Humans typically assume the world to be a benevolent place; we regard ourselves with favorable self-esteem, and attempt to minimize chance in determining life events by believing in an abstract sense of justice, personal control, or a spiritual force that brings order to a potentially chaotic world. Illusory as these beliefs may be, as long as they go untested, they provide a stable cognitive framework for making sense of an individual's experiences and for providing meaning and purpose to his or her life. However, in facing a life crisis, such as confronting one's own death or the death of one dearly loved, these assumptions and beliefs may shatter, may be turned upside down, and might no longer be useful as a foundation to understanding the world or one's place in it.
For example, what happens to our beliefs in personal control of our world when confronted with our own death or when forced to respond to a loved one's painful illness, over which personal control is futile? Or how can a parent continue to assume that the world is just and fair, or that people get what they deserve, or that there is a loving God, after experiencing the death of a child by sudden infant death syndrome, random gunfire, or an automobile accident? Confused, depressed, and devoid of insights, answers, or coping skills, one can find oneself on the brink of a spiritual crisis.
Spiritual crisis or spiritual emergency is recognized by the American Psychiatric Association as a distinct psychological disorder that involves a person's relationship with a transcendent being or force; it might be accompanied by assumptions related to meaning or purpose in life. The disorder may be accompanied by any combination of the following symptoms, which include feelings of depression, despair, loneliness; loss of energy or chronic exhaustion not linked to a physical disorder; loss of control over one's personal and/or professional life; unusual sensitivity to light, sound, and other environmental factors; anger, frustration, lack of patience; loss of identity, purpose, and meaning; withdrawal from life's everyday routines; feelings of madness and insanity; a sense of abandonment by God; feelings of inadequacy; estrangement from family and friends; loss of attention span, self-confidence, and self-esteem; and frequent bouts of spontaneous crying and weeping.
As fundamental beliefs are brutally strained and the rules that previously guided our lives are nullified, distress builds, until we are challenged to deal with the crisis. In this effort some individuals will rely on long-held religious beliefs for guidance; some will embark on a spiritual quest in search of newer ways of finding meaning in life; some will reject religion and become bitter; and some will turn to philanthropic and other care-giving activities in the struggle to find solace and a renewed sense of purpose.
Spiritual Crisis and Loss: The Death of a Child
Parents mourning the death of their child are especially prone to spiritual crisis because the bond between parent and child is so powerful and unique. Most bonds between individuals are contractual— people enter the bonds based on an understood group of mutual obligations. The bond between spouses or friends, for instance, is contractual and, as such, may be abandoned if the interactions are no longer reciprocal and mutually satisfying. The bond between a caring parent and a helpless child is, obviously, not reciprocal. As with religious obligations or duty to God, to ancestors, or to an abstract principle, it is the sacred or spiritual nature of the parent-child relationship and its underlying assumptions that makes mourning the death of a child such a long, agonizing, and, at times, transformative process.
The parent's search for meaning in the child's death often results in the formulation of religious loss rationales. In their study of grieving parents, Cook and Wimberley isolated three parental loss rationales: reunion, reverence, and retribution. The most frequently used rationale was the notion that the child had gone to heaven, where parents and the dead child would eventually be reunited (reunion). Another frequent explanation was that the child's death served some religious purpose, for example, as an inspiration for parents to do good works (reverence). Finally, in some cases, the child's death was interpreted as a punishment for the sins of the parents (retribution).
In another study of bereaved parents participating in a chapter of Compassionate Friends, a support-group for parents-in-mourning, Dennis Klass found that nearly all the parents in the group rejected simple loss rationales, such as that their child's death was God's will, and instead confronted their spiritual crisis by creating new assumptions. Klass discovered that, in many cases, profound forms of psychospiritual transformation were an integral part of the healing process for bereaved parents. He states, "Many of these parentsin-mourning find solace in connections with that which transcended the physical and biological world, and with their perception of an underlying order in the world. These spiritual aspects of the resolution of the grief were central elements in the parents' rebuilding of their lives to be able to live in a changed world." Confronted with a profound and intense spiritual crisis, the bereaved parents in this study were forced to undertake a spiritual quest for individual meaning and solace and to "transcend the human limitations they find in the death of their child. They reveal what people in ... 'the extreme situation' do and what all persons must do" (Klass 1995, p. 264).
Spiritual Crisis and the Search for Meaning
Other strategies for finding spiritual meaning exist for persons who cannot reconcile the "why" of their loss through traditional or modern religious doctrine. Some people may become involved in philanthropic, political, or caregiving work that relates to the illness or manner of death experienced by their loved one. By so doing—coping actively with the spiritual crisis rather than passively—the mourner may discover meaning in the loss, as if to say, "This death was not in vain."
The American businessman and philanthropist George Soros, for example, contributed more than $200 million to charitable projects, including the Project on Death in America, following his own spiritual crisis following the death of his parents. "I chose the culture of dying as one of the areas I wanted to address . . . because of my experiences with the death of my parents, both of whom I was very devoted and [to] loved dearly" (1995, p. 2). Soros was not present at his father's death:
I let him die alone. The day after he died I went to my office. I didn't talk about his death. I certainly didn't participate in it. After reading Kübler-Ross, I learned that ... I could have held his hand as he lay dying. . . . I just didn't know that it might have made a difference—for both of us. (1995, p. 3)
Years later, confronted with a second spiritual crisis involving his dying mother, Soros was present and participated in her dying: "I reassured her. Her dying was really a positive experience for all of us." The attempt to bring meaning to these experiences of loss prompted Soros to found the Project on Death in America with the goal of promoting "a better understanding of the experiences of dying and bereavement and by doing so help transform the culture surrounding death" (1995, p. 2).
These quests for meaning, whether they involve an affirmation of long-held religious beliefs, a search for new spiritual insights, or philanthropic work, often continue beyond the grieving process into the larger mourning process and include revising and restructuring one's assumptions regarding his or her own existence; integrating memories and meanings associated with the deceased into new ways of relating to the world; restoring one's self-esteem and sense of self-mastery; and exploring transformations in one's spiritual beliefs and practices.
Spiritual Crisis and the Experience of Dying
Because humans are essentially order-seeking creatures, the reality of dying presents a powerful cognitive upheaval to our sense of self and an intense challenge to our spiritual beliefs and assumptions. Perhaps we cannot imagine what it will be like to die, but we can easily imagine what it might be like to no longer cope, feel vulnerable and helpless, be dependent on others to meet our everyday physical needs, and to feel like we are no longer in charge of our own lives. We know what happens when we are admitted to hospitals. We are literally stripped of almost everything that is familiar—clothing, routine, personal objects—and we are told when to eat and sleep. Even when treated in a courteous manner, there is still an undeniable sense of dependency and vulnerability.
For the patient who is hospitalized for a short stay and a cure, the feeling of loss of control may be fleeting and masked by the visits of family and friends—and the good news of a successful treatment. The terminal patient, however, is in a much more vulnerable and tenuous position and much more likely to experience a spiritual crisis connected to the loss of integrity, control, and human connection. For many persons facing imminent death, coping strategies provide comfort and a sense of meaning within the context of traditionally held religious beliefs. For example, in a study of the role of spirituality in persons with AIDS, researchers found that it is not uncommon for AIDS victims to be drawn even closer to their traditional religious beliefs, including beliefs in a caring, higher power; the value of life; the importance of support from religious laypersons and close friends; living an ethical life; the importance of facing death; and the presence of an inner peace in identifying a meaning to their lives. Likewise, the greater religiosity of older persons, those most likely to die in modern societies, has been interpreted by some as evidence of such spiritual needs.
Another study of fifty hospitalized cancer patients also revealed that many found comfort and meaning in traditional religious beliefs, but over half had concerns involving spiritual issues connected with long-held religious beliefs; about one-third were actively struggling with a spiritual crisis. The crisis, according to respondents, involved conflicts between religious views, as when dying patients experience anger toward God or believe that their illness is somehow due to their sins; loss of religious support from their congregation or a particular minister; pressure to adopt a different religious position, as when a husband urges a dying wife to adopt his particular religious conviction; and, an all but obsessive preoccupation with religious/spiritual questions in an effort to understand what is happening to them in the process of dying.
Spirituality and Needs of the Dying
The psychologist Abraham Maslow viewed human motivation as consisting of needs ranging from those related to basic survival, such as needs for food and water, to "higher" psychological needs, such as the need for love, knowledge, order, self-fulfillment, spirituality. Maslow wrote of the need for "something bigger than we are to be awed by" (1971, p. 105). Exploring these higher reaches of human nature is always difficult, but is especially challenging in the midst of coping with one's own dying.
An important feature of Maslow's theory is the idea that some needs are more fundamental than others and need to be at least partly satisfied before other, higher needs become active. Thus, in living our dying, one must first satisfy his or her basic physiological needs (e.g., hunger, thirst, pain control) and safety needs (e.g., living in a secure, nurturing environment) before being motivated to satisfy needs higher up on the pyramid. Once physiological and safety needs are met, people begin striving to satisfy emotional needs (e.g., the need to receive affection from others and to feel part of a group) and self-esteem needs (e.g., the need to feel positively about oneself and to be esteemed by others). Finally, at the top of the pyramid, is the need for self-actualization—the desire to attain the full use of one's potential in acceptance of self, others, nature, and spiritual yearnings and insights. Based on his work with the dying, the German thanatologist David Aldridge contends that abandonment, suffering loss of hope and meaning, and the transitions from living to dying are essentially spiritual, not solely physiological, psychological, or social. He argues that in many instances, all of these contexts are interlinked in coping with a spiritual crisis.
Kenneth Doka has identified three principal spiritual tasks for those who are dying: First, the need to find the ultimate significance of life. Answers do not necessarily have to be found in religious beliefs, but an inability to find meaning can create a deep sense of spiritual pain. The dying person's belief system can give a sense of purpose in life and help sustain personal values. Second, the need to die an appropriate death. People who are dying need to accept their death within a framework that is congruent with their values and lifestyle. In some cases, individuals may need help in making decisions about the way in which they will die. Guidance from a special friend or from someone they recognize as a spiritual leader may be helpful in developing cognitive coping strategies. Third, is the need to transcend death; transcendence can be achieved through renewed assurance of immortality in religious doctrine, new spiritual insights, or the acknowledgement of future generations in recognizing that their deeds will live long after they die. To find meaning in the final moments of life, to die appropriately, consistent with one's own self-identity, and to find hope that extends beyond the grave may be among the most important cognitive transformations humans can experience during a crisis of spirit.
Spiritual Crisis and Hospice Care
Because many spiritual and existential aspects of human existence become magnified as death approaches, spiritual care has been an integral part of the hospice movement since its inception. For this reason, hospice clergy have been central to the work of the hospice team in caring for the dying. Clinical observations suggest that hospice clergy have two important roles to play in caring for the terminally ill—spiritual guide to the dying patient and teacher for family members and health care professionals about death and dying. All team members must attend to the physical, social, psychological, and spiritual needs of the patient and family members as death becomes imminent and questions and fears arise. But the chaplain, as a representative of faith and spirituality, must serve as aresource to the patient, family members, and staff.
Gentile and Fello believe that many of the patients to whom hospice chaplains minister have become estranged from formal religious beliefs and practices and hope to reconnect themselves with their spiritual roots. A chaplain with a caring and compassionate nature may, with sensitivity and discretion, facilitate the dying person's exploration of spiritual issues and thus allow the patient to die with greater dignity.
Spiritual Transformation, Faith, and Joy
For many persons, coping with and overcoming a profound crisis of spirit involves faith; that is, the willful suspension of humans' order-seeking, controlling behavior. People simply agree to accept that there is some greater order, purpose, structure, and meaning that is not self-evident in the seeming absurdity of events such as the premature death of a loved one. The exercise of faith and the acceptance of an order beyond one's control does not mean he or she concedes free will or relinquishes the desire to be in control. People achieve their greatest control over the living when they choose to exercise faith. When confronted by a grieving parent whose child has died and who asks, "Why has God done this to me?," there is no satisfactory answer. However, when the mourner has worked through the grieving/mourning process, there may be an emergence of faith and a willingness to accept one's suffering as a part of some greater pattern that escapes the cause-effect logic of his or her scientific worldview.
In fact, having met the challenges of a spiritual crisis, many mourners are able to identify positive, joyful, and triumphant aspects of their mourning experience. Kessler, for example, discovered that many of her subjects regarded the mourning process as liberating: Over half mentioned feeling freed from previously limiting ties. Many subjects in the study felt that they had become stronger and more confident people. Shuchter also found that after two years, the majority of widows and widowers studied were able to regard their spiritual crisis as "growth-promoting." Their experiences enabled them to reflect on their personal values, put things in a new perspective, and appreciate more important things in life. They perceived themselves to be more realistic, patient, sensitive, autonomous, assertive, open, and spiritual in their everyday lives.
In resolving the spiritual crisis, according to Klass, "The person feels his or her life is more authentic, more meaningful, the person's thinking is 'set straight' or true, and his or her actions toward others are right and true" (1995, p. 244). Such insights into leading a meaningful, spiritually based life have been codified in various religious traditions, as in the doctrine of Christianity, the dharma of Hinduism, the Tao of Chinese religion, and the notions of right living, action, and intention embedded in the Buddha's eightfold path to enlightenment.
Research reveals that during periods of profound loss, one's cognitive world may be turned upside down. The assumptions that guided one's life— that life is fair, that people get what they deserve, that God is benevolent, that the old die before the young, and so on—are strained and sometimes shattered. This collapse in beliefs and assumptions about the world and one's place in it has can lead to a spiritual crisis. Whether faced with our own imminent death or in coping with the death of a loved one, we confront the challenge of reconstructing our assumptions about the world.
People have much to learn about spiritual experience, cognitive upheaval, and psychospiritual transformation in the face of death; however, they do know that personal philosophies, religious belief systems, spiritual explorations, and the search for meaning are especially important at such times. Professional and voluntary caregivers are becoming more aware of these spiritual needs and the obstacles that prevent some individuals from fulfilling them.
This new research on dying, mourning, and spirituality suggests that the ways in which people rediscover meaning—such as belief in traditional religious doctrine, the afterlife, reincarnation, philanthropy, or a spiritual order to the universe— may be less important than the process itself. In other words, in the midst of dealing with profound loss in our lives, the ability to re-ascribe meaning to a changed world through spiritual transformation, religious conversion, or existential change may be more significant than the specific content by which that need is filled.
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ROBERT L. MARRONE