Spirituality is one of four essential aspects of being human: biological, psychological, social, and spiritual. Our wellness depends on the integrity of each of these aspects and their balanced interrelationship. Spirituality, therefore, is not a healing modality per se. Rather, it is an aspect of life that, like the others, may be "dis-eased" and may therefore require healing. The modalities for spiritual healing are the spiritual disciplines: prayer/meditation, forgiveness, service, and religious practice (including such religious healing practices as the "laying on" of hands), among others. Because the four aspects of being are interdependent, weakness or illness in one inevitably strains the others. If the ill organism is to regain its balance and optimal functioning, the vitality of all four aspects must be addressed.

The manifestation of spirituality in people's lives has been described in numerous ways: a belief in a power operating in the universe that is greater than oneself (Post et al. 2000); an awareness of the purpose and meaning of life (Gundersen 2000); a sense of interconnectedness with all living things; and the development of personal, absolute values. Although spirituality is often associated with religious practice, many believe that personal spirituality can be developed outside of organized religion. Acts of compassion, altruism, and the experience of inner peace are all characteristics of spirituality.

Many Americans are expressing increasing interest in the role of spirituality in their health and health care. Some observers believe this may be due, in part, to dissatisfaction with the impersonal nature of our medical system, and to the realization that medical science does not have answers to all questions about the maintenance of health and wellness (Gundersen 2000).

In most healing traditions and through generations of healers in the early beginnings of Western medicine, concerns of the body and spirit were intertwined. With the advent of the mechanistic, technological approach to health and healing that characterized the scientific revolution and the Enlightenment, non-rational considerations were expunged from the medical system (Gundersen 2000). Today, there seems to be a renewal of interest in exploring how the spiritual dimension of existence impacts health.

Scientific surveys indicate that spirituality plays an important role in the majority of patients' lives. Ninety-four percent of patients believe doctors should ask the seriously ill about their religious beliefs (Ehman et al. 1999). Sixty-four percent feel that physicians should pray with patients who request it (Astin et al. 2000), and forty-five percent state that religion would influence their medical decisions if they were seriously ill (Ehman et al. 1999). Twenty-five percent of patients report that they use prayer as a healing therapy for themselves (Koenig 2000).

• Spirit is considered the essential nature of a person.

• Spiritual healing involves "the intentional influence of one or more persons upon another living system without utilizing known physical means of intervention" (Astin et al. 2000).

• Spiritual awareness describes an awareness of that which is not tangible or material, especially of the ultimate meaning and purpose of life. There may be a heightened awareness of, and concern for, such matters during times of illness or when facing death.

• Prayer may be defined as openness to or communication with the transcendent, and may be practiced within or outside of an organized religious context. Transcendence can be thought of loosely as the nonmaterial or universal aspects of being that go beyond one's individual existence.

• Intercessory prayer involves "asking a higher power to intervene on behalf of [another] individual" in order to benefit that person's well being (Astin et al. 2000). Intercessory prayer and distance healing are frequently used interchangeably in medical literature, although one distinction may be that distance healing refers to any "dedicated act of mentation," not necessarily prayer in the classic sense of the word (Astin et al. 2000; Sicher et al. 1998). In either intercessory prayer or distance healing, the person performing the prayer or act of mentation frequently does not know the person for whom they pray.

Mechanisms of Action

Spiritual disciplines potentially improve coping skills and social support; foster feelings of optimism and hope; promote healthy behavior, such as avoidance of tobacco and alcohol; and reduce feelings of depression and anxiety (Gundersen 2000). Spiritual practices can induce the relaxation response and allow people to participate in uplifting rituals (Matthews 2000). Thus, such practices ameliorate stress responses involving neurological, endocrine, immune, and cardiovascular function (Koenig 2000). The effects of spirituality seem to be explained best by Mind-Body Medicine, now frequently referred to as psychoneuroimmunology, which represents bi-directional communication between the central nervous, neuroendocrine, and immune systems (Masek et al. 2000). Prayer seems to confer an additional advantage: Those who engage in regular prayer are more likely to avail themselves of available medical resources (Matthews 2000).

Clinical trials demonstrate that personal prayer has physiological effects on the patient similar to those of meditation, including reduction of hypertension (Koenig 2000). How intercessory prayer works is not clearly understood or easily explained (Gundersen 2000). A possible theory involves the influence of the belief system of the person engaging in spiritual activities, or for whom, in the case of distance healing, others are praying (Krucoff 1999).

Physicians who feel uncomfortable or unfamiliar with spirituality and prayer should refer patients with spiritual issues to a member of the clergy, a chaplain, pastoral counselor or other spiritual authority (Koenig 2000; Post et al. 2000). Such religious professionals discuss spiritual beliefs and concerns with patients, and, if appropriate, encourage patients to pray and then pray along with them. Pastoral counselors often make available to their clients a clinical psychological perspective as well as an array of spiritual resources. Follow-up appointments are scheduled as needed. If a patient is without a religious affiliation or prefers a practice outside of organized religion, there are non-religious disciplines, such as tai chi and yoga, which for many encompass spiritual qualities. Please see the monographs on those individual modalities for more information.

Spiritual disciplines may be especially effective for drug and alcohol addiction, since popular and successful programs, such as Alcoholics Anonymous, incorporate a strong spiritual component and maintain a conviction that a spiritual awakening is crucial to full recovery (Gundersen 2000).

Research on intercessory prayer for cardiac patients indicates that although length of stay in a coronary care unit (CCU) was not affected, blinded intercessory prayer did reduce morbidity of CCU patients as measured by the Mid America Heart Institute-Cardiac Care Unit scoring system (MAHI-CCU). The MAHI-CCU score includes factors such as the development of unstable angina, pneumonia, hypotension, anemia, congestive heart failure, and arrhythmias; the need for medication, Swan-Ganz catheterization, pacemakers, cardiac defibrillators, and major surgery; and cardiac arrest. Also of note from this same study is the fact that the CCU patients and those involved with their medical care were unaware that lay intercessors, who did not know and never met the patients, were praying for them (Harris et al. 1999).

Intercessory prayer has also been reported to reduce pain, fatigue, tenderness, and swelling, and to improve grip strength and function for patients with rheumatoid arthritis (Matthews 2000). Although such observations are intriguing, methodological limitations of studies on intercessory prayer make it difficult to draw definitive conclusions about clinical applications (Astin et al. 2000).

Spiritual disciplines enhance the coping skills of people with chronic illness by reducing uncertainty and promoting self-esteem. Religious practices have shown some evidence-based success as an adjunct in treatment for specific chronic conditions such as arthritis, cystic fibrosis, diabetes, chronic renal failure, coronary artery disease, and spinal cord injury (Matthews 2000). These practices may also be particularly suited for chronic disabilities that are unresponsive to medical treatment, and for anxiety, depression, and stress-related disorders (Koenig 2000). Religious affiliation specifically may improve quality of life, as studies show that regular church attendance improves health and increases longevity (Gundersen 2000).

The inclusion of spiritual considerations in health care is controversial and raises a number of ethical questions (Post et al. 2000). Some physicians feel that adverse effects may result if they are involved in areas outside of their expertise. Others hold that physician advocacy of spiritual practices can be inappropriate and intrusive and may induce guilt or harm, leading patients to believe that ill health is a result of insufficient faith. There is also the possibility that physicians could influence or be insensitive to a patient's religious beliefs or lack thereof (Gundersen 2000). Finally, there is the risk that people may substitute prayer for medical care, or that spiritual practices could delay the receipt of medical treatment; in this regard, children with parents whose religious beliefs conflict with conventional medical practices may be at particular risk (Koenig 2000).

No specific contraindications to spiritual disciplines are known to be reported in the literature to date. See section on Risks, Side Effects, Adverse Events for additional details.

There is a need for more well-designed, controlled clinical trials that exclude such confounding factors as psychological comorbidity and health behaviors affected by religious practices (Gundersen 2000; Astin et al. 2000). Future research also needs to focus more on spiritual practice beyond church attendance and organized religious activity (Gundersen 2000).

More than 30 medical schools in the United States have incorporated spiritual teachings into their curricula, with a focus on how to talk to patients about their spiritual beliefs and needs (Gundersen 2000). However, as illustrated in the section on Risks, Side Effects, Adverse Events, physicians remain divided over what role they should play in assisting or guiding patients in spiritual matters (Gundersen 2000; Post et al. 2000).

If physicians do inquire about or engage in spiritual and prayer-based forms of healing, they should do so with an open, accepting, and sensitive attitude that addresses all religious beliefs with dignity, respect, and integrity. Spirituality and prayer may be a safe and cost-effective adjunct to medical treatment (Matthews 2000).

Priests, nuns, pastors, and rabbis receive training in pastoral care from their respective institutions. In addition, certified chaplains and pastoral counselors are extensively trained in the spiritual and emotional needs of ill, disabled, or terminal patients (Koenig 2000).

For additional information regarding the discipline of pastoral counseling specifically, contact the American Association of Pastoral Counselors in Fairfax, Virginia at 703-385-6967 or on the web at www.aapc.org. To learn more about the role of spirituality in health, including the latest research, contact the National Institute for Healthcare Research in Rockville, Maryland at 301-984-7162 or on the web at www.nihr.org.

Astin JA, Harkness E, Ernst E. The efficacy of "distant healing": a systematic review of randomized trials. Ann Intern Med. 2000;132(11):903-910.

Ehman JW, Ott BB, Short TH, Ciampa RC, Hansen-Flaschen J. Do patients want physicians to inquire about their spiritual or religious beliefs if they become gravely ill? Arch Intern Med. 1999;159(15):1803-1806.

Gundersen L. Faith and healing. Ann Intern Med. 2000;132(2):169-172.

Harris WS, Gowda M, Kolb JW, et al. A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Arch Intern Med. 1999;159(19):2273-2278.

Krucoff MW. Mitchell W. Krucoff, MD: the MANTRA study project. Altern Ther Health Med. 1999;5(3):75-82.

Koenig HG. Spiritual healing and prayer. In: Novey DW, ed. Clinician's Complete Reference to Complementary and Alternative Medicine. St. Louis, Mo: Mosby; 2000:130-140.

Masek K, Petrovicky P, Sevcik J, Zidek Z, Frankova D. Past, present and future of psychoneuroimmunology. Toxicology. 2000;142(3):179-188.

Matthews DA. Prayer and spirituality. Rheum Dis Clin North Am. 2000;26(1):177-187.

Post SG, Puchalski CM, Larson DB. Physicians and patient spirituality: professional boundaries, competency, and ethics. Ann Intern Med. 2000;132(7):578-583. 

Sicher F, Targ E, Moore D II, Smith HS. A randomized double-blind study of the effect of distant healing in a population with advanced AIDS. West J Med. 1998;169(6):356-363.