of healing, that is, integration into the community, and improving and maintaining the available pool of labor; and while w e may know the psychological implications of healing, that is, happier and contented patients (Fehring, Brennan & Keller 1987) relieved of stress and sexually satisfied (Malatesta et al. 1988)-we remember little of the spiritual intentions of healing. Miracles had a deeper purpose than the restoration of physical health. It is not that the age of miracles is past, rather that their spiritual significance is no longer understood and has been supplanted by material and emotional satisfactions alone (Shah 1964).

A s yet we cannot understand healing energy through effectively measuring its properties, although its effects may be accessible to bioassav.

Perhaps what is more important, we systematically fail to define health. Recent considerations of holistic health or whole person medicine have included the idea of well-being and the unity of body, mind, and spirit. Gregory Bateson (1991) reminds u s that it is difficult to talk about living systems that are doing well.

It is easier to describe living systems when they are disturbed; we separate out the disturbed parts and thereby lose the necessary connections. While dissecting corpses brought an important understanding of the anatomy of the body in terms of the geometry of itsparts, the necessary connections of those parts in the dynamic processes of living were lost. This restoring of connection, the making of the completed whole, is the task for whic11 we are prepared as practitioners and healers, yet it eludes our descriptions as scientists an-d researchers.

Finally, I must point out that this paper is not an evangelical tract on behalf of spiritual healing. The reader is not being asked to change his or her belief system, merely to acknowledge that what the patient believes is of importance and will have an influence on the way in which health initiatives are accepted and maintained.

Furthermore, prayer is seen by many cultures as a n important activity in the maintenance of well-being, as a coping response in times of stress, as a healing activity, and as a source of comfort. To ignore such a powerful agent with the elderly, the dying, and the chronically ill is a folly. Removing the pillar of spirituality from

The expression of religious beliefs by patients appears t o help deter affective disorders such as depression, to encourage health-seeking behavior, and t o promote compliance with medical initiatives. our culture is as absurd as removing the pillar of science.

Illness may be seen as a step on life's way that brings us in contact with who we really are. The positive aspect of suffering has been neglected in our modern scientific culture, with the result that, as practitioners and patients, we search for immediate relief. This is not to advocate suffering, rather to assert that we d o not lose the potential of suffering for transformation of the individual. To accept the teaching of suffering, while pursuing relief from that suffering and comforting the sick, would also restore the doctor to the status of teacher.

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Journal of the Royal Society of Medicine Volume 84 September 1991

well be able to prescribe dressings the need for a doctor's prescription for pharmacological agents is unlikely to change.

It is only after a considerable amount of further work, interest and enthusiasm has been shown for this subject that it is likely to produce an improvement in the standard of care offered to all patients. Although leg ulcers may not directly lead to the death of many patients they can certainly make the patient's life extremely miserable when they are present.

References 1 Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic leg ulceration; the extent of the problem and the provision of care. BMJ 1985;290:1855-6 2 Cornwall JV,Dore CJ, Lewis JD. Leg ulcers epidemiology and aetiology. Br J Surg 1986;73:694-6 3 Blair SD, Wright DDI, Backhouse CM, Riddle E, McCollum CM. Sustained compression and chronic venous ulcers. BMJ 1988;297:1159-61 4 Colgan MP, Dormandy JA, Jones PW, Schraibman IG, Shank DG, Young RAL. Oxpentifylline treatment of venous ulcers of the leg. BMJ 1990;300:972-5

K G Harding Director, Wound Healing Research Unit, Department of Surgery University of Wales College of Medicine Heath Park, Cardiff CF4 4 X N

only temporary. A degree of personal responsibility is still demanded in those situations where the problem does not respond to treatment, where there are problems of mental health, chronic disease, family disorganization or sexually transmitted disease.

Within both church and medicine important changes These behaviours are couched in psychological, social, have taken place. Issues related to health and well-being have been raised which question the ethical and legal terms. Perhaps none more so than fundamental practices of these institutions. Principally by the new health and well being advocates. Rarely these issues are about the definition of health and who do we find diagnoses which include the relationship is to be involved in healing. These issues are not new. between the patient and their God. The descriptions It is the contention that such issues are raised at times we invoke have implications for the treatment of transformation when the old order, whether it be strategies we suggest. Patience, grace, prayer, in church or medicine, is being challenged. meditation, forgiveness and fellowship are as From the lay community there is a growing demand important in many of our health initiatives as for involvement in health issues and for initiatives medication, hospitalization, incarceration or surgery. promoting a healthy life style. Within the church too The spiritual elements of experience help us to rise there are demands by the laity to be actively involved above the matters at hand such that in the face of in the life of the church and for lay ministries to be suffering we can find purpose, meaning and hope. recognized. Communities are eager to make decisions Medicine has a system of explanations for what it about matters which affect their daily lives and are does. These are predominantly scientific, and it was no longer willing to abdicate the sole process of this coherence of cogent ideas whiph was influential decision making to licensed and expert professionals historically in the separation of scientific medicine who may be far removed from them in terms of from the influence of the church and metaphysical educational background, social class and experience. notions of healing.

This does not mean that there is a revolt against The history of the spiritual in healing reflects the expert health from the health professional or the growth of scientific knowledge, demands for religious clergyman. What is proposed is that these experts renewal and the continuing shift of understanding become facilitators and informed advisers. concerning what is health within a broader cultural Such a participative approach provides a real context. Throughout the last 2000 years Christian opportunity to remove the apartheid between church healing, reviving vitalist theories and shifting away and medicine in dealing with matters of our corporate from Greek concepts of hygiene, survived under the health. threat of Roman persecution by inspiring followers The natural science base of modern medicine. and by acts of healing and other inspirational gifts. the way in which it is delivered, often ignores many As Christianity gradually became accepted and of the social and spiritual factors associated with established, healing, which depended upon individuals illness. The over-riding concern of medical decisions being inspired by the spirit as opposed to being is that of correct diagnosis. Such diagnoses are licensed by law, was seen as a threat to the hierarchy concerned to discover the hypothesized cause of of the church. Furthermore, physicians began to the problem within the person. Health invariably organize themselves into guilds and medicine itself becomes defined in anatomical or physiological terms. began to form itself into a body of knowledge o141~07681gll In this way problems of living are translated replicable in university centres throughout Europe. ogo5160y/S02,0010 into physical descriptions; and, more importantly, Metaphysics became increasingly idiosyncratic and 1991 submitted to physical interventions. While this may open to individual interpretation and sentimentality. The ~~~~l give the sick a legitimate status and remove them Christianity surrendered the sole authority to speak Society of fromDavid condemnation is neurology of life, birth and death to a materialistic science which 23Medicine Aldridge as sinners, this situation Collected papers

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their presence. Patients can be far removed from the verified human life in the same way in which it healing group. Healers emphasize that a special state verified the physical universe. That the human body of mind is required for this influence to occur. could be organized by subtle forces and represented While the state of mind necessary for healing has the presence of a higher intelligence in the universe been elusive to research there has been quite was abandoned. extensive research into spiritual healing phenomena In spite of rational healing explanations and which has included investigations using controlled scientific medicine spiritual healing has survived trials1. Enzymes and body chemicals in vitro have throughout modern Western Europe, and continues been studied, as have the effects of healing on cells to flourish. During this century there have been new and lower organisms (including bacteria, fungus and calls for a healing revival from some church groups. yeasts), human tissue cells in vitro, the motility of This has culminated within the last decade with simple organisms and plants, on animals and on a recognition of the Christian churches healing human problems. While spiritual healing is often ministry, albeit contentiously, and is often associated dismissed a s purely a placebo response, the evidence with a general interest in complementary medical from studies of lower organisms and cells would initiatives calling for a consideration of the 'whole indicate that there is direct influence. Even if person'. There are also spiritual healing groups who we introduce the idea of expectancy effects as an have no church or religious affiliation and whose sole influence on experimental data we are still left with existence is the pursuit of spiritual healing. a body of knowledge which begs understanding. In In England these various spiritual healing organizafact the explanations of placebo and expectancy are tions, and some religious groups, have formed no less metaphysical as those given for healing themselves into a national federation so that they phenomena. can practice in hospitals and take referrals from At the level of daily practice general practitioners physicians. This federation issues strict guidelines for have been willing to entertain the idea of spiritual practice and conduct which have been worked out healing and incorporate it into their practice, to use with the help of the British Medical Association and spiritual explanations for some of their patient some Royal Colleges. The code of conduct covers legal contact, or as part of their referral network. Both obligations, how to handle t h e relationship with the patient regarding medical treatment and doctors and clergy have worked together to care for the dying. emphasizes full cooperation with medical authorities.

There are clear guidelines for healers visiting Prayer is described by several authors as valuable in terms of care for the elderly across several hospitals which include instructions about not wearing culture^^-^. Prayer and medical help seeking are not white coats, how to behave on the ward and how to mutually exclusive, prayer being considered as a n obtain permission from the nursing officer. Unlike active coping response in the face of stressful medical doctors healers must disclaim a n ability to cure but offer to attempt to heal in some measure, without any problems. Physicians believe that religion has a promise of recovery. If healing should take place in positive effect on physical health and that the older patient may ask the physician to pray with them. such stringent conditions of psychological pessimism, From a broader medical perspective intercessory then placebo explanations must surely be found prayer has been investigated in terms of coronary care wanting.

Explanations given for how such spiritual healing and proved to be beneficial6. For renal patients, prayer and looking a t the problem objectively were works are various; paraphysical, magnetic, psychoused most in coping with stress7. It is interesting to logical and social. The principal explanatory principle see that a t the pragmatic level of the patient, prayer offered by most commentators is that there are divine and looking a t the problem objectively are not energies which are transformed from the spiritual exclusive but complementary activities in their level by the agency of the healer and which produce a beneficial influence upon the 'energy field of the system of beliefs.

It is a t the level of health beliefs which the most patient'. This notion of 'energy field' is the sticking point between orthodox researchers and spiritual acceptable forms of healing explanations take place. practitioners in that if such a field exists then it For black American women with AIDS8 the sources of their illness and their remedies were classified should be possible to measure by physical means. The problem probably lies in the use of the word 'energy' as natural and supernatural. Prevention, prayer and spiritual were included in a treatment prowhich has a broader interpretation in spiritual gramme which incorporated traditional beliefs. This healing and is likened to organizing principles of incorporation of modern and traditional has also vitalism and life force which bring about a harmonbeen described in treating various ethnic groups izing of the whole person. Rather than considering throughout the world. What is important to learn 'energy' as an explanatory metaphor, we may be from these experiences is that patients have concerns better advised to develop the concept of 'information for the origins and meanings of symptoms that are exchange'. While the concept of 'information' in important for them and for the way in which they may this sense is also metaphoric, it is perhaps more be healed. It is as important to recognize and respect illustrative of the processes involved, and addresses the language of the person being treated as it is to the issue of illness having a meaning rather than a cause. remove a source of bacterial or viral infection.

Symbolic meaning plays a n active part in disease There are two predominant forms of spiritual healing in Western Europe. The first involves a hand formation, classification, the cognitive management contact, or near contact, between the healer and the of illness and in therapy. It provides a bridge between patient. This is also seen in the church ritual of the cultural and physiological phenomena. Symbolic meanings are the loci of power whereby illness is 'laying on of hands'. The second form is absent or explained and controlled. These symbolic meanings distant healing where a healer or group of healers are often contained pray David or meditate for the patient who is absent from neurology Aldridge Collected papers within particular ritual practices, 24

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hence the prohibition of spiritual healers from wearing white coats in hospitals. If such healers did wear white coats there would be a confusion of symbolic realities and hierarchies belonging to particular rituals of orthodox medicine. Griffith9 describes this cultural discrepancy well in a churchbased healing clinic which mixed both orthodox modem medicine and spiritual healing. Not only were there differences in healing realities, there were differences in rituals and also differences in hierarchies of practitioners. While separate rituals may exist in parallel, it is another gigantic step to ask that they work in unison. Some authors see unity as diluting the richness of the culture in that marginal practices will be medicalized and lose some of their vitalitylO. It is a change in the sense of meaning of life which appears to characterize many reports of healing rituals. Marginalized individuals; the sick, the poor, the lonely and the elderly, are brought into a group context. For some participants this offers a way of self expression and fulfilment within a social context thereby ritually affirming the social worth of the individuall1. Thus some church-based healing groups are more concerned with lifestyle approaches rather than physical pathologies. Sickness when placed in the hands of a divine authority releases the patient to a new form of living and integration within a community. This is the significance of the sacrament of the laying on of hands as a sacred reality and not to be equated as some writers do with the therapeutic touch of the doctor as a secular reality. Traditionally spiritual healers have not been allowed to benefit materially from their practice, the expectation has been that they support themselves with other work and divine healing is given free of charge.

It is clear that both medicine and spiritual healing can bring about the conditions under which healing can occur. But neither orthodox tradition, be it church or medicine, can explain how healing occurs. Nor will either until we begin to accept that our knowledge is wanting and our searching is guided by the wrong principles. Healing research or clinical outcome trials only measure the products or efficacy of healing endeavours. Our spiritual understanding of the intention of healing is lost. While we may know the social implications of healing; ie integration into the community, improving and maintaining the available pool of labour; and the psychological implications of healing; ie happier contented patients relieved of distress, we remember little of the spiritual intentions of healing. Miracles had a deeper purpose other than the restoration of physical health. It is not that the age of miracles is past, rather that the spiritual understanding is hidden and has been supplanted by

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material and emotional satisfactions alone. This applies to both spiritual healers and medical scientists who doggedly pursue evidence of events solely a t the physical level, events which occur within another realm entirely.

While people claiming active membership of a religious institution in England is very low, many people report that they have had a religious experience at some time or another12.While it may not be usual to bring the sacred into the discourse of medical consultations, secular knowledge is found to be wanting a t particular critical moments in those consultations. For the patient it is vital to make sense of experience. It is a search for meaning in the face of chaos, loss, hopelessness and impending or current suffering. New efforts for lay involvement in medicine and the church, and a call for spiritual (or wholistic) understandings of illness are the expressions of individual calls for such meaning. It is not for medicine or the church alone to answer, rather that we search together. In this way we are healed.

D Aldridge Medizinische Fakultat Universitat Witten Herdecke Beckweg 4, D-5804 Herdecke (Ruhr), Germany

References 1 Benor D. Survey of spiritual healing. Complementary Med Res 1990;4:9-33 2 Bearon L, Koenig H. Religious cognitions and use of prayer in health and illness. Gerontologist 1990; 30:249-53 3 Chatters L, Taylor R. Age differences in religious participation among black adults. J Gerontol 1989; 44:S183-9 4 Koenig H, Bearon L, Dayringer R. Physician perspectives on the role of religion in the physician, older patient relationship. J Fam Pract 1989;28:441-8 Markides K. Aging, religiosity, and adjustment: a longitudinal analysis. J Gerontol 1983;38:621-5 Byrd R. Positive therapeutic effects of intercessory prayer in a coronary care unit population. South Med J 1988;81:826-9 Sutton T, Murphy S. Stressors and patterns of coping in renal transplant patients. Nurs Res 1989;38:46-9 Flaskerud J , Rush C. AIDS and traditional health beliefs and practices of black women. Nurs Res 1989;38:210-15 Griffith E , Mahy G. Psychological benefits of Spiritual Baptist "mourning". Am J Psychiatry 1984;141:769-73 Glik D. Symbolic, ritual and social dynamics of spiritual healing. Soc Set Med 1988;27:1197-206 Griffith E , Mahy G, Young J. Psychological benefits of Spiritual Baptist "mourning", 11:An empirical assessment. A m J Psychiatry 1986;143:226-9 Hay D, Morisy A. Secular society, religious meanings: a contemporary paradox. Rev Religious Research 1985;26:213-27

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A Rejoinder by Aldridge Patients and Their Spiritual Needs David Aldridge

The very fact of our existence is a prayer and compels us to prayer so that it could indeed be said: "I am, therefore I pray - sum ergo oro."

It is a quality of the Divine basis of existence while acknowledging our temporal material existence.

-Schuon

1989, p. l28

I would like to thank the varying authors for the time and care they have taken in responding, in part, to my original article. As the reader will have seen, the field of spirituality in the healine " endeavor is broad based and the languages used to describe are varied. Surprisingly, I might say, the commentators, when mentioning religions, were rather limited to a Judeo-Christian approach with little mention of Islam, and no mention of Christian Science or Native American healing.

T h e intention of my. original article was to offer some evidence from a variety of sources to show that spirituality in the medical discourse is a viable idea &orthy of debate. There was n o intention to present an evangelical tract, simply to put forward an argumentof which our patients often struggle to remind us. This has led some authors, no doubt in their eagerness to convince, to misunderstand my intentions. Apart from the decision not to embark upon a lengthy discourse as to what counts as "evidence" of healing in health care, it was never m y intention to put forward a detailed and comprehensive argument for each and every direction in spiritual healing. Such an endeavor is better left to each specialist author.

Furthermore, I am not convinced that long lists, presented as weight of evidence in terms of papers published, are as powerful in argument as illustrated examples from pertinent areas of research. Certainly my experience from talking with a variety of health care practitioners is that they require examples such that they can grasp what is being proposed. In addition, as languages for describing spiritual healing are so varied, it is necessary to offer bridges between various understandings.

Talking about spiritual healing, and active considerations of spirituality, can enter even the most traditional of medical forums (see

Aldridge 1991a, 1991b), but the language must be chosen carefully.

The need for delicacy in the use of language is apparent in discussing the idea of "energy" and healing. Although I tried to offer a liberal explanation of energy, this failed to satisfy the "hard core" energeticists. While the energy argument is based on a persuasive set of modern and traditional arguments, and both clinical and experimental data, it is essentially a partial explanation and inescapably materialistic. I say partial because the energy polemic often disregards the need for an informational mode.

Gregory Ba teson (1979,1991) argues that it is possible for us to be wrong about how we form our opinions and organize our descriptions regarding healing in that the epistemology for healing-that is, our understanding of form and pattern differs-from that of hard science, which concerns energy and matter. Mental processes are triggered by differences, and they involve not energy but information. Biological systems are organized by information, that is, significant differences, rather than by forces or impacts. "The letter that you d o not write, the apology that you d o not offer, the food that you d o not put out for the cat" (Bateson 1979, p. 56) contain no energy, but they d o contain information. It is the world of thought which is of importance, because, as w e are discovering, what people think and believe has implications for what they do. Mind affects matter.

F o r example, I have no doubt infuriated the spiritual energy lobby who may respond with elevated blood pressure and even vocal expressions. N o "energy" has been exchanged between the writer and the reader. Energy exchange is not necessary between self-energizing systems. However, energy release may have been triggered by words, and that is a different dimension of interaction. Bateson (1979, p. 11) writes: "If there are still readers who want to equate information and difference with energy, l would remind them that zero differs from one and can, therefore, trigger response. The starving amoeba will become more active, hunting for food; the growing plant will bend away from the dark, and the income tax people will become alerted by the declarations you did not send. Events which are not are different from those which might have been, and events which are not surely contribute no energy."

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A REJOINDER BY ALDRIDGE What the energy debate misses is the symbolic nature of the healing act, and mirrors the blindness of natural science materialism.

While Kaplan quite rightly corrects me that I have disregarded children's spirituality and forgiveness, his argument only reinforces for me the confusion and, indeed, poverty of thinking regarding scientific approaches to spirituality. His questions regarding possible avenues for research demonstrate not onlv a fundamental ignorance of the meaning of forgiveness but, I must say, the profanity of our current scientific thinking that attempts to objectify and operationalize that which is clearly subjective (see Aldridge 1992).

Forgiveness is an act of relationship.

Giving freely does not entail a contract between two persons, nor one becoming a doormat. Nor can forgiveness be spoken of until we discuss what becoming whole is; neither can forgiveness be understood, in its spiritual sense, until we experience that which forgives. (I write elsewhere of the necessity of forgiveness and prayers of penitence as part of the sacrament of healing [Aldridge 19871.) While Kaplan calls for a taxonomy of spiritual healing, which benefits researchers, what I am calling for is an understanding of how those who come to us for healing, as patients, talk about their problems in the context of their relationship with their God. Koenig is essentially writing about religion and coping from a Judeo-Christian background rather than spirituality as such. He writes " I am skeptical about scientific, naturalistic studies that attempt to prove supernatural phenomena," in that it is "faith" that moves a person to be healed. However, he calls later for a rigorous controlled scientific study to determine exactly what the health effects are of specific patterns of belief and practice. To embark on such a mammoth undertaking would indeed be no less an act of faith given the scientific weakness of controlled clinical trials, the impossibility of finding homogenous population~,the variability of belief systems, the lack of accepted variables for indicating changes, and the organizational challenges involved.

Furthermore, the statistical support for the validation of significance in such a study is based solely on belief; that is, a belief that tomorrow will be the same as yesterday. While such a philosophy sustains modern scientific practitioners and researchers in their flight from the reality of dying, or change, there is no reason why we should accept this position as anything other than an act of faith.

We see a touching faith in science in the way in which several commentators have

The intention of m y original article w a s to offer some evidence from a variety of sources t o show that spirituality in the medical discourse is a viable idea worthy of debate. It w a s never m y intention to put forward a detailed and comprehensive argument for each and evey direction in spiritual healing.

echoed my example of the Byrd study (1988).

While the study is well constructed, and a fine example of medical research that highlights a healing phenomenon itself defying modern science, it is based on statistical inferences that are essentially flawed, or at least, open to interpretation. Belief in mathematical abstraction is an act of faith.

While Larson et al. provide a persuasive argument for incorporating spirituality in practice, they too fall prey to the a priori hypothesis paradigm. The whole point of the spiritual argument, so aptly related in the "Book of Job," is that the spirit leads we know not where. The generating of hypotheses restricts the changes to a range of known possibilities, which leaves no place for transcendence. In spiritual healing, it could be that no material change occurs, but the individual transcends the immediate situation. The profanity of science is that it attempts to predict and control by human agency, whereas the spiritual brings that which is new and sacred by Divine agency.

Whether this . agency is described as emerging from within the person or occurring externally. depends on . religion and culture. he best empirical scientific methods for understanding are simply not the best methods for understandingthe impact of spirituality; empiricism is that which is understood through the senses, and thereby material. Frithjof Schuon (1998, p. 120) writes: "We must not also abase things which transcend us, for then our virtue loses all its value and meaning; to reduce spirituality to a 'humble u t i l i t a r i a n i s n ~ ~ ~ tis, h ato t a kind of materialism-is to cast aspersions on God." In my original paper I described my friend George who had leukemia. His parish priest asked me to visit him in hospital (see also Aldridge 1987). We discussed hypnosis, at his initiation, as a means of pain management and for strengthening his resolve. I gave him a prerecorded tape to prepare him for the sound of

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W e have a long w a y t o go in our understandings of the phenomena of w h a t it means t o be healed. M y plea i s simple, and that is that we learn t o accept and understand the expectations of our patients.

my voice and as a precursor to any therapeutic interventions. Ironically, under the pressure of need, he used it within the first few days to gain rest and sleep within the context of a busy hospital ward and between varying medical procedures (his bone marrow was removed and treated, and replaced). From this basis, we developed a set of visualizations that encouraged him to experience the flow of healing within him, and other methods that he could use in facing his various difficulties and challenges (the struggle to carry on after the exhaustion of hospital treatment, to survive the various rounds of hospital visits and tests, and to overcome the worry of daily living). These interventions were psychological and social.

At the same time, the specialist dealing with cancers of the blood was making interventions which were biomedical.

W h a t we did, priest, psychologist, patient, spouse, and physician, was to cooperate in our approaches. We were trying, in the light of the failing medical interventions, to develop an ecology of treatment at various levelsphysical, psychological, social, and spiritualwhich would meet George's needs and those of his family. The cancer specialist responsible for his medical treatment knew that George needed something more than he could give, even though he was himself working to the limit of his technical abilities. A surprising event was that during a visualization of his bodily processes, George "knew" that certain cells had failed to respond, indeed that they had been killed by a residue of the cytotoxic treatment. This insight was later proved in the laboratory.

At the same time, there were regular sessions of prayer, the laying on of hands, and a celebration of the Christian Eucharist at George's home. Family and friends from near and far were invited to visit. Some wanted to "lay on hands" and pray directly for George even though they, like George and his family, had not experienced such a healing practice before. In their reported experience there was no exchange of healing energies, nor did 84

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"laying on of hands" mean that their hands had to touch. In their understanding, the symbolic act of "reaching out" was an outer sign of something that is hidden. The reaching out of a friend for George, was the reaching out of God to heal.

Please note that I am not saying that others cannot experience this as involving energies, rather that those involved had another language and system of beliefs to explain their experience, and this too must be respected.

George was dying and, as he said, literally living on the blood of others. For him, then, this sacrifice of blood from human donors, and the celebration of the blood and body of Christ with bread and wine took on a powerful spiritual meaning. This too affected the friends who were involved with him at that time. Toward the end, the use of psychological techniques for pain management were combined with medication. Eventually George died at home in the arms of his wife with his children beside him. Our treatment failed, yet we, physician, priest, and psychologist, believed he was healed.

W e have a long way to go yet in our understandings of the phenomena of what it means to be healed. My plea is simple, and that is that we learn to accept and understand the expectations of our patients. Some authors have suggested that spiritual healing is the coming mode of medicine for the next century. I would completely disagree. Clean water, adequate nutrition, protection from the vagaries of fire and flood, charity toward the poor, and living in peace with our neighbors are, as in the past, of importance for promoting and sustaining health in the world. To understand the symbolic meaning of these material realities, and how we encourage their delivery, is the challenge to medicine for the next century.

Finally, I would like to return to my original concern about how to talk about healing,and how difficult it is becoming to use a spiritual vocabulary intelligibly. I would argue that understanding grace and sacrament are vital for accon~panyingour patients through the process of dying, yet these words are strange to the vocabulary of both medical students and teachers. My call to the reader is not to abandon his or her vocabulary of science, but to enrich the vocabulary of healing even to the point that we speak not only of mind and matter but also of spirit. In this way we transcend our normal existence to the very stuff of living.

REFERENCES Aldridge D. 1992. "The Needs of Individual Patients in

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A REJOINDER BY ALDRIDGE Clinical Research." Advances. 8,4:58-65.

Aldridge D. 1991a. "Spirituality, Healing and Medicine." British Journal of General Practice. 41:425-427.

Aldridge D. 1991b. "Healing and Medicine." Journal of the Royal Society of Medicine. 84516-518.

Aldridge D. 1987. "One Body: A Guide to Healing in the Church." Society for the Preparation of Christian Knowledge: London.

Bateson G. 1991. A Sacred Unity. New York: HarperCollins Bateson G. 1979. Mind and Nature. Glasgow: Fontana Byrd R. 1988. "Positive Therapeutic Effects of Intercessory Prayer in a Coronary Care Unit Population." Southern Medical Journal. 812326-829.

Schuon F. 1989. Understanding Islam. New York: Mandala

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