August 2008 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Delaney, C. and Barrere, C. "Blessings: the influence of a spirituality-based intervention on psychospiritual outcomes in a cardiac population." Holistic Nursing Practice 22, no. 4 (July/August 2008): 210-219.
SUMMARY and COMMENT: In our June 2005 Article of the Month, we highlighted Colleen Delaney's Spirituality Scale. That scale has since been the most frequently requested of any instrument featured on our website. In the current month's article, Dr. Delaney and Cynthia Barrere build upon the previous work and test a clinical intervention developed specifically with the Spirituality Scale in mind.
A convenience sample of 46 patients with cardiovascular disease (CVD) was recruited from inpatient, outpatient, and community settings. Participants completed Delaney's Spirituality Scale, the State Trait Anxiety Inventory, and a demographic questionnaire. They then received the spirituality intervention, consisting of music and imagery on a CD created for the study, following which they retook the spirituality and anxiety measures. They were instructed to repeat the intervention on their own at least 3 times a week for the next 4 weeks and then take for a third time the spirituality and anxiety measures (self-administered). Halfway through the 4-week period, researchers telephoned the participants to check on progress, answer questions, and hear of the experiences of the intervention. Participants also were invited to write of their experiences in a small journal to be returned with the third round of measures (self-administered) at the end of the study.
Quantitative analysis of the Spirituality Scale and the State Trait Anxiety Inventory data showed a significant increase in the spirituality score and a significant decrease in the anxiety score between the baseline and the first post-intervention assessments. However, only 24% of the participants continued to the end of the 4-week study period and returned the third set of measures. Analysis of the final data set from the remaining 13 participants did not show a significant further change in spirituality or anxiety outcomes.
The qualitative findings (from the telephone and journal data) revealed that most participants' had a highly positive experience of the music and imagery intervention, especially in terms of the relaxation response it engendered. As they repeated the intervention, some also found in it "a deeper meaning behind the words in the imagery script" and an increasing capacity to utilize the exercise to "take their experience to a new level" [p. 217]. Only 5 participants reported that they found no benefits in the intervention, though others indicated that the time that it took became problematic.
These findings suggest that the intervention piloted here may be a valuable element of a multifaceted, holistic approach to the care of CVD patients, and the study data should be useful to future research into complementary and alternative therapies. The intervention itself is worth further attention. The authors write: "…this is the first study to our knowledge that combined a spiritual assessment instrument with an intervention specifically developed for the instrument, in this case the Spirituality Scale, to provide general spiritual care" [p. 218]. The Blessings CD used as the intervention was created by Suzanne Jonas, EdD, founder and director of the Inner Harmony Health Center in Walland, TN [--see Related Items of Interest (below), nos. III and IV]. After consultation with Dr. Delaney about the domains of the Spirituality Scale, Dr. Jonas…
...then reflected on the Spirituality Scale and developed a voice-guided imagery exercise that (1) facilitates relaxation, (2) enhances spiritual awareness of the personal, interpersonal, and transpersonal domains of spirituality, (3) uses a walk through a garden to frame a multisensory experience intended to enhance a feeling of appreciation of and connection to self, others, environment, and a Higher Power/Universal Intelligence, and (4) uses language that everyday people can relate to. [p. 214]
Background music for the guided imagery was Chuck Wild's recording, Liquid Mind IV: Unity [--see Related Items of Interest (below), no. III].
This music was selected because it facilitated relaxation and was slow in tempo, low in pitch, matched in respiratory rhythm, harmonious, and captured people's attention, and according to Dr Jonas, contained spiritual qualities from her perspective. [p. 214]
NOTE: The fully correct title for the Wild album is Liquid Mind IV: Unity. The text of the article mistakenly lists this album as Spirit (which is actually the extended title for Wild's Liquid Mind VI).
This is a well laid out article, offering a clear description of methodology and results. This reader, though, would have appreciated more detail about the changes between the initial post-intervention scores and the third assessment scores, because while that "time 2 to time 3" comparison did not evidence a significant change, it seems to me striking that the scores do not appear to show patients backtracking, and the Blessings exercise may be useful to patients as a maintenance intervention during the burdensome "journey" of CVD. Perhaps some future study could investigate how such a guided imagery exercise plays into patients' sense of personal steadiness and resiliency --a subject hinted at by Delaney and Barrere in their question for additional research: "What is the effect of music/imagery over time?" [p. 218]. There is also a good bibliography (38 references). The article would seem to invite pastoral caregivers and chaplain researchers to consider closely how music and guided imagery may be explored and implemented in the care of particular patient populations.
Suggestions for the Use of the Article for Discussion in CPE:
This month's article should engage any CPE student group, from residents/interns new to research to advanced students with special interests in methodology. While it might be paired with Delaney's original study of the validity/reliability of the Spirituality Scale, there is sufficient explanation of that measure in the text (pp. 213-214). The well-outlined methodology in the article suggests a number of questions for discussion, including the length of time that may be required for a spiritual intervention to effect outcomes, and how interventions may influence not just a patient's state but also trait characteristics. Students may enjoy experiencing for themselves the Blessings CD [--see Related Items of Interest (below), no. III] and considering this in light of their own familiarity with music and guided imagery as tools for personal spiritual growth and pastoral care. Guided imagery, of course, is itself a potent topic for CPE, since it potentially raises questions of the nature and role of interventions that can lead a patient rather than follow the patient's lead in pastoral interaction. Students might discuss the insight of one of the study participants:
As time went on, I found I ignored the vocal directions and began to envision my own peaceful scenario. I began to drift away with my own images. I feel I have been able to successfully find what works best for me and I can use this in the future. [p. 217]
How might the capacity for such personal appropriation of the intervention as indicated by this participant differ by patient groups or by the stage of diagnosis/treatment? How might a routine (ritual) like the Blessings exercise offer both structure and freedom of expression for patients? What are the practical issues regarding the time commitment for exercises to facilitate relaxation and/or spiritual nurturing?
Related Items of Interest:
I. See the June 2005 Article of the Month for more on Colleen Delaney's article: "The Spirituality Scale: development and psychometric testing of a holistic instrument to assess the human spiritual dimension," Journal of Holistic Nursing 23, no. 2 (June 2005): 145-167
II. For more on the practice of guided imagery in the clinical setting, see:
Brown-Saltzman, K. "Replenishing the spirit by meditative prayer and guided imagery." Seminars in Oncology Nursing 13, no. 4 (November 1997): 255-259. [This older review of literature on meditative prayer and guided imagery, out of the Department of Nursing at UCLA Medical Center, provides a helpful background, especially for the care of oncology patients. Overall, the author assesses that this early literature indicates interventional effectiveness. (This article is part of a special theme issue of the journal on Spirituality & Cancer.)]
Lane, M. R. "Spirit-body healing II: a nursing intervention model for spiritual/creative healing." Cancer Nursing 31, no. 3 (May-June 2008): E24-31. [(Abstract:) This article describes an advanced intervention for spiritual healing that evolved from spirit-body healing, a hermeneutic phenomenological research study. The research study examined the lived experience of art and healing with cancer patients in the Arts in Medicine program at Shands Hospital, University of Florida. Max Van Manen's method of researching the lived experience was used in 63 patients over a 4-year period. Healing themes that emerged from the research were (1) go into darkness, (2) go elsewhere, (3) art becomes the turning point, (4) slip through the veil, (5) know the truth and trust the process, (6) embody your spirit, (7) feel the healing energy of love and compassion, and (8) experience transcendence. The intervention we offer allows nurses to apply creativity and guided imagery as advanced therapeutics and to continue to provide the leadership needed for integrating spiritual healing into patient care. It is one that personifies the nursing mission formalized by many hospitals: a commitment to treat the bodies, minds, and spirits of patients to the best of our ability as part of our routine care.]
Marr, J. "The use of the Bonny Method of Guided Imagery and Music in spiritual growth." Journal of Pastoral Care 55, no. 4 (2001): 397-406. [The author, from the University of Melbourne in Australia, reports two case studies illustrating the value of a particular method of guided imagery and music for discovering spiritual and emotional insights in patient care and facilitating healing and spiritual growth.]
Scherwitz, L. W., McHenry, P. and Herrero, R. "Interactive Guided Imagery therapy with medical patients: predictors of health outcomes." Journal of Alternative & Complementary Medicine 11, no. 1 (February 2005): 69-83. [This study, out of the California Pacific Medical Center in San Francisco, assessed a practice of Interactive Guided Imagery (IGI) with 323 medical patients who received 6 IGI sessions over two months. The intervention, outlined on p. 71, revolves around patients imagining both a relaxing scene of their own choosing and an image representing their symptoms or concerns. The patients and 23 involved practitioners completed questionnaires that measured cognitive, emotional, behavioral, and spiritual aspects of the intervention. The authors conclude (from the abstract:) The process of doing IGI and the relationship with the practitioner were both independently associated with the patients' insight into their health problems.]
III. Media used in this month's featured research:
||Suzanne Jonas' Blessings CD was developed specifically for the study by Delaney and Barrere. It is available directly from Inner Harmony Health Center (www.innerharmonyhealthcenter.com).
||The music used in Jonas' Blessings CD is from Chuck Wild's Liquid Mind IV: Unity. See the Liquid Mind website (www.liquidmindmusic.com), specifically the page for the Unity CD, for more information and links to purchase the music from such sites as iTunes and Amazon.com.
For more on Suzanne Jonas' views about the relationship between music and healing, see the following news and journal articles:
Long, J. B. "Sounds can soothe, heal body." Knoxville News Sentinel. June 28, 2008 [newspaper article], available online.
Mason, R. "The sound of healing: interviews with Jonathan Goldman, B.Sc., M.A., and Suzanne Jonas, B.A., M.A., Ed.D." Alternative & Complementary Therapies 12, no. 2 (April 2006): 81-85. [(Abstract:) Although the medical use of sound in modalities such as ultrasound and sonograms has been widespread for at least 50 years, using audible sound for healing is, for many practitioners, an obscure, unproven concept. The reality, however, is that over the past 2 decades, research has demonstrated that specific sounds can be used to foster wellness. Consequently, there is a growing amount of material, research, and new technology supporting the use of sound for healing. Jonathan Goldman, B.Sc., M.A., and Suzanne Jonas, B.A., M.A., Ed.D., are two innovative and dedicated professionals who, 25 years ago, began to recognize the value and importance of sound as a healing modality. Each of them intuitively understood that using sound represents, in many respects, the future of medicine. Their belief has been borne out in cutting-edge sound research that shows extraordinary promise for the future. Both agree that nearly every illness or condition can be either remedied or greatly helped by specific sounds, and that certain tones and recordings can enable a listener to achieve high states of consciousness, awareness, and often ecstasy. These states, Mr. Goldman and Dr. Jonas say, are indicative of where humans might consciously evolve in the future--toward a greater sense of interconnectedness and well-being.]
For more on the field of Music Therapy, in general:
See the Journal of Music Therapy. Among articles that consider spirituality are:
Lipe, A. W. "Beyond therapy: music, spirituality, and health in human experience: a review of literature." Journal of Music Therapy 39, no. 3 (2002): 209-240. [(Abstract:) In the current healthcare environment, there is a growing interest in the relationship between spirituality and health. The connections between music and both medicine and religious experience are well-established, but little is known about how the musical and spiritual aspects of human experience work together to influence well-being. A review of the healthcare literature from 1973-2000 identified 52 published reports on the topic of music, spirituality, and health. The majority of the papers were narrative descriptions or case studies, and appear within a variety of clinical contexts. Fifty-two percent of the authors were credentialed music therapists. Examination of the literature indicated that many papers used terms and concepts associated with both spirituality and health interchangeably, which might lend support to the basic interconnectedness of these two aspects of being. The function of music across the literature was explored, and a transformational model of music experience derived from the literature is proposed. Based on the findings of the review, several conclusions about the future role of music in spirituality and health are drawn, and recommendations for further research are offered. (46 references)]
Wlodarczyk, N. "The effect of music therapy on the spirituality of persons in an in-patient hospice unit as measured by self-report." Journal of Music Therapy 44, no. 2 (2007): 113-122. [This small study from Florida State University and Big Bend Hospice assessed, by means of the Spiritual Well-Being Scale (Ellison & Paloutzian, 1982), a 30-minute music therapy intervention with 10 participants in an in-patient hospice unit. After four rounds, results indicated that the intervention significantly improved spirituality scores.]
The Boyer School of Music and Dance at Temple University (Philadelphia, PA) maintains a very useful web page of Select Internet Resources.
For a chaplain's select bibliography regarding the effect of music on patients' experiences of physical pain, click HERE.