Spiritual-Religious Coping – Health Services Empowering Patients’ Resources

It is known that health is determined by physical, mental, social, and spiritual factors. During the last decades there has been a considerable increase in the number of studies showing positive associations between spirituality-religiosity and health. The most important works in that area began it be deeds in the 1980 decade and are increasing worldwide. Scientific literature have recorded that spiritual well-being is associated with better physical and mental health, according to psycho-neuro-immune models of health. Spirituality and religion can help patients, their families and caregivers dealing with illness and other stressful life events.


Introduction
It is known that health is determined by physical, mental, social, and spiritual factors. During the last decades there has been a considerable increase in the number of studies showing positive associations between spirituality-religiosity and health. The most important works in that area began it be deeds in the 1980 decade and are increasing worldwide. Scientific literature have recorded that spiritual well-being is associated with better physical and mental health, according to psycho-neuro-immune models of health. Spirituality and religion can help patients, their families and caregivers dealing with illness and other stressful life events.
Concerning physical health, studies show that appropriate religiousness is related to better general health and longevity (due to better immunologic function and cardiovascular health) and less frequency to health services utilization [1]. In mental health, religiousness is related to less chance to develop and faster recovery of: marital disharmony, depression, suicide attempt, and drugs and alcohol abuse [1]. There are evidences that persons with a well developed spirituality tend to make ill less frequently, to have healthier habits of life and, when make ill, develop less depression and recover more quickly.
Many patients put their suffering into religious frameworks. Religion and spirituality are prevalent coping strategies both for physical and for mental illness. For many patients religion and spirituality play a significant role in their lives and may help them cope with their symptoms. Patients' personal beliefs may be fundamental to their sense of well-being and could help them to cope with negative aspects of illness or treatment. However, incorporating spirituality into medical practice continues to pose many challenges. Spirituality is often seen as a private and subjective area that lies outside of the therapeutic context, but patients' beliefs can have a substantial impact on construction of the meaning of illness, coping behavior, and preferences about treatment.
This chapter is intended to present evidences and discuss proposals on how health care services can empower spiritual-religious resources of patients in order to they can be used as an efficient coping strategy. Concepts will be discussed, such as faith, spirituality, religion, and the concept of spiritual-religious coping itself. The characteristics of the spiritual-religious coping structure will be described. The spiritual distress due to nonattended spiritual needs will be discussed, followed by a description of defensive behaviors that patients may adopt in these situations. The chapter ends proposing some suggestions for health care professionals and services to use these knowledge in practice.

Concepts
The terms faith, spirituality and religious beliefs have been used interchangeably but have significant conceptual differences which may be relevant in trying to understand their influence on medical treatment. While many people use the words spirituality and religion as synonyms, they are in fact very different. Although these terms are associated, they are not interdependent.
Faith: The concept of faith has never been defined fully and encompasses elements of both spirituality and religious beliefs, which may be further modified by culture and personal value systems [2]. Faith has a cognitive and an experiential aspect. The cognitive one associates "to have faith" with the profession of the learned doctrine. The experiential aspect is the inner courage that works as a shelter to help the person to endure difficulties of life.
Prayer may be defined as an intimate conversation with a higher being for the purpose of imploring or petitioning for something or someone. Prayer can be practiced as an individual or as a group. It can be practiced inside or outside of the presence of a spiritual healer or place of worship. You or your group can pray for yourself or pray for others, even people you don't know (intercession). You can pray near someone or at a distance (remote). You can pray with or without the knowledge of the recipient; and that is not to say who you are praying to and whether you consistently believe in a transcendent being.
Spirituality has many definitions on scientific literature. Perhaps the most complete associates spirituality to "the aspect of humanity that refers to the way individuals seek and express meaning and purpose, and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred" [3]. Spirituality is a complex and multidimensional part of the human experience, as an inner belief system. It helps individuals to search for the meaning and purpose of life, and it helps them to experience hope, love, inner peace, comfort, and support. Spirituality can be understood as the set of beliefs that brings vitality and meaning to the events of life. It is the human propensity for the interest for others and for himself. Spirituality can encompass both secular and religious perspectives.
Spiritual Well-Being: The World Health Organization has declared that spirituality is an important dimension of quality of life. How someone is faring spiritually affects that person's physical, psychological, and interpersonal states, and vice versa. All contribute to overall quality of life. Thus, it is particularly useful to try to measure spiritual well-being or its opposite, spiritual distress. [4]. Aspects of spirituality may have a beneficial effect on a variety of health-related physiological mechanisms. In particular, spirituality's emphasis on emotions, for example contentment, forgiveness, hope and love, may positively affect an individual's physical wellbeing. Furthermore spirituality may reduce feelings of negative emotions, such as anger, fear and revenge, reducing tension levels. [5] Spiritual needs: they commonly identifies three basic concerns [6]: the need to find meaning in illness or disability; the need to affirm one's relationship or connect with others (including the Whole or a Supreme One); and the need to realize transcendent values, such as hope, faith, thrust, courage, love, and peace. Note that these needs are not necessarily religious. Before spiritual needs can be met, they must be recognized. Initially, it consists on documenting patient's religious affiliation, preferred religious practices and patient's beliefs on sources of hope and strength [6].
It is not always certain what the precise spiritual needs of a patient might be. Some might want help with specific religious rituals. Some might want to talk to members of their own faith communities about the meaning of suffering. Still others might want pastoral counseling regarding their fear of death. Defining the spiritual needs of patients is a matter that is being investigated empirically, but there are, at present, no well-validated research instruments for this purpose. Patients report a wide spectrum of spiritual needs, and meeting spiritual needs is correlated with patient satisfaction with care and their ratings of the quality of medical care [4].
Religion is an organized or institutionalized belief system that attempt to provide specific answers to mankind's general spiritual needs and questions [7]. Religion is a specific expression of spirituality, which involves elements as doctrine (structure of formal belief), myth (narrative religious), ethics (rules for life), ceremonial (organized practices), experience (personal commitment), and social institution (church, synagogue, etc.). Religion may be seen as multi-dimensional and it is divided it into a number of inner and outer dimensions. The inner ones include belief, non-organizational religiosity (private prayer), subjective religiosity (importance of religion in one's life), religious experience, religious knowledge and religious well being. The outer dimensions include affiliation or denomination, organizational religiosity (participation in church or synagogue activities), and religious commitment. The outer aspects may influence the construction of the inner ones.
Even if there are interfaces between religion and health, the primary goal of every religious life is beyond the matters of physical, mental, and social well-being. The goals are variously designated: salvation in Christianity; the elimination of avidya (mu-myung) to achieve the state of One-Mind (Il-shim) in Buddhism; the union of Yin and Yang in Tao in Taoism; and achieving the ability of ecstasy to combine the celestial and earthly worlds in shamanism [8].
Religiosity: it concerns the behaviors and attitudes a person has with respect to a particular religion. Measurable items include behaviors such as church attendance, prayer, the reading of sacred texts, and attitudes, such as strength of religious belief [4]. 'Religiosity' covers all measures of religious belief or religiousness as expressed in membership in religious communities, religious behavior and spiritual dimensions of religious belief. Religious beliefs represent a specific doctrine system shared by a group of people and defined by prescribed rules, value systems and practices of social participation that may mimic formal secular counseling, support and psychotherapeutic activities [2].
Relations between Spirituality and Religion: Many people find spirituality through religion; however, some people find spirituality through communing with nature, music, the arts, quest for scientific truth, or a set of values and principles [7]. Not everyone is religious, nor is religion a requirement for spiritual wellbeing. It is possible to have a well developed spirituality without being committed to a religion. The inverse is also true. Spirituality may be strong in persons of different religions, as well as in persons with individual beliefs that are not fitted in a formal religion. In the opposite sense, a person may have a strong religiosity (attending worships regularly), but have a low developed spirituality (by not deeply experiencing these aspects). Many people attend religious services diligently without relating to spirituality, and many who do not belong to a formal religion seek contact with the spiritual. To make this differentiation easier, table 1 confronts the main aspects that can be used to differentiate both concepts.

Spiritual-religious coping
Spiritual-Religious (S-R) coping is the use of religious beliefs, attitudes or practices to reduce the emotional distress caused by stressful events of life, such as loss or change, which gives suffering meaning and makes it more bearable. Religious beliefs and practices are used to regulate emotion during times of illness, change, and circumstances that are out of patients' personal control [1].
Spirituality has an impact on patients' ability to cope with illness. For many individuals, spiritual beliefs and practices provide a source of comfort, supply a font of wisdom to help make sense of what seems otherwise senseless, and prescribe a ritual pathway for addressing the basic spiritual questions of meaning, value, and relationship [4]. Aspects of religious coping include [7]:

•
Cognitive aspects: the way we make sense of the world around us. They include questions such as: "Why do bad things happen to good people?" "What happens after death?" • Experiential aspects have to do with connection and inner resilience. They encompass questions such as: "Am I alone or am I connected to something bigger?" "Can I find hope in this difficult situation?" • Behavioral aspects have to do with ways in which a person's spiritual beliefs and inner spiritual state affect his or her behavior and life choices.
The response to life stressors may be directly mediated by S-R factors which provide a cognitive framework for providing meaning, which enables a healthier appraisal of those stressors through the provision of meaning and coherence. This may provide greater psychological resilience in the face of negative life events. Suffering is given a meaning in the world religions although there is marked variation in how this is done. It is not necessarily seen as destructive or humiliating, to be avoided at all cost [9].
Spirituality provides growth in several relationship fields. In the intrapersonal field (with himself), brings hope, altruism and idealism, purpose for life and for suffering. In the interpersonal field (with others) brings tolerance, unit, and the sense of belonging to a group. In the transpersonal field (with a supreme power), awakes the unconditional love, worship and the belief of not being alone [10].
Spiritual beliefs may assist people in providing a sense of control in understanding, coping with and interpreting events or experiences. Previous studies indicate that individuals who hold religious beliefs allow an individual to reduce the stressful reactions to events that they deem to be uncontrollable by reframing or reinterpreting those events, possibly gaining a new meaning and understanding from them [5].
It is important to have meaning or purpose in life. This sense of meaning is diminished by an illness. This loss and its associated rediscovery were central aspects of both depression and spirituality. Spirituality may provide such a sense of meaning through its emphasis on liturgy, worship and prayer found in the major religious traditions [9]. Adverse life events may be appraised in a different way. Religion provides a meaning context in which adversity can be understood.
Words such as spirituality and religion carry a variety of meanings for different people. Not all S-R coping is positive. S-R perceptions and rituality may well be a double-edged sword. Although much of the literature is suggestive of an overall positive effect of religion on health, at times religious practice might have a deleterious effect. What appears to be ultimately important in terms of health outcome is not religious involvement (e.g. church attendance) but how people actually deploy their religious beliefs to cope with adversity.  Table 2. Some aspects of positive and negative S-R coping

Effects of spirituality-religion over health
A relation between better health and religion or spirituality is found in studies covering heart disease, hypertension, cerebrovascular disease, immunological dysfunction, cancer, longevity, pain, disability, and less frequent health services utilization. Also higher religiousness affects behaviors and correlates such as taking exercise, smoking, substance misuse, alcohol abuse, burnout, and family and marital breakdown [11]. In mental health, higher religiousness is related to less chance to develop the following conditions, and faster recovery when they appear: marital disharmony, depression, anxiety, suicide attempt, and drugs and alcohol abuse [11]. The benefits are almost always threefold: aiding prevention, speeding recovery, and fostering equanimity in the face of ill health.
Studies on spirituality and mental health have looked at the mechanisms involved in spirituality, which may improve mental wellbeing. There is some evidence that positive coping styles can be very positive in terms of people's mental health [5]. Aspects of spirituality may have a beneficial affect on a variety of health-related physiological mechanisms. In particular, spirituality's emphasis on contentment, forgiveness, hope and love, may positively affect an individual's physical wellbeing. Furthermore spirituality may reduce feelings of negative emotions, such as anger, fear and revenge, reducing tension levels. [5] The theories that can explain how S-R wellbeing may improve health are various. Some involved mechanisms may be the positive cognitive appraisal, the altered status of mind during prayer, and congregational benefits from the religious community.
Cognitive appraisal: Religion provides a source of hope. For instance, in Christianity and Judaism, no matter how bad the world is now, the current state will imminently change with the coming of a messianic age. The belief in an omnipotent God who supports a person through a crisis can be psychologically beneficial. Indirect benefits may surge from faith, such as relieving the fear of death among elderly people. Those who are religious often turn outwards towards others, away from self -reflection and this may have beneficial effects [9]. So, there are many healthy impacts from faith, hope and optimism.
Prayer: Some types of prayer may have a known biomedical explanation for their impact, based on the connection of body-mind-spirit, or even divine action. Prayer, like meditation, can invoke a relaxation response, where measurable impact on the human body can be gauged, such as the heart rate slowing, brain waves altering and respiration rates lowering. In addition to the relaxation response, psychological mechanisms that may impact a person's health through prayer may include increased social support, hope or decreased distress. Also there are psychological factors such as the emotional impact of worship. These mechanisms may explain the positive impact of praying for oneself or praying for another in their presence or with their knowledge.
Congregation and Cultural Effects: Religious congregations naturally supply favorable conditions for the promotion of physical and mental health, and are a powerful factor that modify the individual's attitudes toward life, death, happiness, and suffering. Many theories have been proposed in the literature to explain the reduced health risks amongst members of religious communities, including [5]; [8]; [12]: healthy and abstinent life style; religious fellowship protecting people from social isolation; strengthening family and social networks; providing individuals with a sense of belonging and self-esteem; and offering spiritual support in times of adversity. Individuals' mental health is often supported through engagement with members and leaders of religious congregations. Collective religious ceremonies have been been identified with higher community belonging, moral standards and self-esteem.

Spiritual distress and defensive behaviors
Human beings are complex, with physical, mental, and spiritual aspects. Suffering can result from issues pertaining to any of these aspects. Spiritual distress is a state of suffering due to spiritual causes. For example: a mother having difficulty understanding why a loving God would allow her child to die [7]. The spiritual distress refers to the existential anguish experienced by patients when their belief system cannot provide relief.
When patients suffer, they experience a sense of their own vulnerability and finitude, as well as a disruption and fracture of their own person and sense of community. As a result, the experience of suffering can be an opportunity to experience his own spirituality [13]. When well constructed, the belief structure is a source of comfort, welfare, security, meaning, idealism and force. Many patients use their beliefs when coping with its illnesses, and the cure can be influenced by the positivist reinforcement of the patient.
In contrast, a dysfunctional belief system may originate negative reactions that harm the healthcare evolution. If there is a disruption of the belief system, the spiritual distress can surge. It may be expressed by many ways, some of them are below described.

Attempt To Bargain For Recovery:
The belief on the possibility to negotiate with deities, spirits, saints, or even God, to achieve a specific outcome results from certain parts of many scriptures where a worthy believer has his(her) plea attended. It is very common to see this behavior among patients, especially in life-threatening diseases. There is no problem when this attitude brings some hope to patient, but some people may exaggerate at a point of impair treatment.

Belief Of Being Deservedly Affected (Low Self Worth):
Concepts associated with the idea of a fatalistic karma may put the patient in a "sell out" position, confounding submission to the will of God with apathetic waiver to all major happenings of life. An apparent resigned attitude may hide other negative values that are guiding the decisions of the patient.

Diminished Sense of Meaning and Purpose (Demotivation):
It is important to have meaning or purpose in life. This sense of meaning is diminished by an illness. This loss and its associated rediscovery were central aspects of both depression and spirituality. Spirituality may provide such a sense of meaning through its emphasis on liturgy, worship and prayer found in the major religious traditions. The struggle to recover or sustain meaning, that is, the worthwhileness of living, is an expression of the patient's spirituality [14]. Religion provides a source of hope. Spiritual beliefs may assist people in providing a sense of control in understanding, coping with and interpreting events or experiences. Individuals with a dysfunctional religious beliefs system cannot reduce the stressful reactions to events that they deem to be uncontrollable by reframing or reinterpreting those events, possibly gaining a new meaning and understanding from them.

Guilt, Confusion, Religious Stigmas (Disruption):
Some religious groups such as Orthodox Judaism and Catholicism may engender guilt and thus may be detrimental psychologically [9]. A constellation of confounding feelings may paralyze the individual and consume energy in a behavior similar to walk in circles. For example, some possible misconceptions from people with strong religious views [15]: (a) do not take pain medication (or don't take enough of it) for fear of becoming addicted; (b) pain should be dealt with only in spiritual terms, and taking medication for pain relief is relying on something other than God; (c) pain should not be relieved because it results in spiritual growth; (d) if you still have pain, then your faith is not strong enough.

Sorrow, Betrayal, Angry to God (Disappointment):
The idea of a supportive God, who is with you in your suffering, the omnipotent God who supports a person through a crisis can be psychologically beneficial. This concept is sometimes linked to the idea of a reward due to past good actions. When a person's pray is not attended, a negative feeling of abandonment may surge.

Subtle Perception of Vulnerability and Finitude (Fear):
When patients suffer, they experience a sense of their own vulnerability and finitude, as well as a disruption and fracture of their own person and sense of community [13]. The fear of loose something (a physical function, independence or even the life) may interfere with the emotional balance.
The consequent defensive behaviors patient can develop under spiritual distress may affect clinical treatment and quality of life. Below are described some manifestations of such behaviors.
Naïve Reliability on Religion Omnipotence: Religion would assist people in developing stronger coping styles. When religion is used as part of a wider approach to coping this typically provided a beneficial outcome for mental health and reduced mental distress. This is in direct contrast to those coping styles which used deferring (where the individual waits for God to intervene on their behalf ) [5]. Excessive reliance on religious rituals or prayer may delay seeking necessary help for their mental health problems, leading to worsening the prognosis of psychiatric disorder. At the most extreme, strict adherence to a 'religious philosophy' might precipitate suicide as occurred in rare new religious movements. An example of a patient's thought inspired by negative coping is given by this phrase: "When the Lord wants to take me, He'll take me whatever I do. I don't see the need to bother with a bunch of new pills." [16].

Sudden Turn to Unusual Religious Practices:
Since religious sentiment and sectarianism may rise during times of increased personal stress, unusual religious movements may sprung up during the times of rapid change and uncertainty. Individuals stressed by life or health shifts are more likely to get involved with unusual or innovative or charismatic religious movements [17]. The seek for reconnection with religious practices is positive only if it is not a desperate action to escape from reality.

Dependency on Religious Leaders Conduction:
Long term involvement in a religious group may predispose to dependency on religious leaders. Patients have the legitimate right to consult a clergyman before forming an opinion about health issues. But it is dangerous to delegate decisions to a third part that represents only the religious view.
Obsessive Ritualistic Behavior: Formal religious organization and particularly religious rituals and religiously based moral or ethical reasoning can be considered as examples of the human cognitive capacity to order experience and to seek meaning. This tendency is also a healthy human capacity to be promoted. As with the attachment dimension, however, there are clinical excesses in the ordering of and attributing meaning or significance to experience [14]. Religions which emphasize rituals, such as Islam and Judaism, may predispose to obsessional behavior. [9]. Some pathologic expressions of attachment behavior that are desperate in nature, require therapeutic action that promotes modulation and containment. Therapeutic action encouraging containment of the expression of such attachment needs is important to avoid chaos in all aspects of such individuals' lives, including the religious dimensions of their lives. Faith-based efforts to order experience can hypertrophy to the degree that rituals lose their spiritual base. [14].
Sectarianism, Isolation, Fanaticism: Many devastating effects can be elicited by the over dominance of fanatic belief and consequent up rootedness from the instinctive foundation. Excessive devotion to religious practices might result in family break-up if the sole preoccupation of one spouse is towards religious practice. Differences in the levels of religiosity between spouses may result in marital disharmony. Religion can promote rigid thinking, overdependence on laws and rules, an emphasis on guilt and sin, and disregard for personal individuality and autonomy.
Refuse to Certain Kinds of Treatment: The beliefs system of the patient can affect clinical decisions when particular interpretation interfere with healthcare. Some religious assumptions can originate ideas that conflict with treatment, induce spiritual stigmas that create tension, and interfere with the adhesion to the diagnosis and to the treatment [18]. Religious views may influence a person's acceptance of various management approaches and her or his treatment goals. Koenig [11] lists four misconceptions about pain management that might be held by patients with strong religious views: 1) reluctance or refusal to take pain medication (or to take sufficient medication) because of addiction fears; 2) belief that pain should be dealt with only in spiritual terms, and taking medication for pain relief would be relying on something other than God; 3) belief that pain should not be relieved because pain may result in spiritual growth; 4) persistent pain may be regarded as a sign that the patient's faith is not strong enough.

Attitudes from health care professionals and services
To support the utilization of the spiritual resources by the patient, the Joint Commission on Accreditation of Healthcare Organizations suggests that each institution must [19]: Obstacles to implementing spiritual care must not be underestimated, and include [21]: education (lack of training); economics (lack of staff or resources); environment (lack of space or privacy); personal (sensitivity or own belief systems). To achieve the benefits and overcome difficulties, the below discussions lists some suggestions for health care professionals and services. More systematically, we discuss a list of actions to promote the positive impact of spirituality and religiosity on the health treatment process, which would be followed by health care professionals and services (compiled from information from Saad [22] and Lucchetti [23]) Staff Training On Respect And Tolerance: Deriving from the writings of Freud in Totem and Taboo and The Future of an Illusion, clinicians have held religion to be a negative force in patients' lives, leading to guilt, dependency, obsessive behavior and illusory beliefs [9]. But health professionals are called both to cure and to care. Care involves recognition of the fragility and vulnerability of every human being as one who deserves our total commitment. Important values for this field are compassion, creativity, equanimity, honesty, hope, joy, patience and perseverance It is important to know the basic precepts of the most prevalent religions in the hospital, especially about objections to suspension of treatments, to organs donation, to the necropsy and body cremation. Good clinical care includes sensitivity and curiosity about the cultural and religious values and beliefs of our patients. While substantial progress has been made in incorporating spirituality into the curriculum in a growing number of medical schools, the quality and depth of that instruction is quite varied [16].
The goal of staff training must be to develop an ability to understand better how one's patient engages illness and interprets therapeutic interventions, without prejudice and with an appreciation for the particular cultural and religious perspective brought to the clinical encounter by the patient. Even physicians who are not themselves religious can acknowledge and be sensitive to the spiritual dimensions of their work.
An example on how simple may be the training of healthcare professionals is this model adopted by our institution. A list of positive attitudes include: Empathy (being present, realist and honest); Respect to beliefs of the patient; Consider spirituality as component of the well-being; Remember the relation between illness and spiritual suffering; Inform the ways for spiritual support of the hospital. A list of negative attitudes: "To prescribe" religious activities for health improvement; To impose your religious beliefs to patient; To initiate prayers without know appreciation of the patient; To perform task proper of a priest; To give deep religious counseling.

Routine Religious Screening:
It is crucial to examine the religious cultural background of the patient to understand the personality-particularly in respect to his or her value orientation. Always know the religious affiliation of the patient and try to determine the degree of observance regarding this religion. Inquiry about sources of hope, actual beliefs, personal practices, integration in a religious community, rituals, and importance in health care decisions. To ascertain a patient's spiritual beliefs, physicians may ask a set of questions that can be integrated into the patient's history. It may be done by asking a simple open-ended question, "What is your faith or belief? Do you consider yourself spiritual or religious? What role does spirituality or religion play in your life? What things do you believe in that give meaning to your life"? [24].
Treatment planning can usefully involve active attention to patient cues about their faith's importance, consideration of questions in the context of the patient's spiritual background, processing of questions to look for deeper spiritual questions or issues, and asking clarifying questions to assure accurate identification of spiritual development. It is important that the clinician have accurate information about the family's worldview to avoid prescriptions that might be offensive or undermine key precepts of the family's faith [25]. One way to begin is to ask the patient about what she or he finds meaningful or important in life and whether her or his spiritual views have relevance for these issues. It may be helpful to ensure that the patient has access to spiritual counselors as well as to a pastoral care team. It may also be beneficial to discuss with the patient and family how their spiritual practices can be incorporated into the care provided by the medical team.
Support Patient Religious Needs: Dein [9] called "The Religiosity Gap" the fact that clinicians are far less religious than the patients who consult them. Patients commonly use religious strategies to help them cope with their psychiatric symptoms. Clinicians must inquire about their patients religious lives in an attempt to facilitate self directed healing. Indeed, some studies indicate that patients are keen for their physicians to inquire about religion.
Trust and good communication are essential components of the doctor-patient relationship.
Patients may find it difficult to trust you and talk openly and honestly with you if they feel you are judging them on the basis of their religion, culture, values, political beliefs or other non-medical factors [26]. By encouraging the family's continuance of healthy religious rituals such as prayer, communion, and anointing, the therapist can enhance family coping responses and possibly increase the efficacy of treatment [25]. Religion and spirituality are not confined to church attendance or affiliation, reading sacred writings, or celebrating Holy Days, or even to praying. There are also non-biblical inspirational literature, religious music, radio and television programming, books on tape and motivational recordings, religious parenting books, and religious books, tapes, and videos.
When the patient brings religious issues up, the physician should always acknowledge the spiritual concerns raised by the patient, respond to the patient, listen respectfully, and refer to pastoral or spiritual care when appropriate. Addressing patients' spirituality is warranted because it is associated with clinical outcomes and patient coping, because patients want it, and because it can affect their decision making. The spiritual concerns of patients affect them as whole persons and in their overall sense of well-being [4].
Spiritual approaches to pain management can take many forms, from prayer, to participation in religious services and rituals, to therapeutic touch, spiritual healing, mindfulness meditation, Reiki, and other strategies. Some of these strategies are explicitly religious, whereas others take a more secular spiritual approach. In some cases the strategy will have roots in religious tradition but will have been modified to make it more amenable to a diverse group of people. For example, mindfulness meditation has roots in Buddhism but is typically used in Western culture separately from its traditions within Buddhism.
Assisting the patient to engage in religious-spiritual activities involves [6]: referring to clergy; informing patient about resources; providing religious material; allowing for prayer, meditation and other practices; and helping the patient to attend religious services and related activities. Barriers to fulfill spiritual needs will always be in one of these groups [6]: personal, situational or knowledge related. Also there is the inability to differentiate psychological needs from spiritual needs. Many other spiritual activities may be proposed [5]: Guard Your Own Beliefs Discretely: All doctors have personal beliefs which affect their day-today practice. Some doctors' personal beliefs may give rise to concerns about carrying out or recommending particular procedures for patients [26]. The spiritual views of physicians and nurses may affect their beliefs about the pain management of their patients. For this reason, it may be useful for nurses to reflect on their own spiritual beliefs and values and what they mean to the nurse-patient relationship and to the nurse's beliefs about pain management. Some harm is possible if discussion about spirituality causes health professionals to defend or assert a particular religious perspective. The patient's spiritual views, whether secular, sacred, or religious, must be respected rather than challenged.
Health professionals should not normally discuss personal beliefs with patients unless those beliefs are directly relevant to the patient's care. They must not impose their beliefs on patients, or cause distress by the inappropriate or insensitive expression of religious, political or other beliefs or views. Equally, you must not put pressure on patients to discuss or justify their beliefs (or the absence of them) [26].
A helpful principle is to inform but not to recommend. For example, it is legitimate for a physician to inform patients of the potential health benefits of moderate consumption of alcohol, but it is ethically questionable to recommend moderate consumption to a patient who abstains from alcoholic beverages for religious reasons. Respect for autonomy requires that physicians leave it to such patients and their spiritual guides to determine whether a religious practice is worth an elevated health risk [14].
When the health professional has strong reservations about the religious or spiritual tradition to which the patient adheres and feels that such a referral would constitute a tacit endorsement of that religious or spiritual tradition, this fact should be disclosed to the patient. A patient's spirituality should be explored with an open-mindedness and neutrality that allows for tolerance of difference and avoids prejudice against (or for) particular spiritual or religious beliefs or practices. It is important to assess and consider the value of consultation with or referral to clergy. Yet a well-timed religious or spiritual consultation with clergy is often necessary for effective and efficient treatment [25]. A chaplain may be seen as the legitimate person to whom spiritual issues may be addressed and can provide a model of 'holistic care'. But chaplains require a basic knowledge of health issues to ensure that they can pick up major mental illness and refer people for appropriate help.
Although all clinical settings do not have chaplains, most hospitals have chaplains on staff or available within the community. Chaplains who have completed clinical pastoral education training have a breadth of background to provide collegial and informed assistance in dealing with clinically relevant religious issues with most patients. Although chaplains are frequently consulted when approaching end-of-life issues with patients and their families, their potential for service is much broader [16].
For some traditions, it is vital that prayer and counsel come from fellow members of (or even authorities) in that tradition; for other traditions, this is unnecessary. These issues can often be avoided by referrals to appropriate persons within the patient's religious or spiritual tradition. Religious congregations are considered an important mechanism in molding people in terms of their mental health. Individuals' mental health is often supported through engagement with members and leaders of religious congregations. A spiritual community may provide a variety of support, including [5]: • Protecting people from social isolation • Providing and strengthening family and social networks • providing individuals with a sense of belonging and self-esteem, and • Offering spiritual support in times of adversity.
Physicians who anticipate conflicts between their own commitments and the requests of their patients (or their patients' families) should discuss with a chaplain or minister of the patient's religion the nature of the conflict, and should discuss with the patient or family about transference of care to a physician who will not experience such conflict.
Is This Treatment Really Necessary? Health professionals must honestly reflect to make distinction between ordinary versus extraordinary, proportionate versus disproportionate, and obligatory versus non-obligatory health care. Economic, social, psychological, and moral costs associated with treatment, or by the unlikelihood of achieving health [27]. Some little concessions may satisfy the patient and tranquilize the need to accomplish religious obligations. Many simple issues are common to practitioners of several religions, as the preference of the patient to be attended by a professional of the same sex. Also, patient may want to consult a religious leader of his-her denomination before to accept a procedure; this should be respected whenever possible.
For some patients, acknowledging their beliefs or religious practices may be an important aspect of a holistic approach to their care. Discussing personal beliefs may, when approached sensitively, help to work in partnership with patients to address their particular treatment needs. The staff must respect patients' right to hold religious or other beliefs and should take those beliefs into account where they may be relevant to treatment options [26]. It is important to assess whether the treatment plan is consistent with the family's religious beliefs. Clinicians have contact with families at life's critical transition points. By accurately identifying the family's beliefs, clinicians can work with families to accommodate the treatment for the best interest of everyone involved on it.
Should health professionals recommend that patients participate or cease participation in religion or spirituality for their well-being? Here, respect for the religious or spiritual adherence of the patient (or for his or her lack thereof) may conflict with what the professionals believes is in the therapeutic interest of the patient or with the religious or spiritual adherence (or lack thereof) of the professionals. The question is the degree of confidence with which a professional can determine that a religious belief, commitment, practice, or symbol is correlated with (or the cause of) a positive or negative condition that psychotherapy can affect [14].
Open discussion with the patient and her or his family about spiritual views and how they can be incorporated into the management plan will likely be beneficial for both the patient and the team. A person-centered approach is key to ensuring that the patient's spirituality is understood from her or his perspective. For some patients, the best health treatment will be that which is consistent with their spiritual or religious views.  Figure 1 illustrates how to solve the problem of meeting the special needs of patients by healthcare professionals and services. The elements that are at stake are the institutions (health care and rehabilitation), the people associated with the process (physicians, nurses, other professionals) and individual values of patient (religious and spiritual). The forces that bind these elements are the scientific research on the subject, the good practices adopted by institutions and government policies that support these achievements.

Conclusion
This chapter is intended to present evidences and discuss proposals on how health care services can empower spiritual-religious resources of patients in order to they can be used as an efficient coping strategy. It is known that a relation between better health and religion or spirituality is found in studies covering several physical and mental conditions. Spiritualreligious coping is the use of religious beliefs, attitudes or practices to reduce the emotional distress caused by stressful events of life, such as loss or change, which gives suffering meaning and makes it more bearable. Spiritual distress is a state of suffering due to spiritual causes. Generally it may be associated with unfulfilled spiritual needs. The consequent defensive behaviors patient can develop under spiritual distress may affect clinical treatment and quality of life. Health care services must invest on some actions, in order to minimize conflicts between religious interests of patients and medical treatment. We discussed a list of actions to promote the positive impact of spirituality and religiosity on the health treatment process, which would be followed by health care professionals and services. The elements that are at stake are the institutions (health care and rehabilitation), the people associated with the process (physicians, nurses, other professionals) and individual values of patient (religious and spiritual).