Spiritual Histories and Appropriate Spiritual Care Interventions/Recommendations

In FACT, chaplains have
a spiritual assessment tool

Spiritual assessment has become part of healthcare chaplaincy. Mark
LaRocca-Pitts outlines five ‘spiritual history’ tools (CSI-MEMO, FICA,
HOPE, FAITH, and SPIRIT) and then presents FACT which, he argues, is a
spiritual assessment tool for chaplains (and perhaps other healthcare
clinicians) to use in an acute care setting.

Healthcare chaplaincy continues to develop as a clinical profession. Competencies for
certification, professional codes of ethics, and standards of practices are part of the
professional chaplain’s landscape in the United States, as evidenced by the Spiritual Care
Collaborative.1 A new language for this new landscape is needed. Spiritual assessment is
part of this new language and a professional chaplain needs to speak it.
Within this broad category called “spiritual assessment”, distinctions can be
made, such as the differences among a spiritual ‘screen’, a spiritual ‘history’, and a
spiritual ‘assessment’. This article will describe these differences and discuss the use of a
spiritual history.2

Screens, histories and assessments

Furthermore, the category called “spiritual history” now constitutes a
genre. This article will delineate the chief characteristics of this genre and provide
examples. Against this backdrop, we will evaluate whether FACT qualifies as a spiritual
history.

A spiritual screen, a spiritual history and a spiritual assessment are distinct in form and
function (Massey, Fitchett & Roberts, 2004).

A spiritual screen is the shortest and generally uses one or two static questions aimed at
determining the patient’s faith affiliation and whether the patient has special religious
and/or cultural needs, such as diet, observances, and/or restrictions (e.g., blood products).
A spiritual screen obtains information that rarely changes in the course of a patient’s
admission.

Generally, a clerk during registration performs the spiritual screen, though
sometimes it forms part of a nursing admission form. Chaplaincy departments are
constantly seeking the perfect one or two questions that will generate an appropriate
chaplaincy referral (Fitchett and Risk, 2009).

A spiritual history is more involved than a screen. Its questions engage the dynamics of
the patient’s faith or spiritual experience identifying “specific ways in which a patient’s
religious [or spiritual] life, both past and present, impact the patient’s medical care”
(Massey, Fitchett, & Roberts, 2004).

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Not only are the questions dynamic, but so are the answers in that they may
change during the course of a patient’s hospitalisation. A patient admitted with
pneumonia may have sufficient spiritual resources to cope effectively, but if diagnostic
procedures reveal the pneumonia is an opportunistic infection related to the patient’s
until-then-unknown HIV+ status, then the patient may find that he/she has insufficient
spiritual resources to cope effectively. Just as the medical history changes to reflect this,
so might the spiritual history.

A spiritual history may need to be performed more than once during a single
hospitalisation and periodically during the progression of a disease. A physician, nurse or
chaplain can take a spiritual history and place salient information in the medical chart
(Massey, Fitchett, & Roberts, 2004).
Furthermore, whereas a spiritual screen is limited in its form and function (i.e.,
one or two static questions asked at the time of admission), the spiritual history can be
used in various settings and at various times.

A spiritual history can be administered either as a formal checklist or as an
informal one. When used as a formal checklist, it easily forms part of a larger, more in-
depth assessment, such as a physician’s history and physical, a nurse’s admission
assessment, or a professional chaplain’s spiritual assessment. A spiritual history functions
like a social history: identifying a need that may result in a referral.

When used as an informal checklist, it serves as a tacit guide around which a
clinician can organise a conversation in order to obtain clinically relevant information
pertaining to a patient’s spiritual well-being.

This latter use fits well within the ongoing relationship a clinician develops with a
patient. If and when significant changes occur in the patient’s treatment process or if and
when a patient initiates the topic of faith, the clinician can use that opportunity to
reevaluate the patient’s spiritual well-being by using what appears to be casual
conversation.

When taking a spiritual history, a few guidelines are recommended.
• A clinician should always show respect for the patient’s expression of his or her

own faith or beliefs, even if the clinician’s differs radically. Imposing one’s faith
on another is never the goal of a spiritual history.

• A spiritual history focuses less on what a person believes and more on how the
person’s faith and/or beliefs function to help them cope positively with their
illness crisis.

• The clinician does not conduct a spiritual history in order to ‘fix’ anything. If
something presents that makes the clinician uncomfortable or that is outside the
clinician’s training, then the clinician places the appropriate referral for follow up.

• Many patients use their faith to help them cope. When the clinician shows an
interest in the patient’s spiritual path, then the clinician provides a therapeutic
intervention. Even when patients do not use faith or spirituality to help them cope,
if the clinician respects this and is not judgmental, then the clinician again
provides comfort.

A spiritual assessment differs significantly from a screen and a history. A spiritual
assessment is an in-depth look at the patient’s spiritual makeup with the goal of

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identifying potential areas of spiritual concern and determining an appropriate treatment
plan.

In general, a spiritual assessment begins with the patient’s needs, hopes and
resources in order to build a spiritual profile. Based on this profile, outcomes are
determined that will contribute to the patient’s healing and well-being. This results in a
spiritual care plan that includes appropriate interventions and a way to measure
effectiveness (VandeCreek & Lucas, 2001).

Often, along with a series of questions, a spiritual assessment may incorporate a
complex algorithm in which various answers will result in different questions (e.g., If
“yes,” then ask … If “no,” then ask …). Due to the in-depth nature of a spiritual
assessment and the training needed to use such a complex tool, the administration of a
spiritual assessment should remain in the hands of a professional chaplain who has the
appropriate training.

Examples of spiritual assessment tools include Art Lucas’ “The Discipline”
(VandeCreek & Lucas 2001b), George Fitchett’s “7×7” (Fitchett 2002), and Larry
Austin’s “A-SNAP” (Austin 2006).

Chaplain-developed spiritual assessment tools, however, have two problems: their
depth and complexity. As noted by Massey, Fitchett, and Roberts (2004), Paul Pruyser
laid the foundation for spiritual assessment in his The Minister as Diagnostician (1976).
Pruyser’s model, which was designed by a psychologist for the parish-based pastor,
assumes both the time for in-depth uninterrupted pastoral conversations and the
opportunity for repeated counselling sessions.

Chaplains providing spiritual care in an acute care setting do not have the luxury
of time and multiple follow-ups in the same way pastors do or as their colleagues in sub-
acute, long term care or hospice settings might have. Acute care chaplains need a spiritual
assessment tool that fits the requirements of their setting: short and easy, versatile, and
focused.

The spiritual history genre
A spiritual history arguably forms its own genre. A “genre” is defined as “a category of
artistic, musical, or literary composition characterised by a particular style, form, or
content” (Webster, 1977). Harold Koenig provides the groundwork for this genre study in
Spirituality in Patient Care where he presents five criteria he considers critical for a
spiritual history (2007):
1. It must be brief.
2. It must be easy to remember.
3. It must obtain appropriate information.
4. It must be patient-centred.
5. It must be validated as credible by experts.

When all five of these criteria are used together, the critic is able to adjudicate the
strengths and weaknesses of various spiritual histories (LaRocca-Pitts, 2008b). However,
when discussing spiritual histories as a distinct genre only the first three of these criteria
are needed.

When we modify these three criteria in light of published spiritual histories, we
get the following requirements for this genre:

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1. A spiritual history is brief: it contains a brief series of categories or topics with
pertinent questions.
2. A spiritual history is easy to remember: a memorable acronym is used to recall the
categories.
3. A spiritual history obtains appropriate information: its questions address the patient’s
spiritual resources, the patient’s use of them in his/her past and current situation, and how
these resources and uses impact the patient’s medical care.

In what follows, we will look briefly at five examples of this genre and then
compare these findings with FACT (LaRocca-Pitts, 2008ab).

CSI-MEMO (Koenig, 2002)
CS – Do your religious/spiritual beliefs provide Comfort, or are they a source of Stress?
I – Do you have spiritual beliefs that might Influence your medical decisions?
MEM – Are you a MEMber of a religious or spiritual community, and is it supportive to
you?
O – Do you have any Other spiritual needs that you’d like someone to address?

FICA (Puchalski & Romer, 2000).
F – Faith, Belief, Meaning: “Do you consider yourself spiritual or religious?” or “Do you
have spiritual beliefs that help you cope with stress?”
I – Importance or Influence of religious and spiritual beliefs and practices: “What
importance does your faith or belief have in your life? Have your beliefs
influenced how you take care of yourself in this illness? What role do your
beliefs play in regaining your health?”
C – Community connections: “Are you part of a spiritual or religious community? Is this
of support to you and how? Is there a group of people you really love or who are
important to you?”
A – Address/Action in the context of medical care: “How would you like me, your
healthcare provider, to address these issues in your healthcare?”

HOPE (

E – Effects on medical care and end-of-life issues: Has being sick (or your current
situation) affected your ability to do the things that usually help you spiritually? (Or
affected your relationship with God?) As a doctor, is there anything that I can do to help
you access the resources that usually help you? Are you worried about any conflicts

Anandarajah & Hight, 2001)
H – Sources of hope, meaning, comfort, strength, peace, love, and compassion: What is
there in your life that gives you internal support? What are the sources of hope, strength,
comfort, and peace? What do you hold on to during difficult times? What sustains you
and keeps you going?
O – Organised religion: Do you consider yourself as part of an organized religion? How
important is that for you? What aspects of your religion are helpful and not so helpful to
you? Are you part of a religious or spiritual community? Does it help you? How?
P – Personal spirituality/practices: Do you have personal spiritual beliefs that are
independent of organised religion? What are they? Do you believe in God? What kind of
relationship do you have with God? What aspects of your spirituality or spiritual
practices do you find most helpful to you personally?

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between your beliefs and your medical situation/care decisions? Are there any specific
practices or restrictions I should know about in providing your medical care?

FAITH (King, 2002)
F – Do you have a Faith or religion that is important to you?
A – How do your beliefs Apply to your health?
I – Are you Involved in a church or faith community?
T – How do your spiritual views affect your views about Treatment?
H – How can I Help you with any spiritual concerns?

SPIRIT (Abridged: Maugans, 1997; Ambuel & Weissman, 1999)
S – Spiritual belief system: Do you have a formal religious affiliation? Can you describe
this? Do you have a spiritual life that is important to you?
P – Personal spirituality: Describe the beliefs and practices of your religion that you
personally accept. Describe those beliefs and practices that you do not accept or follow.
In what ways is your spirituality/religion meaningful for you?
I – Integration with a spiritual community: Do you belong to any religious or spiritual
groups or communities? How do you participate in this group/community? What
importance does this group have for you? What types of support and help does or could
this group provide for you in dealing with health issues?
R – Ritualised practices and Restrictions: What specific practices do you carry out as part
of your religious and spiritual life? What lifestyle activities or practices do your religion
encourage, discourage or forbid? To what extent have you followed these guidelines?
I – Implications for medical practice: Are there specific elements of medical care that
your religion discourages or forbids? To what extent have you followed these guidelines?
What aspects of your religion/spirituality would you like to keep in mind as I care for
you?
T – Terminal events planning: Are there particular aspects of medical care that you wish
to forgo or have withheld because of your religion/spirituality? Are there religious or
spiritual practices or rituals that you would like to have available in the hospital or at
home? Are there religious or spiritual practices that you wish to plan for at the time of
death, or following death? As we plan for your medical care near the end of life, in what
ways will your religion and spirituality influence your decisions?

FACT (LaRocca-Pitts, 2008ab)
F – Faith (or Beliefs): What is your Faith or belief? Do you consider yourself a person of
Faith or a spiritual person? What things do you believe that give your life meaning and
purpose?
A – Active (or Available, Accessible, Applicable): Are you currently Active in your faith
community? Are you part of a religious or spiritual community? Is support for your faith
Available to you? Do you have Access to what you need to Apply your faith (or your
beliefs)? Is there a person or a group whose presence and support you value at a time like
this?
C – Coping (or Comfort); Conflicts (or Concerns): How are you Coping with your
medical situation? Is your faith (your beliefs) helping you Cope? How is your faith
(your beliefs) providing Comfort in light of your diagnosis? Do any of your religious

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beliefs or spiritual practices Conflict with medical treatment? Are there any particular
Concerns you have for us as your medical team?

Up to this point, FACT fits well with the spiritual history genre: it is brief, it is
using a memorable acronym, and it is obtaining appropriate information. But with the
next step, the T – Treatment plan, FACT moves beyond the content and purpose of the
generic spiritual history and asks for a judgment.

Instead of obtaining information only, as with a generic spiritual history, FACT
asks the clinician to make an assessment upon which the clinician provides an
intervention. Thus, describing FACT as a spiritual history was unfortunate (LaRocca-
Pitts, 2008b).

The question now becomes: What is the significance of this difference between
FACT and the generic spiritual histories? Before answering this question, we will finish
describing the tool.

T – Treatment plan: If patient is coping well, then either support and encourage or
reassess at a later date as patient’s situation changes. If patient is coping poorly, then 1)
depending on relationship and similarity in faith/beliefs, provide direct intervention:
spiritual counselling, prayer, Sacred Scripture, etc., 2) encourage patient to address these
concerns with their own faith leader, or 3) make a referral to the hospital chaplain for
further assessment.

Explicitly addressing treatment provided an important and significant difference
when FACT, a chaplain-developed tool, was compared to other physician-developed
tools (LaRocca-Pitts, 2008b). This sets it apart as a strength. It also sets it apart from
spiritual histories in general. In fact, it falls exactly into the niche between the physician-
developed spiritual history and the generally too in-depth and complex chaplain-
developed spiritual assessment. In other words, FACT is a spiritual assessment tool that
fits well the needs of an acute care chaplain: it is short and easy, versatile, and focused.

For example, FACT can be used effectively in the span of a five- to ten-minute
initial visit. In the context of a discipline-appropriate conversation (i.e., “Hi, I’m the
chaplain. …”), the chaplain can take a brief spiritual history, assess immediate spiritual
needs, and provide an appropriate intervention with the intended outcome of supporting
the patient.

An intervention might range from simply supporting and encouraging the patient
to providing a prayer (treatment option #1) to conducting, time and length of stay
permitting, a more in-depth assessment (treatment option #3) at that time or in a follow-
up visit.

In addition, some healthcare clinicians believe praying with patients is within
their scope of practice (Koenig, 2007). Using FACT may prevent the clinician from
crossing ethical and professional boundaries (Post, Puchalski, & Larson, 2000). If the
clinician judges a direct and personal intervention is needed, such as praying with the
patient, then the clinician may do so, but with extreme care (Sloan et al., 2000).

Choosing this option means the clinician has already administered a spiritual
history and established the following things: (1) that the patient and the clinician share a
similar faith; (2) that the patient would welcome such an intervention; and (3) that the
clinician would not be imposing his or her beliefs onto the patient (Koenig, 2007).

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With proper training, clinicians using FACT will also help identify patients who
would benefit from treatment option #3 (referral to the chaplain).

Conclusion
The spiritual history is a genre unique from that of a spiritual screen and a spiritual
assessment. Technically, FACT does not qualify as a spiritual history tool (LaRocca-
Pitts, 2008ab): it is three parts spiritual history and one part spiritual assessment. In other
words, it is a hybrid spiritual assessment tool that fits well the needs of a professional
chaplain in an acute care setting.

It also works well with other healthcare clinicians who believe the scope of their
practice includes addressing spiritual needs, such as providing spiritual encouragement or
prayer and making referrals to chaplains.

Mark LaRocca-Pitts, M.Div, PhD, is a staff chaplain at Athens Regional Medical Center
in Athens, in the US state of Georgia, board certified with the Association of Professional
Chaplains and a minister of the United Methodist Church. His doctorate was in Near
Eastern languages and civilizations, and he is an adjunct faculty member in the Religion
Department at the University of Georgia.

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Austin, L. (2006). Spiritual assessment: A chaplain’s perspective. Explore: The Journal of
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LaRocca-Pitts, M. (2008a). The FACT spiritual history tool. PlainViews, 5. Retrieved May 7,
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1 The Spiritual Care Collaborative is comprised of six North American professional chaplaincy
organizations: Association of Professional Chaplains, Association of Clinical Pastoral Education, National
Association of Catholic Chaplains, American Association of Professional Counselors, National Association
of Jewish Chaplains, and Canadian Association of Pastoral Practice and Education. See
Retrieved on 11/30/09.

2 In a review that appeared in this journal, the reviewer, commenting on a previous article of mine
(LaRocca-Pitts, 2008b), said, “To this writer, titling FACT as a spiritual history tool seems unfortunate.
FACT does not gather a history in the way a physician gathers a medical history. Rather, it provides
information for an assessment, upon which an intervention might be planned.” This article is a response.

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