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April 2018 Article of the Month
 
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.

 

Laures-Gore, J. S., Lambert, P. L., Kruger, A. C., Love, J. and Davis, D. E. Jr. "Spirituality and post-stroke aphasia recovery." Journal of Religion and Health (2018): published online ahead of print, March 15, 2018.

[Editor's Note: Because this article is available ahead of print, no final page numbers can be cited. Quotations noted below are referenced by manuscript [MS] page numbers.]

 

SUMMARY and COMMENT: "This study represents the first exploration of spirituality and its possible effects on recovery from post-stroke aphasia" [MS p. 10] and comes from Georgia State University's Department of Educational Psychology, Special Education, and Communication Disorders and Department of Counseling and Psychological Services. Co-author Don E. Davis, Jr. has published extensively on the psychological study of spirituality, and Jacqueline Laures-Gore has studied mindfulness meditation in aphasia. The article should be of interest to chaplains as an entreé to the topic of post-stroke aphasia, as a report of findings emphasizing the role of spiritual coping from the perspective of psychology, as a challenge to think about how to accomplish spirituality research with a communication-impaired population, and as a "foundation for future inquiry into the contribution of spirituality to post-stroke aphasia recovery" [MS p. 9]. Appendices conveniently provide the items for the study's questionnaire and semi-structured interview.

Noting that there has been "[l]imited empirical work...examin[ing] how an individual's spirituality is involved in the process of stroke recovery" [MS p. 1] and that "researchers have never examined spirituality in stroke survivors experiencing aphasia" [MS p. 2], Laures-Gore and her colleagues state:

...the purpose of the present study is to examine the spiritual experience of stroke survivors to clarify the direction of future inquiry and to better understand the role of one's spirituality in the aphasia recovery process. Specifically, we investigate whether these adults with aphasia view themselves as spiritual, what their characterization of spirituality is, and then, whether they attribute their aphasia recovery to spirituality. [MS p. 3]
The definition of spirituality is given as: "a general feeling of closeness and connectedness to the Sacred," with the clarification that "[t]he Sacred is whatever a person considers central to their spirituality, such as God, nature, humanity, or the transcendent" [MS p. 2].

A convenience sample of seven men and six women with a current diagnosis of mild aphasia was recruited from the Georgia State University Speech-Language-Hearing Clinic and rehabilitation clinics in the Atlanta area. Three were African American and ten were Caucasian, aged 41 to 71 years, with a high education level (85% college-educated) and with a post-stroke range of 3 months to over 18 years. All completed a questionnaire based upon the Trait Sources of Spirituality Scale [--see Related Items of Interest, §I, below]. Subsequent 20-40-minute interviews where audiotaped at the Aphasia and Motor Speech Disorders Research Lab, at the individual's home, or "at a quiet location closer to the individual's home" [MS p. 4]. Four participants were accompanied by a spouse or caretaker for assistance with word-finding and details of past events.

Among the results:

  • "All participants identified as being spiritual or religious in some manner." [MS p. 8] Note: Included here are two participants who "referred to their personal philosophy as a source of comfort" [MS p. 7]. "One of two participants cited a personal philosophy of goodness as important to her, and she credited her family for her recovery. The second participant reported life-long, dream-like experiences of transcendence, and cited these and her personal philosophy as giving meaning to her experience of aphasia. She credited her family and therapists for her recovery." [MS p. 8]
  • "Eleven of the participants referred to a higher power as important to their understanding of themselves and as contributing to their recovery and improved communication." [MS p. 8]
  • Six participants "(and mostly males) described God or a higher power as being in control of events and directing their survival and recovery. These participants reported only infrequently engaging in prayer or other practices." [MS p. 8; and see illustrative quotes in Table 2, MS p. 6]
  • Five participants "described their relation with God or a higher power as a source of help and strength in dealing with their stroke and aphasia. These participants reported more frequent religious and spiritual practices." [MS p. 8; and see illustrative quotes in Table 2, MS p. 6]
  • "All 13 participants stated that other people, particularly family and health care providers, were important to their recovery. In many cases, being connected to others was noted as having a spiritual meaning. Peer visiting, volunteering, community membership, and being involved with church were cited as spiritual factors involving other people that participants believed contributed to their recovery. For example, three participants described their experiences as peer visitors to other people who had recently suffered from strokes, and they credited helping others in this way as aiding in their own recovery. Two participants indicated they believed that attending church was helpful to them, specifically knowing that other people were praying for their recovery." [MS p. 7]

These findings are discussed in light of the psychology of coping and meaning-making and connected to a "neuropsychobiology of stress framework"* [MS pp. 2 and 8; and see Related Items of Interest, §II, below]. For the six participants who indicated a view of a greater power in control of events and who reported only infrequently engaging in prayer or other practices, the authors write:

...this type of invocation of a higher power can be interpreted as attribution of control to forces outside the self and does not involve much personal activity or agency in relation to the power or to the recovery. This belief is most akin to God control or deferring control to God (a coping behavior) in which the locus of control of the events in one's life is external.... This coping behavior--if not appropriately paired with other coping strategies--could potentially have negative implications for the amount one is actively involved in his/her stroke recovery. [MS p. 8; and see Related Items of Interest, §III, below]
In contrast, for the five participants who focused on a greater power as helper and who reported more frequent religious/spiritual practices:
For those who viewed the Sacred as a personal being, viewing the Sacred as a source of help aligns well with attachment theory.... Namely, the stressor causes existential distress, and this distress causes individuals to seek greater closeness to the Sacred for comfort and relational support. These proximity seeking behaviors might involve engaging a variety of spiritual resources to understanding the meaning of the stroke and aphasia. [MS p. 8]
The authors say, "The idea that spirituality offers a form of coping for these adults is significant; it may be a resource for individuals with aphasia to use when enduring the life changes accompanying an event such as stroke" [MS p. 9].
Clinically, this is important because spirituality may be a helpful component to recovery, understanding, and acceptance of life changes associated with aphasia. Additionally, the results indicate that spiritual activities offer opportunities for adults with aphasia to practice using language and interacting with others which may contribute to positive outcomes. As one participant explained, spiritual activities provide ways for individuals with aphasia to communicate with others "instead of sitting at home watching television." [MS p. 11]
Ultimately, they observe: "Making spiritual meaning, especially reworking a negative event into a more positive and redemptive story can be difficult, but participants were able to indicate that this can be done" [MS p. 10].

Limitations of the study are quite well lined out [--see MS pp. 9-10], including the low sample size, demographic characteristics, the US "Bible Belt" geographic context, the range of time since stroke, the presence of spouses or caretakers in some interviews, and possible confusion around conceptualizations of spirituality and religion. Constructive suggestions for future research accompany each limitation, along with the general acknowledgement of room for improvement of the questionnaire and interview items after this "first attempt at exploring this topic in a novel population" [MS p. 10].

The very undertaking of research into the experience of people with communication difficulties is methodologically daunting, which explains why patients with aphasia were excluded from earlier investigation into spirituality & stroke [--see MS p. 2]. Indeed, only people with mild aphasia were enrolled in the present study, "to ensure a functional level of auditory comprehension and ability to answer questions" [MS p. 3]. The allowance of spouses or caretakers to be present at some interviews is a nod to the need of assistance with communication even with this group, and even at the risk of influencing results [--see MS p. 10]. And yet, there is certainly demand for understanding the experience and role of spirituality in the lives of these and less communication-accessible individuals. Chaplains routinely work with patients struggling with communication barriers in acute and long-term settings, and we may be good partners with other providers for research with such populations. For patients with aphasia, chaplains could help explore the interplay between language and spirituality, how a problem with one may affect the other, and how not only might spirituality be a resource for coping with distress but how a condition like aphasia might be the means for a deepening sense of spiritual journey.

*NOTE: The text on MS p. 2 regarding the 2015 article includes the sentence: "Within this framework, spirituality could be one of a variety of individual factors that modules stress reactivity and the course of aphasia recovery." The word modules here is a typographic error, and the correct word should be modulates.


 

Suggestions for Use of the Article for Student Discussion: 

This month's article might best be used with a group that has had enough clinical practice to have encountered patients with aphasia or at least patients with transient difficulties understanding or expressing speech. What has it been like being with such patients, how did you work with the communication difficulty, and what was your sense of patient spirituality? Did they find that these patients were intentionally using spirituality to cope? How did the patients' communication issues seem to affect them spiritually? Then, perhaps the group could turn to the article and general impressions of the study. Discussion could focus on the two themes of a greater power being in control or as helper. Do the students see the logic of the authors' explanation of these themes [--see MS p. 8], and what sense do they have of their own pastoral perspective in relation to the authors' psychological perspective? Is there some overlap, or tension, or just a different way of talking about the same thing? What do the students think about the statement, "...the spiritual experience typically occurs within the context of a community" [MS p. 8], in terms of social/community needs of patients for whom communication difficulty may be isolating? If they have visited with aphasia patients, did those individuals appear to think that problems of communication with other people extended to an impediment in communicating with God? If so, did the students -- in the role of chaplain -- somehow help the patient overcome that impediment? The group could also go over the illustrative quotes from study participants [--see Table 2, MS p. 6]. Finally, the group could look at the items from the questionnaire and especially the semi-structured interview, helpfully provided in the appendix [MS pp. 10-12], to see how the researchers sought to prompt participants for the most relevant information to address the research goals [MS p. 3, top paragraph].


 

Related Items of Interest:

I.  The authors of this month’s featured article state that they used a "truncated variation" [MS p. 3] of the Trait Sources of Spirituality Scale for their questionnaire and also derived their interview items in part from the same source. Note that co-author Don E. Davis, Jr. is also a co-author on the referenced article for the scale.

Westbrook, C. J., Davis, D. E., McElroy, S. E., Brubaker, K., Choe, E., Karaga, S., Dooley, M., O'Bryant, B. L., Van Tongeren, D. R. and Hook, J. "Trait Sources of Spirituality Scale: assessing trait spirituality more inclusively." Measurement and Evaluation in Counseling and Development 51, no. 2 (2018): 125-138. [(Abstract:) We develop the Trait Sources of Spirituality Scale (TSSS), which assesses experiences of closeness to the sacred, within and outside a religious tradition. After using factor analysis to finalize the scale, we examine evidence of construct validity, including latent profile analysis that reveals 5 patterns of how spirituality is experienced.]

 

II.  Our authors point to a 2015 article that sets up a broad framework for thinking about stress and which may offer "a way of understanding how spirituality may influence the appraisal and coping process for adults with aphasia" [MS p. 2]. However, that article does not explicitly address spirituality.

Laures-Gore, J. S. and Buchanan, T. W. "Aphasia and the neuropsychobiology of stress." Journal of Clinical and Experimental Neuropsychology: Official Journal of the International Neuropsychological Society 37, no. 7 (2015): 688-700. [(Abstract:) Individuals with aphasia face significant challenges in their lives. These challenges stem from the difficulties caused by impaired language function. Impairment in the ability to successfully communicate could be a significant source of stress to individuals with aphasia. The purpose of the current paper is to present a review of the literature on the neuropsychobiology of stress and aphasia, give a contemporary conceptualization of stress (both neurobiological and psychological), offer a framework and directions for future investigations in stress and aphasia, and finally suggest clinical implications for this line of inquiry.]

 

III.  Regarding the authors' reference to "deferring control to God" [MS p. 8] as a coping strategy, they mention a 2013 article: McLaughlin, B., et al., "It is out of my hands: how deferring control to God can decrease quality of life for breast cancer patients," which was our January 2014 Article-of-the-Month. See that previous feature for more on religious coping strategies/styles.

 

IV.  Little has been written about spiritual care to people with aphasia in particular, but see especially:

Moon, H. "Pastoral care to patients with aphasia." Journal of Pastoral Care and Counseling 61, no. 4 (Winter 2007): 379-381. [This is a brief, first-hand account by a hospital chaplain of the case of a patient with aphasia of unknown etiology after a second stem cell transplantation. The author writes of her work as part of the interdisciplinary team and of a breakthrough moment when the patient was able to recite (along with her) several Christian prayers following communion. The chaplain postulates, in light of the work of Oliver Sacks, that the patient had been able to connect with her spiritual memory and ritual roots, and this connection with her spiritual core gave her the hope and inner strength to expedite the recovery process, as she slowly was able to acquire her full speech once again. The frustrating difficulty of communication, especially in the initial pastoral encounter, is succinctly described.]

Mundle, R. G. "Engaging religious experience in stroke rehabilitation." Journal of Religion & Health 51, no. 3 (September 2012): 986-998. [The author refers to aphasia passim. (Abstract:) In this article, I respond to the problem of engaging with religious experience in health care environments. In particular, I illuminate the relational aspects of religious experience in the context of stroke rehabilitation by providing a commentary on data gathered from existing qualitative research and personal narratives in the acute and rehabilitation phases of stroke recovery. In so doing, I address the necessary balance of empathy and alterity in the art of resonant listening. I also provide some critical reflections on interdisciplinary approaches to engaging with religious experience with reference to a largely overlooked group of health care professionals-hospital chaplains.]

 

V.  The following research may be of interest, coming from outside of chaplaincy:

MacKenzie, S. "Sacred work? Exploring spirituality with therapists working with stroke patients with aphasia." Journal for the Study of Spirituality 6, no. 1 (2016) 78-88. [(Abstract:) Speech and language therapists (SLT), occupational therapists (OT) and physiotherapists (PT) on stroke rehabilitation wards have long worked in an holistic way, with the client at the centre of their interventions. However, if we consider our clients to be tripartite beings, comprising body, mind and spirit, do we, in fact, give credence to the spiritual dimension? Are there particular considerations in this regard when we consider those patients who present with communication difficulties following a stroke? Are we able to facilitate expressions of spiritual distress/need in our clients with aphasia who have difficulty verbalizing their thoughts and, if so, is it our role to do so? As part of a larger study exploring stories of spirituality with people with aphasia, I interviewed members of the multidisciplinary team on an acute stroke ward. I wanted to explore their understanding of their professional role vis-à-vis spirituality. This article focuses on some of the themes which emerged in the interviews with the therapists on the stroke ward: an OT, SLT and PT. Using a hermeneutic phenomenological approach, I encouraged them to talk about their interventions with people with aphasia, their definition of spirituality, and whether they considered facilitation of expressions of spirituality in their clients with aphasia as part of their therapeutic remit. Although, of course, this represents a very small sample of therapists, nevertheless some interesting themes have begun to emerge, which I hope will contribute to further dialogue.]

Also, a research project is currently underway through the Weston Area Health NHS Trust, UK, by Katharyn Mumby, PhD (katharyn.mumby@nhs.net), a Speech Language Therapist: "A feasibility study to pilot an assessment of spiritual health ('SHALOM') and a Spirituality Toolkit ('WELLHEAD') with people with Aphasia." For more on the two resources noted in the title, see the website for WELLHEAD and the following articles regarding the SHALOM spiritual assessment: Fisher, J., "Development and application of a spiritual well-being questionnaire called SHALOM," Religions 1, no. 1 (2010): 105-121; Fisher, J., "Selecting the best version of SHALOM to assess spiritual well-being," Religions 7, no. 5 (2016): 45 [electronic journal article designation]; and Fisher, J., "You can't beat relating with God for spiritual well-being: comparing a generic version with the original spiritual well-being questionnaire called SHALOM," Religions 4, no. 3 (2013): 325-335.

 

VI.  For more on aphasia per se, see the website of the National Aphasia Association. And for an overview of aphasia from a medical standpoint, see:

Fama, M. E. and Turkeltaub, P. E. "Treatment of poststroke aphasia: current practice and new directions." Seminars in Neurology 34, no. 5 (November 2014): 504-513. [(Abstract:) Aphasia is an acquired neurologic disorder that impairs an individual's ability to use and/or understand language. It commonly occurs after stroke or other injury to the brain's language network. The authors present the current methods of diagnosis and treatment of aphasia. They include a review of the evidence for the benefits of speech-language therapy, the most widespread approach to aphasia treatment, and a discussion of newer interventions such as medication and brain stimulation. These methods hold much promise for improving patient outcomes in aphasia; however, additional research regarding the best approaches to aphasia treatment will greatly improve our clinical approach.]

 

VII.  A recent Wall Street Journal article briefly accounts the work of Julie Shulman, who advocates for the spiritual integration of people with aphasia who are adherents of speech-based faiths. See: Schuss, G. F., "Learning to pray when words fail," Wall Street Journal (March 15, 2018): online at www.wsj.com/articles/learning-to-pray-when-words-fail-1521153496.

 

 


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