The Impact of Religion and Spirituality on Rehabilitation Outcomes Following Amputation
May 2018 Issue
In a 2014 survey by the Pew Research Center, 63 percent of the respondents indicated that they were "absolutely certain" in their belief in God, and 20 percent reported that they were "fairly certain." More than half of the U.S. population considers religion "very important" in their lives, and another 24 percent consider religion "somewhat important."1 Clinical experience and research has shown that amputation can lead to significant challenges related to the perception of well-being, including depression, anxiety, post-traumatic stress disorder (PTSD), chronic pain, social discomfort, body-image issues, feeling burdensome to others, loss of abilities, and major changes in work, social, and personal life. Given the high rate of belief in God, it is likely that clinicians will encounter individuals who incorporate religion and spirituality (R/S) in dealing with these challenges. Unfortunately, there is a lack of communication between medical professionals and patients regarding R/S. In a study conducted at a Brazilian rehabilitation facility, 69.5 percent of 110 subjects reported that religion was important to their rehabilitation. While 87.3 percent wanted to be asked by a physician about their religion or faith, only 8.2 percent stated that their physician discussed these topics with them.2 A study published in 2015 in the Journal of the American Medical Association (JAMA) analyzed the quantity and quality of R/S discussions among surrogate decision makers and healthcare professionals in an intensive care unit. Out of 457 subjects, 77.6 percent considered R/S fairly or very important in their lives. However, only 16.1 percent of subjects reported having discussions about R/S with medical professionals. Notably, 26 of 40 conversations were initiated by the patient and not the practitioner.3
In 2004, Chally and Carlson published a review in the Archives of Physical Medicine and Rehabilitationof studies related to the impact of R/S on rehabilitation outcomes.4 Additional studies completed since then have evaluated the impact of R/S on quality of life outcomes, cognitive processing, coping, mental health, and person-reported physical outcome measures following amputation. Research findings confirm an influence of R/S on rehabilitation outcomes for this patient population. Validated measures used in these studies include depression, anxiety, and self-esteem scales, Post-traumatic Growth Inventory, Short Form-36, Trinity Amputation and Prosthesis Experience Scale, WHO Quality of Life/Spirituality Religiousness Religious Beliefs, and the Spiritual Well-Being Scale. Common themes in the research are that R/S is a tool for coping with the negative psychological effects of amputation and is associated with a higher quality of life. R/S may involve beliefs related to the unconditional worth of an individual, a plan for one's life, that all will be well in the end, and that the body will return to a state of wholeness after this life. These beliefs can help people manage feelings of uncertainty during the adjustment to amputation. Feeling connected to God or a power greater than oneself can help provide a sense of security and well-being and may engender a sense of hope. R/S may also involve a sense of gratitude (which can bring perspective to cope with difficult situations) and may help subjects process thoughts and feelings about the amputation, find meaning in their circumstances, and be motivated to participate in rehabilitation. Finding meaning can lead to positive coping and decreased suffering. R/S is associated with feelings of empowerment, positive outlook, being motivated for rehabilitation activities, and a decrease in stress and anxiety. Other findings include higher general health and social integration, negative correlations with depression and pain, and positive correlations with cognitive functioning.
Positive and Negative Coping
Psychological growth does not occur automatically following a traumatic event, but from the individual's struggle with and development of a new reality following that event.6 Cognitive appraisals are made by an individual during the rehabilitation process regarding the fairness of their situation, the new challenges that may arise, their identity and roles, and the activities they will be able to perform. An individual also chooses whether to further rely on their R/S system.5 Once made, these cognitive choices create the lens through which individuals view their lives. Adjustment and growth comes from individuals' psychological interpretations of their circumstances and how they respond. Individuals' thought processes can influence motivation in rehabilitation, acceptance of prosthetic use, quality of life, life satisfaction, motivation to reintegrate into society, and adjustment. One key theme in the literature is the role R/S has on positive or negative cognitive processing. A 2008 study by Phelps et al. reported that negative cognitive processing significantly predicted depressive symptoms, PTSD, and higher distress. On the other hand, positive cognitive processing predicts post-traumatic growth and lower symptom severity.7 These results are confirmed in other studies, which demonstrate how positive cognitive processing leads to hope, better quality of life, and increased coping. According to Phelps et al., positive cognitive processing included "active cognitive processes, such as altering one's basic assumptions or core beliefs to better accommodate the traumatic experience, revising goals and priorities, or seeking beneficial aspects of the experience, such as deepened relationships or a richer spiritual life."7 Negative cognitive processing included "ruminative thoughts, such as ‘Why me?' speculating about how things would be different had a trauma not occurred, blaming others, or perceiving oneself as a victim rather than a survivor, [and] is associated with greater distress following a trauma."7 Negative cognitive processing was reported in a study that reported on subjects who blamed God for their circumstances.8
Talking About Religion
Cognitive processing of an amputation is an important aspect of rehabilitation, and R/S can encourage both positive and negative thought processes. Holistic care involves considering all factors that impact a patient's care and health outcomes in the context of a trusting patient/practitioner relationship.9 This may include asking questions to understand a patient's internal state when developing a treatment plan. A discussion about R/S provides an opportunity for patients who consider those issues important to express how they influence their mindset about amputation and rehabilitation. It may also help the practitioner better understand the patient and gain insight into how to provide care most effectively. Clinicians must be sensitive to perspectives that are different than their own and communicate with patients about R/S in a neutral way that neither promotes nor belittles any belief system. This can build rapport, help guide medical decisions specific to each patient, and promote positive psychological adjustment during rehabilitation after an amputation.
No doubt many practitioners feel more comfortable abiding by the well-known advice to avoid discussing religion or politics in polite company. The primary focus of our encounters, after all, is usually on functional and mobility concerns. However, as healthcare professionals, we routinely have discussions about coping and adaptation with patients who have sustained a debilitating injury such as an amputation. We can make those conversations more helpful by understanding patients' perspectives on R/S and encouraging them toward positive cognitive processes and coping mechanisms. It may not be necessary to broach these subjects with every patient but knowing how to navigate them when they are initiated by the patient can result in a more constructive exchange. Two psychiatrists, Josephson and Peteet, suggest a series of questions that clinicians can ask when discussing R/S. These questions are intended to be part of a psychiatric encounter but are general enough that they may prove useful in O&P encounters.10 Indirect questions include: "For what are you deeply grateful? From where do you draw your strength? Where do you find peace? Who truly understands your situation? When you are afraid or in pain, how do you find comfort?"10 Direct questions include: "Is religious faith an important, daily part of your life? How has this faith influenced your life? Are you currently part of a religious community? Are there spiritual aspects that you would like to address in the development of a treatment plan?"10 The motivation behind asking these questions is to understand the patient's perspective, rather than to influence the beliefs themselves.
An article titled "Culturally Sensitive Care" (The O&P EDGE, May 2017) included a story about an elderly patient with a transtibial amputation whose religious beliefs included the idea that since God had allowed her leg to be amputated it was not right to replace it.11 This belief complicated her prosthetic rehabilitation in specific ways. A simple question identified that the source of her repeated follow-up visits was this belief, and not problems with the fit or function of the prosthesis. Affirming her right to make this deeply personal decision appeared to free her up to re-evaluate the belief and decide to engage more actively in gait training. Research suggests that positive thought processes and coping strategies can improve the quality of life and other outcomes following an amputation. Finding ways to discuss sensitive subjects that are meaningful to our patients, including R/S, is an important part of providing care. Focusing on those themes may be an effective way to support the ongoing rehabilitation and function of our patients.
Roger Ramos Rose recently completed the Master's in Prosthetics and Orthotics program at Northwestern University Prosthetics-Orthotics.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
Authors' note: This article includes a summary of a review conducted as part of a capstone research project. A full list of references is available upon request.
Lucchetti, G., A. G. Lucchetti, A. M. Badan-Neto, P. T. Peres, M. F. Peres, and A. Moreira-Almeida A, et al. 2011. Religiousness affects mental health, pain and quality of life in older people in an outpatient rehabilitation setting. Journal of Rehabilitation Medicine 43(4):316-22.
Ernecoff, N. C., F. A. Curlin, P. Buddadhumaruk, and D. B. White. 2015. Health care professionals' responses to religious or spiritual statements by surrogate decision makers during goals-of-care discussions. JAMA Internal Medicine 175(10):1662-9.
Chally, P. S., and J. M. Carlson. 2004. Spirituality, rehabilitation, and aging: A literature review. Archives of Physical Medicine and Rehabilitation 85(7 Suppl 3):S60-5; quiz S6-7.
Luis Diaz, J., C. Leal, K. Schriewer, and P. Echevarria. 2016. Suffering of traumatic amputees in Spain: Meaning, spirituality, and biomedicine. Holistic Nursing Practice 30(6):312-21.
Benetato, B. 2011. Posttraumatic growth among operation enduring freedom and operation Iraqi freedom amputees. Journal of Nursing Scholarship 43(4):412-20.
Phelps, L, R. Williams, K. Raichle, A. Turner, and D. Ehde. 2008. The importance of cognitive processing to adjustment in the 1st year following amputation. Rehabilitation Psychology 53(1):28-38.
Baldacchino, D., K. Torskenaes, M. Kalfoss, J. Borg, A. Tonna, and C. Debattista, et al. 2013. Spiritual coping in rehabilitation—A comparative study: Part 2. British Journal of Nursing 22(7):402-8.
Mueller, P. S., D. J. Plevak, and T. A. Rummans. 2001. Religious involvement, spirituality, and medicine: Implications for clinical practice. Mayo Clinic Proceedings 76(12):1225-35.
Josephson, A. M., and J. R. Peteet. 2007. Talking with patients about spirituality and worldview: Practical interviewing techniques and strategies. Psychiatric Clinics 30(2):181-97.