4 - Sadness, Discouragement, Despair - 

The continuum here, as resulting from the reason for seeking health care, runs from:      

 Missing the dog   <------Considering termination of dialysis <--------> Suicidal Depression

Whatever has discouraged this person may lie so deep within her that  it can only be surfaced with careful listening, like from a friend or a therapist. A spiritual clinician considers taking careful listening seriously, from herself or a more available helper, before rushing to pharmacology for depression, which may prevent the healing to which savvy, focused and calm  conversation and referral might lead.

        The concept of grief has accelerated the process of caring for a great deal of the sadness seen in hospital situations. Sadness is often a component of the complex array of feelings experienced in normal grieving, and can often be ameliorated even by conversation, and received verbal reminiscences of the lost one, validation, focused empathic questions, and conveyed empathy.

5 - Hurt (to the Core) -  Hurt is probably the most neglected feeling, not even recognized by many people in themselves. We tend to identify it as anger, which generally follows it. Or it is expressed as fear, of being hurt again. A given patient's hurt regarding the care she is receiving or her caregivers' treatment of her, lies somewhere on the continuum of actual hurt between:                            

                 a nurse's snub<------------------------->  a fatal iatrogenic caregiver mistake 


Distinguishing hurt from self pity can be difficult and perilous. As a result it is generally not addressed in health care settings. Yet greiving is human, healthy and normal, while self pity is self sabotaging and usually flys out of the awareness of the hurt one. Self pity can be highly self destructive to some people. Addicts for example, carry an unconscious pool of resentments within them that can serve as a segue to self pity, a rationalized reason to get high one more time. Calling sadness by the name :self pity" generally results in quick anger, a fairly solid indicator that it is indeed self pity rather than grief-- an approach only rarely recommended in health care settings.

        Hurt that is devastating to the human spirit, from such horrible mistreatment as combat, rape, torture, or child abuse of any kind, most often results in spiritual and psychological pathology difficult to treat and even to refer. But lesser hurts generally respond to acknowledgement as significant by an empathetic listener.

        On the other hand, unearthing a chronic deep hurt as mentioned above, constitutes an opportunity for the bearer of that hurt to unload more of it, with the current caregiver or with a referral resource either during or after hospitalization. (see Axis 4: Ethics and Referral)

Outcomes for Study:

1. Outburst of emotion

2. Allows caregiver's quiet, persistent presence

3. Articulates a/the reason for the current upset

4. Discovers chronic anger that flares in specific situations

5. Subdues emotions with show of authority (physician, security officer) 

​6. Visibly calms down

Axis One: 6 Emotional Support Needs

3 - Hostility & ResentmentBoth of these stem from residual anger from being overwhelmed by hurt in either the recent or remote past. Anger is sometimes a face of inner fears and verbal processing will help, if the listener does not expect the anger to diffuse immediately with logic and information. When hostility and resentment are chronic however, as in combat, rape, child abuse or addiction, they need a different kind of extended help that may have been approached in the past but never effective. Deep hurt stories wait for years and sometimes even decades for the interpersonal listening context in which they can be told.  Sorting out the most significant components of hostility can be an extensive therapeutic task, while situational or functional anger can often be addressed by a calm, savvy listener.  

                        On the other hand, virtually every patient is losing something and that angers all of us on some level. Mostly we manage that displeasure for the sake of smooth caregiver relationships. When a patient or family member doesn't restrain her/himself it is likely because s/he can't. Allowing a patient to express anger at his brother in law for example, is part of health care, though it doesn't fit with the job description of most health care clinicians and other staff. While not directly related to the current health care need, it likely does affect healing and recovery as impinging on the patient's attitudes and frame of mind regarding treatment.


Anger in health care runs this assessment gamut:

                situational annoyance< --------------------------------------------->psychotic rage
Making an appraisal, or even an observation or a guess, about where this person is on the continuum may at least provide interdisciplinary colleagues a "heads up" warning, and a concept to foster discussion about treatment plans in rounds.

2 - Fears and Anxiety - Except for those who work in health care settings, everyone is a little scared of those places, and some are markedly bewildered by that milieu in addition to their trepidation over whatever health needs bring them there.Fearsrange on a continuum between: 

                 a little apprehensive<--------------------------> frantic, or truly paranoid 

   

Anxietydiffers in that it remains unfocused and feels pervasive. Psychiatric theorist Harry Stack Sullivan once called anxiety, "roughly equivalent to a blow on the head". Nobody knows how many of the one in five American adults that take medication for anxiety or depression could be helped by referral to counseling or psychotherapy if finances were available. A spiritual clinician pursues that possibility first however, believing that personal growth exceeds pharmacological maintenance in overall, long term health. Attempting to calm anxiety with logic and information however, or even personal presence and reassurance, may be unconsciously sabotaged by parallel processes between a patient and a practitioner's own underlying anxiety level. 

       Fear may respond somewhat to information carefully and patiently imparted. And establishing emotional rapport virtually always enhances the learning process. Anxiety on the other hand often benefits more from a quiet presence, patient conveyed empathy and gentle conversation.      

 1 - Need to Talk, Express Yourself - Most adults benefit from verbally processing significant  happenings in their lives. The  process of sharing stories and their related emotions diminishes negative experiences and enhances positive ones, both of which shore up maintenance of  the spirit. Humans run the gamut between: the pressured talk of manic states on the one hand, and the taciturn brevity of the cowboy on the other. Most of wander in between, just wanting to be understood by a knowledgeable person who communicates care in at least minimally warm tones.

          It takes a specific interpersonal soil for the soul to rise in conversation. Careful personal listening is often the only way to discover deeper spiritual issues. Bold questions often remain fruitless by exacerbating defensiveness. Person-oriented or relationship oriented care  requires heart motivation, practiced skill and a little patience. Nobody does it perfectly, but persistent efforts do pay off.

         The need to talk almost always appears along with other needs that emerge almost reflexively through the talking. All manner of theorists have written about this phenomenon, from Sigmund Freud to Carl Rogers to  recently popular books on the value of listening. In health care settings one of the lively issues that need expression will virtually always be the health care need for which they are being treated, but that need also touches other serious personal issues not generally cared for by anyone. As person or relationship oriented care evolves it will include attending to some of those more urgent needs as contributions to overall health. 

Outcomes for study:

​1. Verbally or non-verbally expresses fear

2. Responds to care by describing the fears as thoroughly as possible

3. Receives basic, relevant information patiently provided

4. Asks clarifying questions

5. Acknowledges anxiety as an ongoing issue, with or without mention of medication

6. Visibly relaxes

7. Expresses gratefulness or accepts prayer 


6 - Empowerment - Highly dependent people adamantly resist empowerment of any kind. But regression remains a temporary feature of many more stable patients, taking refuge in an earlier, more helpless developmental stage of life. Some victimized tones of helplessness can be assisted by gentle inquiry into the person's past experience of caring for himself in difficulty. Serious dependence erupts into outright anger with the mention of self pity. The anger can then be easier to stomach than the victim mode. The continuum: 

situational regression<--------->dependent character disorder/ chemical dependence

Outcomes for study:

1. Verbally hints at serious mistreatment.

2. Responds to conveyed empathy with details of the event

3. Shows emotion in the telling

4. Considers referral for further care

5. Expresses gratefulness or requests prayer 

Outcomes to Study: 

​1. Identifies the reason for sadness upon query

2. Expands on the history of the sadness

3. Show tears

4. Receives grief care if indicated

5. Receives touch

6. Receives quiet presence

7. Expresses gratefulness 

Outcomes for Study:

​1. Talks energetically

​2. Shows emotions (anger, sadness, joy, hurt, fear,

guilt/shame)

​3. Shows tears

4. Is able to reflect cognitively on issues disclosed

​5. Considers use of further helping resources

if suggested

Outcomes for Study:

1. Whines, complains, or requests emotional help 

2. Accepts caregiver interruptions of self pitying stories
3. - Non-verbally expresses appreciation for presence, caregiver-imparted knowledge and quiet understanding   
4. Discusses his/her coping, including way(s) s/he has previously coped with difficult situations
5. Mentions or explores options
6. ​Expresses increased awareness of the limitations of health care systems

7. Reduces whiney tone