In Part 1 of this article, we discussed how a spiritual assessment of each patient is now considered a core component of quality patient care. Since the mid-1990s, I’ve taught the “GOD” spiritual assessment in CMDA’s Saline Solution and Grace Prescriptions conferences and small-group curricula. The “GOD” questions can be used when you take a social history from a patient:

• G = God:
  • May I ask your faith background? Do you have a spiritual or faith preference? Is God, spirituality, religion or spiritual faith important to you now, or has it been in the past?
• O = Others:
  • Do you now meet with others in religious or spiritual community, or have you in the past? If so, how often? How do you integrate with your faith community?
• D = Do:
  • What can I do to assist you in incorporating your spiritual or religious faith into your medical care? Or, is there anything I can do to encourage your faith? May I pray with or for you?

I’ve used this assessment with hundreds and hundreds of new patients over the last 25 years; however, this spiritual assessment tool, like most described in the medical literature, fails to inquire about a critical item involving spiritual health: religious struggle.

A developing and robust literature shows religious struggle can predict mortality, as there has been shown to be an inverse association between faith and morbidity and mortality of various types. For example, a study conducted among inpatients at the Duke University Medical Center found patients (>55 years of age) who felt alienated from or unloved by God or attributed their illnesses to the devil were associated with a 16 percent to 28 percent increase in risk of dying during a two-year follow-up period, even when all other measured factors were controlled.¹ I call these religious struggles the “LAP factors:”

• L = Loved:
  • Patients who “questioned God’s love for me” had a 22 percent increased risk of mortality.
• A = Abandoned:
  • Patients who “wondered whether God had abandoned me” had a 28 percent increased risk of mortality.
• P = Punished:
  • Patients who “felt punished by God for my lack of devotion” had a 16 percent increased risk of mortality over the two years after hospital discharge, while those who “felt punished by the devil or “decided the devil made this happen” had a 19 percent increased risk of mortality.

One study of outpatients with diabetes, congestive heart failure or cancer found that while 52 percent reported no religious struggle, 15 percent reported moderate or high levels of religious struggle. Even younger patients reported high levels of religious struggle, and religious struggle was associated with higher levels of depressive symptoms and emotional distress in all three patient groups.²

While further research is needed on religious struggle, what is clear is that “clinicians should be attentive to signs of religious struggle” and “where patient’s responses indicate possible religious struggle, clinicians should consider referral to a trained, professional chaplain or pastoral counselor.”³

A New Tool

When I began to realize the importance of these religious struggle factors and that I, as the health professional, needed to inquire about this, I developed and began using and teaching to my students and residents a new tool I call the “LORD’s LAP” assessment:

• L = Lord
• O = Others
• R = Religious struggles or relationship
• D = Do

The “L,” “O,” and “D” questions of the “LORD’s LAP” tool are identical to the “GOD” questions. It’s the “R” part of this acrostic that’s new for me. After completing the “L” and “O” questions, I usually have a pretty good idea if the patient is a religious believer or not. Now, I’m not referring to whether they are a Christian or not, just whether they are or have been a religious believer. If so, I need to ask about any religious struggles they may have. To do this, I use what I call the “LAP” questions,” which are based upon the factors discussed above:

• Love: Has this illness caused you to question God’s love for you?
• Abandon: Has this illness led you to believe God has abandoned you? Have you asked God to heal you and He hasn’t?
• Punish: Do you believe God or the devil is punishing you for something?

If the patient answers positively to any of these questions, then the patient’s risk of mortality may be significantly increased over similar patients not experiencing religious struggle. If the patient does indicate they are having a religious struggle, then I need to either consult with or refer them to a pastor or Christian psychological professional. Or, if I feel comfortable providing spiritual counsel, it certainly would be indicated.

Now, it’s important to point out that I don’t usually take such actions immediately, as the patient likely has more pressing health concerns. But I also no longer ignore religious struggle, which I did for so many years. Furthermore, for the patient with religious struggle, I need to record this on the patient’s problem list. In fact, diagnostic coding systems have codes that can be applied to spiritual or religious struggles or problems.

If the “L” and “O” questions reveal my patient has no religious or spiritual interests or beliefs at all, then the religious struggle (LAP) questions would not be indicated. So, for these patients, I briefly indicate I am in the “LORD’s LAP.”

First of all, I thank the patient for their honesty, let them know I’m aware how difficult it can be to discuss religious or spiritual beliefs and tell them I appreciate their trust. Then I might share a brief testimony that may be something like, “Even though religion and spirituality are not important to you now, I often see patients who, when facing a health crisis or decision, will begin to have spiritual thoughts or questions. When I was younger, I had similar questions that resulted in my coming into a personal relationship with God. I just want you to know that if you ever want to discuss these things, just let me know.”

Then, the final step of the “LORD” acrostic involves the “Do” questions. For believers, I might ask, “What can I do to assist you in incorporating your spiritual or religious faith into your medical care? Do you have any spiritual beliefs of which I need to be  aware?” Or, “Is there anything I can do to encourage your faith? Do you need any spiritual resources or to see a chaplain?” Or for a hospitalized patient I may add, “May I have the staff let your pastoral professional know you’re here?” For believers and non-believers, I may ask, “May I pray with or for you?”

Putting It into Practice

I remember the first patient with whom I used the “LAP” questions. I was rounding on a middle-aged man who had been admitted in respiratory distress secondary to bilateral pulmonary effusions secondary to lung cancer. During my social history, he indicated he frequently attended church and had done so since childhood. He prayed and studied the Bible, even memorizing dozens of verses. In the past, I would have offered to pray with and for him. But this day I asked him the LAP questions.

I started with the “L” question: “Does this cause you to question God’s love for you?” His response surprised me as his lips began to tremble and his eyes watered. He could only nod his head.

I then asked the “A” question: “Do you think God’s abandoned you?” His head dropped into his hands and he wept for a few moments. When he composed himself, he whispered, “I’ve asked Him again and again to heal me, and He hasn’t. Even went to a healing service. No luck there, either.”

Taken aback a bit, I pressed on with the “P” question: “Do you believe God or the devil is punishing you for something?” Big tears continued to streak down his cheeks as he confessed, “I’ve sinned in so many ways. I’m sure this is God’s punishment of me.” I was grateful for his honesty, but even more grateful to the Lord for teaching me this new way to approach patients.

Another patient, a lifelong, devout Buddhist who immigrated to the U.S. from Myanmar, shared that she was sure her chronic dermatitis was punishment from God for her lack of devotion. A Muslim patient, when asked about divine punishment as a cause for his injuries from a traumatic fall, looked at me as if I had two heads, smiled and replied, “Of course God’s punishing me. What other explanation could there be?”

With these, and many other patients who have openly shared with me about their religious struggles, I simply would not have known had I not asked. In fact, over the 25 years in which I took spiritual assessments from my patients, I can only remember a few who spontaneously shared their religious struggles with me when I didn’t inquire. I can only wonder how many opportunities for significant spiritual impact passed by because I did not know how to ask.

Conclusion

In the last two years of systematically asking my religious or spiritual patients the “LAP” questions, my impression is that about one of five patients confesses to me one or more religious struggles. I’m thankful I’ve learned this new skill and pleased to see the many ways it helps me bear witness to God and His grace in my practice each day. One large review concluded, “The available data suggest that practitioners who make several small changes in how patients’ religious commitments are
broached in clinical practice may enhance healthcare outcomes.”⁴

In a systematic review I published, my co-authors and I concluded, “Until there is evidence of harm from a clinician’s provision of either basic spiritual care or a spiritually sensitive practice, interested clinicians and systems should learn to assess their patients’ spiritual health and to provide indicated and desired spiritual intervention.”⁵

Duke University psychiatrist Harold Koenig, MD, writes, “At stake is the health and wellbeing of our patients and the satisfaction that we as healthcare providers experience in delivering care that addresses the whole person—body, mind and spirit.”⁶

Most of all, a spiritual assessment allows us, as followers of Jesus and Christian health professionals, to find out where our patients are in their spiritual journeys. It allows us to see if God is already at work in their lives and join Him there in His work of drawing men and women to Himself.

Are you ready to start using these techniques in your practice? For an expanded version of both parts of this article and a complete list of citations, please visit www.cmda.org/spiritualassessment. Part 1 of Dr. Larimore’s article was published in the spring 2015 edition of Today’s Christian Doctor.

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Bibliography
¹ Pargament, K, Koenig, HG, Tarakeshwar, N, et al. Religious struggle as a predictor of mortality among medically ill elderly patients: a two-year longitudinal study. Arch Int Med. 2001(Aug);161(15):1881-1885.
² Fitchett G, Murphy PE, Kim J, et al. Religious struggle: Prevalence, correlates and mental health risks in diabetic, congestive heart failure, and oncology patients. Int J Psych Med. 2004;34(2):179-196.
³ Fitchett. Ibid.
⁴ Matthews DA, McCullough ME, Larson DB, et al. Religious commitment and health status: A review of the research and implications for family medicine. Arch Fam Med. 1998(Mar);7(2):118-124.
⁵ Larimore, WL, Parker, M, Crowther, M. Should clinicians incorporate positive spirituality into their practices? What does the
evidence say? Ann Behav Med. 2002 Winter;24(1):69-73.
⁶ Koenig, HG. Religion, Spirituality, and Health: The Research and Clinical Implications. ISRN Psychiatry. 2012;Article ID 278730.