Rev. Mark LaRocca-Pitts, PhD., on an in-depth look at a spiritual history tool

The FACT Spiritual History Tool*

In all likelihood, as an illness, disease or health problem progresses in severity, the patient and/or the patient’s family will at some point experience an existential or spiritual crisis. One’s sense of meaning and purpose and one’s values and beliefs may be threatened, questioned or reevaluated in light of the health crisis. When this happens, a person often draws more deeply upon their own resources, both social and inner, which may include faith and spirituality. These existential or spiritual resources may or may not be adequate to help the person cope successfully. A healthcare clinician must determine when these resources are contributing to a healthy outcome and when they are not, and then respond appropriately. A well-designed spiritual history tool helps the clinician make this determination.

An example of such a tool is the FACT Spiritual History Tool, which includes three questions (Faith, Availability and Coping) plus an outcome (Treatment). Any properly trained healthcare practitioner can use the FACT Spiritual History Tool (see below for a quick reference sheet). This tool is most effective when used conversationally, instead of as a checklist.

Upon admission to most healthcare institutions, a spiritual screen is performed that often includes one or two questions aimed at determining a person’s particular religion or faith and whether there are any specific spiritual, religious or cultural needs the hospital can address during hospitalization. This is NOT a spiritual history. A spiritual history seeks to understand how a person’s spiritual life and history affect their ability to cope with their present healthcare crisis and is more involved than a spiritual screening. Information obtained during a spiritual screen rarely changes in the course of hospitalization, whereas the information gleaned through a spiritual history can change dramatically as diagnosis, prognosis and/or treatment plans change. It is important to monitor a patient’s ability to utilize their spiritual resources to cope with their health crisis as changes occur—a person who can cope well with an aggressive treatment plan for cancer may not cope as well if the treatment plan changes to palliative care. A spiritual history tool must not only be able to account for a patient’s ability to cope in the often swift-changing dynamics of modern healthcare today, but also provide options for follow-up treatments.

When taking a spiritual history, regardless of the specific tool used, there are a few guidelines that one must follow. The first one is to show respect for the patient’s expression of their faith or beliefs, even if yours are radically different. Your goal is never to impose your faith or system of beliefs on the patient. A second guideline is that a spiritual history is less concerned with what a person believes and more concerned with how the person’s faith and/or beliefs function to help them cope positively with their illness crisis. Evaluating the nuances of what a patient believes should never be done except when the patient invites it, and even then it is best to leave that discussion for someone who has the proper training. A third guideline is the recognition that you are not taking the spiritual history in order to “fix” anything that might come up. If something comes up that makes you uncomfortable or that is outside your training, know to whom you can make a referral. A final guideline is to always remember that many of your patients utilize their faith to help them cope and that when you show an interest in their faith, you are bringing them comfort and providing a therapeutic intervention. Even if patients do not utilize faith or spirituality to help them cope, if you are respectful of that and not judgmental, then you again provide comfort.

The FACT Spiritual History Tool can be used either as a formal and explicit checklist or as an informal and implicit checklist. When used as a formal and explicit checklist, it 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. This formal and explicit use fits well with initial assessments. When used as an informal and implicit checklist, it functions as a guide around which a clinician can organize a conversation in order to obtain clinically relevant information pertaining to a patient’s spiritual well-being. This informal and implicit use fits well within the ongoing relationship a clinician forms with a patient over the course of their hospitalization or illness process: as changes occur, the clinician can continue to reevaluate the patient’s spiritual well-being by using what appears to be casual conversation.

Whether used formally or informally, the process is similar. Within the context of an initial assessment or the ongoing exchange inherent within developing a caring relationship, the clinician will ask what Faith, spiritual path or beliefs the patient practices, whether what they need in order to practice their faith is Available to them, and then how their faith and/or their practices are helping them Cope in their current situation. If the history reveals that the patient has everything he or she needs to practice their faith or to maintain their beliefs and that the patient is using these resources well to help him or her cope, then the clinician may simply encourage the patient to continue accordingly and then at a later time reassess if and when significant changes occur.

If in the course of taking the spiritual history the clinician discovers that the patient’s spiritual resources are not available or are insufficient for coping well with their current healthcare situation, then the clinician has three options for follow-up Treatment. The first option is to provide a direct intervention on the spot, such as, for example, offering to pray with the patient. However, one must be very careful with this option. Choosing this option means the clinician has already 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. Due to the potential for crossing ethical and professional boundaries, choosing this option is not recommended unless there is a strong and well-established relationship between the clinician and patient. Even then, one must tread lightly.

The second and third treatment options for follow-up are less problematic and therefore recommended. The second option is to suggest that the patient speak to their own faith leader about any spiritual concerns that surfaced during the spiritual history. This option is contingent upon the faith leader’s availability and the patient’s desire to address these concerns with their own faith leader.

The third option for treatment follow-up is to make a referral to the hospital chaplain. This option is most recommended, but contingent upon the institution having a professionally trained chaplain on their staff. The Board Certified Chaplain provides in-depth spiritual assessments, which begin with a patient’s spiritual history and spiritual profile. Based on these the chaplain determines what outcomes the chaplain’s care can contribute to the patient’s overall healing and well-being. The chaplain, in conversation with the patient, then designs a pastoral care plan that includes appropriate interventions and a way to measure effectiveness.

One caveat is in order when it comes to making a referral to the hospital chaplain: Do NOT ask the patient if they want to see the chaplain. When you ask them if they want to see a chaplain, you are in essence asking them to self-assess their need for spiritual support and you are assuming they understand the role of the chaplain on the healthcare team. Just as we do not ask them if they want to see a respiratory therapist, so we should not ask them if they want to see a chaplain. If you as the clinician assess they have spiritual needs, then put in the referral to the chaplain. Let the chaplain follow-up on the appropriateness of the referral.

Faith or spirituality is a fact in the lives of many people. It is also a fact that many people use their faith or spirituality to help them cope with a health crisis and to help them make medical decisions. Finally, it is arguably a fact that a person’s faith or spiritual practice affects their medical outcomes. The FACT Spiritual History Tool provides a quick and accurate determination of whether or not a person’s current health crisis is affecting their spiritual well-being and then, based on that determination, it suggests a treatment plan.

A Spiritual History Tool: FACT

An acronym for healthcare professionals when taking a spiritual history: FACT.

F – Faith or Beliefs
A – Availability, Accessibility, Applicability
C – Coping or Comfort
T – Treatment Plan

Specific questions that may be asked to help discuss each element of the tool.

F: What is your faith or belief?

Do you consider yourself spiritual or religious?
What things do you believe that give your life meaning and purpose?

A: Is support for your faith available to you?

Are you part of a religious or spiritual community?
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: 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?

T: Treatment Plan

1. Patient is coping well
a. Support and encourage
b. Reassess at a later date
2. Patient is coping poorly
a. Depending on relationship and similarity in faith/beliefs, provide direct intervention: spiritual
counseling, prayer, Sacred Scripture, etc.
b. Encourage patient to address these concerns with their own faith leader
c. Make a referral to the hospital chaplain (DO NOT ask if patient wants referral—let the chaplain do own
assessment!)

Some general guidelines to remember when taking a spiritual history.

1. Faith is already a FACT affecting the lives and healthcare choices for many patients and most already utilize faith-based practices as complementary treatment modalities: healthcare professionals need to assess how it impacts their treatment choices.

2. A spiritual history is not about what a person believes; it is about how their faith or belief functions as a coping mechanism.

3. Respect the privacy of patients with regard to their spirituality; do not impose your own beliefs.

4. Make referrals to professional chaplains, spiritual counselors and community resources as appropriate.

5. Your own spirituality can positively affect the clinician-patient relationship. Remember: “Cure sometimes; relieve often; comfort always.” Addressing spiritual concerns with your patients can provide comfort. In itself, it is a therapeutic intervention.

© 2007 Mark LaRocca-Pitts, PhD, BCC.

* The FACT Tool was featured in a previous 500 word article in MyPractice (Vol. 5, No. 2). This is a more in depth piece on the FACT Tool.

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