Spiritual Care When You Are Not Religious

"Spiritual care" sounds like something for religious people. That is why a great many patients who would benefit from it never ask. What it actually covers is the set of questions cancer raises that medicine has no answer to. What is this for? Have you done enough? What are you frightened of? What do you want the remaining time to look like? And who are you now that you cannot do what you used to?

None of that requires belief in anything. Hospital chaplains are trained across traditions, and they are used to working with people who have no tradition at all. The National Cancer Institute's summary says they are trained "to work with a wide range of issues as they arise for patients and to be sensitive to patients' diverse beliefs and concerns."

This is the part most likely to surprise a skeptical reader.

The most widely used tool in this field is the FACIT-Sp. It was developed with an ethnically diverse cancer population, and it has two dimensions: faith, and meaning and peace. The NCI's own description makes the design choice explicit: "the wording of items does not assume a belief in God. Therefore, it can be comfortably completed by an atheist or agnostic."

What the scale predicts is substantial. People who score high on it are much more likely to report enjoying life despite fatigue or pain. They are less likely to want a hastened death at the end of life. And they report better psychosocial adjustment.

The dimension doing the work is the non-religious one. Three meta-analyses were published together in the journal Cancer in 2015. They pooled hundreds of studies of religion, spirituality and health in cancer patients. In the mental health analysis, religious behavior showed no significant association at all. That means service attendance and frequency of prayer, and the confidence interval crossed zero. The association came almost entirely from the affective dimension: spiritual wellbeing, a sense of meaning and peace.

The same pattern turns up in a study of breast cancer patients cited by the NCI. A higher level of meaning and peace went with a decline in depression over twelve months. Higher religiousness predicted an increase.

Whatever is going on here, it is not that believing makes people better.

NCI's summary reports a study that put patients into three groups: religious, existential, and non-spiritual. It found that "individuals in the third group were far more distressed about their illness and experienced worse adjustment than the other two groups."

The honest reading of that is not that you should acquire a religion. The existential group had no religious framework, and it did as well as the religious group. What the third group lacked was any framework at all for making sense of what was happening.

That is a real risk for people who have never needed one. It is a reason to take the questions seriously. It is not a reason to answer them in any particular way.

• A chaplain, on your own terms. Open with what you want: that you are not religious, that you would rather not pray, and what you do want to talk about. Chaplains are trained for this and will not be offended.
• Psycho-oncology or counseling. Many cancer centers have a psychologist or psychiatrist just for patients and families. This is the right route if what you are dealing with is closer to depression or anxiety than to questions of meaning. The two overlap.
• Mindfulness or meditation programs. The NCI's patient summary names these, along with yoga, as options for people who do not want a religious framing.
• Creative arts. The same summary names writing, drawing and music therapy. People are often skeptical of these until they try them during a long infusion.
• Nothing at all. The summary is unambiguous: "Patients who do not want to discuss spirituality during cancer care should also be able to count on the health care team to respect their wishes." If you want it noted in your record that you do not want religious visitors, ask.

Because the system is set up so that the patient has to go first. One large study looked at patients with advanced cancer. Most had never received any form of spiritual care from their oncology nurses or doctors. Yet large majorities of the same patients said they considered it an important part of cancer care. The strongest predictor of whether a clinician provided it was training. Most had not been trained in it.

A separate NCI datapoint captures the gap neatly. In a survey of cancer outpatients, a slight majority felt it was appropriate for a doctor to ask about their beliefs and needs. Only one percent reported that this had ever happened.

So asking is not a sign that things are worse than you thought. It is not an unusual request either. It is simply the only way the conversation starts.

Say someone you love is not religious. Do not arrange religious visitors on their behalf as a kindness. It is a common instinct and it lands badly. That is especially true when the person is too unwell to decline politely.

What tends to help instead is asking what they want the time to be about, and then protecting it. Who do they want to see? What do they want said? What do they want done afterwards? Those are the same questions a chaplain would ask. And you do not need anyone's permission to ask them.