by Becky Curtis and Bill Zachry
Spiritual beliefs, faith and/or religious practices are important in the lives of many injured workers, yet claims administrators are often uncertain about whether, when, or how, to address these issues. *(1)
Definition of Faith: Faith, which is sometimes recognized as Religion, is generally understood as a set of beliefs, rituals and practices, usually embodied within an institution or an organization. Spirituality, on the other hand, is commonly thought of as a search for what is sacred in life, one’s deepest values, along with a relationship with God, or a higher power, that transcends the self. Persons may hold powerful spiritual beliefs, and may or may not be active in any institutional religion. Spirituality can be defined as “a belief system focusing on intangible elements that impart vitality and meaning to life’s events” (Maugans, 1996). Many in the baby-boom generation who claim not to be religious, admit to a sense of “reverence” for life, similar to the concept championed by theologian-philosopher Albert Schweitzer.
For the history of workers compensation, claims administrators have had little or no training on the importance of faith in recovery or how to relate to the religious or spiritual side of the injured worker.
Because of the constitutional separation of religion and government, the question of religion or faith has been given a legal protection status and is for the most part institutionally exercised from most conversations involving governmentally mandated benefit programs. As a result, claims administration organizations (insurance companies or TPAs) are very reluctant to raise the question of faith for fear of potentially impinging on the beliefs on injured workers (who may be particularly vulnerable.)
Complicating the identification and use of faith to assist with injury recovery is our nation’s culture of religious pluralism. There are a wide range of belief systems ranging from atheism, agnosticism, to a myriad assortment of religions and spiritual practices. No claims adjuster could be expected to understand the beliefs and practices of so many differing faiths.
As a result, the simplest solution, which is widely followed, is that claims administrators *(1) avoid religious or spiritual content in their interaction with the injured workers.
As with many issues, however, the simple solution may not be the best.
Research indicates that the religious beliefs and spiritual practices of injured workers are powerful factors for many in coping with and recovering from serious illnesses, or catastrophic injuries.
This paper discusses the possibility that within the boundaries of claims adjusting ethics and empowered with sensitive listening skills, claims administrators should be encouraged to find ways to encourage injured workers to engage or use their existing spiritual beliefs assist in the recovery process.
Research shows that faith, religion and spirituality are associated positively with better health and psychological wellbeing (Puchalski, 2001; Koenig, 2004; Pargament et al., 2004). Studies have also demonstrated that faith has been proven to significantly help in recovery from severe injuries.
The most successful program proven to deal with addiction is AA. It has imbedded in it as one of the 12 steps in the program, the acceptance and use of a supreme being.
Unfortunately, most claims operations and examiners are not aware that faith can be a important tool in the toolbox to help assist the injured worker with recovery. Therefore they do not encourage the use of faith in recovery.
More nuanced research has also shown that injured workers who have a crisis of faith or who are not ‘religious” also have a higher risk of mortality (Pargament et al., 2001). Sometimes severe accidents or diseases can result in a crisis of faith.
Religious belief and practice is pervasive in the United States.
Surveys of the U.S. public in the 2008 Gallup Report consistently show a high prevalence of belief in “God” (78%). An additional 15% believe in a higher power (Newport, 2009). In an aggregate of 2013 polls, 56% claim that religion is important in their own lives and 22% claim it is fairly important (Gallup, 2013). In 2010, approximately 43.1% of Americans reportedly attended religious services at least once a week (Newport, 2010). 77% of Americans identified themselves as Christian, 5% with a non-Christian tradition, and 18% did not have an explicit religious identity (Newport, 2012).
These surveys remind us that there is a high incidence of belief in God in the US public. Studies have shown that up to 77 percent of injured workers would like to have their spiritual issues discussed as a part of their medical care, less than 20% of the treating physicians currently discuss such issues with injured workers (King & Bushwick, 1994).
Pargament’s research revealed that some patients who are challenged by serious injuries or illnesses become involved in religious struggle that may have deleterious effects upon their health outcomes (Pargament et al., 2001). He identifies specific forms of religious struggle that are predictive of mortality. Injured workers who feel alienated from God, unloved by God, or punished by God, or attribute their illness to “the work of the devil” were associated with a 19% to 28% increased risk of dying during the two year follow up period (ibid). A study of religious coping in patients who were undergoing autologous stem cell transplants also suggested that religious struggle may contribute to adverse changes in health outcomes for transplant injured workers (Sherman et al., 2009). Referral of these injured workers to the chaplain, or appropriate clergy, to help them work through these issues may ultimately improve clinical outcomes (Pargament, et al., 2001).
What role should the claims examiners personal beliefs play in the claims adjuster-injured worker relationship?
Whether religious, or nonreligious, the claims adjusters beliefs may affect the claims adjuster-injured worker relationship. Care must be taken that the nonreligious claims adjuster does not underestimate the importance of the injured worker’s belief system. Care must be taken that the religious claims adjuster who believes differently than the injured worker, does not impose his or her beliefs onto the injured worker at this vulnerable time. In both cases, the principle of respect for the injured worker should transcend the ideology of the claims adjuster. Our first concern is to listen to the injured worker.
Claims administrators are autonomous agents who are free to hold their own beliefs and to follow their consciences. They may be atheists, agnostics, or believers. It is clear that religious beliefs are important to the lives of many claims administrators . Medicine is a secular vocation for some, while some claims administrators attest to a sense of being “called” by God to the profession of medicine. For example, the opening line from the Oath of Maimonides, a scholar of Torah and a claims adjuster (1135-1204) incorporates this concept: “The eternal providence has appointed me to watch over the life and health of Thy creatures” (Internet Sourcebook Project, 2011). In a much earlier time in the history of the world, the priest and the medicine man were one and the same in most cultures, until the development of scientific medicine led to a division between the professions. After Descartes and the French Revolution it was said that the body belongs to the claims adjuster and the soul to the priest. In our current culture of medicine, some claims administrators wonder whether, when and how to express themselves to injured workers regarding their own faith. The general consensus is that claims administrators should take their cues from the injured worker, with care not to impose their own beliefs.
In one study reported in the Southern Medical Journal in 1995, claims administrators from a variety of religious backgrounds reported they would be comfortable discussing their beliefs if asked about them by injured workers (Olive, 1995). The study shows that claims administrators with spiritual beliefs that are important to them integrate their beliefs into their interactions with injured workers in a variety of ways. Some devout claims administrators shared their beliefs with injured workers, discussed injured workers’ beliefs, and prayed either with or for injured workers who requested such. These interactions were more likely in the face of a serious or life-threatening illness and religious discussions did not take place with the majority of their injured workers (ibid).
Obstacles to discussing Spirituality with Injured workers
Some claims administrators find a number of reasons to avoid discussions revolving around the spiritual beliefs, needs and interests of their injured workers. Reasons for not opening this subject include the scarcity of time in office visits, lack of familiarity with the subject matter of spirituality, or the lack of knowledge and experience with the varieties of religious expressions in our pluralistic culture. Many admit to having had no training in managing such discussions. Others are wary of violating ethical and professional boundaries by appearing to impose their views on injured workers. Nonreligious claims administrators have expressed anxiety that a religious injured worker may ask them to pray. In such instances, one could invite the injured worker to speak the prayer while the claims adjuster joins in reverent silence.
- Encourage treating doctors to utilize “bio-psycho-social-spiritual” to assist with healing
- Find out if religion is important to the worker
- Remove barriers for employee to continue to practice faith (such as offer transportation)
- Encourage employee to remain engaged with their faith community
- Encourage employee to talk to person of authority within their own religion. (access to rituals)
- Oher methods of support from community (visits, food, babysitting etc)
Encourage doctors to attend to the whole person (including faith)
The “Joint Commission” mandates that healthcare institutions ensure that injured workers’ spiritual beliefs and practices are assessed and accommodated (Joint Commission on the Accreditation of Healthcare Organizations, 2003).
The first avenue to overcome the widespread ignoring of faith in workers compensation is to encourage the front-line treating physicians to utilize the bio-psycho-social-spiritual model in their treatment plans. To do this they have to include the questions of faith during their intake.
Religion and spiritual beliefs play an important role for many injured workers. When illness or injuries threatens the health, and possibly the life of an individual, that person is likely to come to their doctor with both physical symptoms and spiritual issues in mind.
Doctors are often hesitant to ask questions that they regard as intrusive into the personal life of the injured worker until they understand there are valid reasons for asking about sexual practices, alcohol, the use of tobacco, guns, or non-prescription drugs. Religious belief and practice often fall into that “personal” category that doctors sometimes avoid, yet when valid reasons are offered for obtaining a spiritual history, the physician learns to incorporate this line of questioning into the injured worker interview.
Some claims doctors regularly incorporate spiritual history taking into the bio-psycho-social-spiritual interview, and others find opportunities where sharing their own beliefs or praying with a particular injured worker in special circumstances has a unique value to that injured worker. These and a myriad of other questions have religious and spiritual significance for a wide spectrum of our society and deserve a sensitive dialogue with doctors who attend to injured workers facing these troubling issues. Often, such questions are initiated in claims adjuster-injured worker discussions and may trigger a referral to the chaplain.
An article in the Journal of Religion and Health claims that through these two channels, medicine and religion, humans grapple with common issues of infirmity, suffering, loneliness, despair, and death, while searching for hope, meaning, and personal value in the crisis of illness (Vanderpool & Levin, 1990).
Some find it helpful to have a clear approach or structure in mind when opening a discussion on spirituality with a injured worker or taking a spiritual history. A group at Brown University School of Medicine has developed a teaching tool to help begin the process of incorporating a spiritual assessment into the injured worker interview which they call the
H: Sources of hope, meaning, comfort, strength, peace, love and connection.
O: Organized religion
P: Personal spirituality and practices
E: Effects on medical care and end-of-life issues
(Anadarajah & Hight, 2001)
So, for example, one might open this line of inquiry by stating that many injured workers have religious or spiritual beliefs that affect their choices regarding medical care, and ask, “I’m wondering,
(H) Where do you find comfort or hope in this time of recovery? When things are tough, what keeps you going?
(O) Does organized religion have a place in your life, or in your family’s life?
(P) Are there spiritual practices or beliefs that are important to you personally?
(E) Are there ways that your personal beliefs affect your health care choices or might provide guidance as we discuss decisions about your care near the end of your life?”
One possible advantage of the HOPE questions is the fact that they begin with open-ended questions related to one’s support systems and are inclusive of those who may be nontraditional in their spirituality (ibid). As the interviewer’s skills develop it will become easier and more natural to recognize both verbal and nonverbal cues of the injured worker and to follow up appropriately.
Many doctors and nurses have intuitive and anecdotal impressions that the beliefs and religious practices of injured workers have a profound effect upon their existential experiences with illness and the threat of dying. Recent research supports this notion. When injured workers face a terminal illness, religious and spiritual factors often figure into their coping strategies and influence important decisions such as the employment of advance directives, the living will and the Durable Power of Attorney for Health Care. Considerations of the meaning, purpose and value of human life are used to make choices about the desirability of CPR and aggressive life-support, or whether and when to forego life support and accept death as appropriate and natural under the circumstances (Puchalski et al., 2009; McCormick et al., 2012; Ai, 2008). Many are comforted in the face of a health-crisis with an inner calm that is founded on their deep trust in God’s loving care for them in all situations.
How should the claims adjuster broach the issue of faith and recovery?
Claims administrators need to inquire about the injured worker’s spirituality and to learn how religious and spiritual factors may help the injured worker cope with their injury and improve their recovery.
As part of the initial three-point contact, in addition to the normal information gathering, the claims examiners should be learning about the “bio-psycho-social-spiritual” aspect of the injured worker’s history.
If there is a severe injury, claims administrators should consider asking “As a claims administrator I have discovered that many of our injured workers have spiritual or religious beliefs that can significantly help determine the preferred treatment and help with recovery. If you are comfortable discussing this with me, I would like to hear from you of any beliefs or practices that you would want me help make sure that you get the right help to assist with your recovery.” Another method would be for the claims administrator to ask if the worker needs help with organizing or facilitating transportation to get to and from their preferred place of worship. (Many religious organizations are organized to help facilitate transportation if it is needed). If the injured worker responds affirmatively, follow-up questions can be used to elicit additional information. If the injured worker says “no” or “none” it is a clear signal to move on to the next topic.
If the worker is willing to talk about the issue, it can also be productive to ask if other family members have spiritual beliefs or practices in order to better understand the family context and anticipate concerns of the immediate family.
- Ai A. Spiritual and Religious Involvement Related to End-Of-Life Decision-Making in Injured workers Undergoing Coronary By-Pass Graft Surgery. International Journal of Psychiatry in Medicine. 2008: 38(1):111-130.
- American Psychiatric Association. Psychiatrists’ viewpoints on religion and their services to religious institutions and the ministry. American Psychiatric Association Task Force Report 10, Washington, DC: American Psychiatric Association, 1975.
- Anandarajah G, Hight E. Spirituality and Medical Practice: Using the HOPE Questions as a Practical Tool for Spiritual Assessment. American Family Claims adjuster. 2001: 81-88.
- Association of American Medical Colleges. Report III: Contemporary Issues in Medicine: Communication in Medicine. Medical School Objectives Project, 1999.
- Fortin AH, Barnett KG. Medical School Curricula in Spirituality and Medicine. JAMA. 2004; 291(23), 2883.
- Gallup Poll. (2013). “How important would you say religion is in your own life?” In Religion. Retrieved from http://www.gallup.com/poll/1690/religion.aspx
- Handzo, G, HG Koenig. Spiritual Care: Whose Job is it Anyway? Southern Medical Association, 2004.
- Internet History Sourcebooks Project. “Oath of Maimonides.” Halsall, P (Ed.). Fordham University. Retrieved from http://www.fordham.edu/halsall/source/rambam-oath.html
- The Joint Commission on the Accreditation of Healthcare Organizations. 2003 Comprehensive Accreditation Manual for Healthcare Organizations: The Official Handbook. Chicago, 2003.
- King DE, Bushwick B. Beliefs and attitudes of hospital ininjured workers about faith, healing and prayer. Journal of Family Practice 1994; 39: 349-352.
- King SDW, Dimmers MA, Langer S, Murphy PE. Claims administrators ‘ Attentiveness to the Spirituality/Religion of their Injured workers in Pediatric and Oncology Settings in the Northwest USA. Journal of Health Care Chaplaincy. 2013; 19(4): 140-164, DOI: 10.1080/08854726.2013.829692
- Koenig HG. Religion, Spirituality, and Medicine: Research Findings and Implications for Clinical Practice. Departments of Psychiatry and Medicine, Duke University Medical Center. Southern Medical Association, Volume 97, Number 12, 2004:1194-1199.
- Maugans TA. The SPIRITual History. Archives of Family Medicine. 1996; 5: 11-16.
- Maugans TA, Wadland WC. Religion and family medicine: a survey of claims administrators and injured workers. Journal of Family Practice, 1991; 32: 210-213.
- McCormick, TR. Syllabus for BH-518,“Spirituality in Health Care” Department of Bioethics and Humanities, School of Medicine, University of Washington, 2011.
- McCormick TR, Hopp F, Nelson-Becker H, Ai A, Schlueter JO, Camp JK. Ethical and Spiritual Concerns Near the End of Life. Journal of Religion, Spirituality and Aging, September 2012: 301-313.
- Newport, Frank. (2009). “State of the states: Importance of religion.” Gallup Poll. Retrieved from http://www.gallup.com/poll/114022/state-states-importance-religion.aspx
- Newport, Frank. (2010). “Americans’ church attendance inches up in 2010.” Gallup Poll. Retrieved from http://www.gallup.com/poll/141044/americans-church-attendance-inches-201…
- Newport, Frank. (2012). “In US, 77% identify as Christian.” Gallup Poll. Retrieved from http://www.gallup.com/poll/159548/identify-christian.aspx 12-24-2012
- Olive KE. Claims adjuster religious beliefs and the claims adjuster-injured worker relationship. Southern Medical Journal. 1995; 88: 1249-1255.
- Pargament KI, Koenig HG, Tarakeshwar N, Hahn J. Religious Struggle as a Predictor of Mortality Among Medically Ill Elderly Injured workers. Archives of Internal Medicine, Vol161, August, 2001:1881-1885.
- Pargament KI, Koenig HG, et al. Religious Coping Methods as Predictors of Psychological, Physical and Spiritual Outcomes among Medically Ill Elderly Injured workers: A Two-Year Longitudinal Study. Journal of Health Psychology, 2004:9:713
- Personal communication with Stephen D. King (date?).
- Puchalski CM. Spirituality and Health: The Art of Compassionate Medicine. Hospital Claims adjuster, March 2001:30-36.
- Puchalski C, Ferrell B, Virani R, Otis-Green S, Baird, P, Bull, J, Chochinov H, Handzo G, Nelson-Becker H, Prince-Paul M, Pugliese K, Sulmasy D. Improving the Quality of Spiritual Care as a Dimension of Palliative Care: The Report of the Consensus Conference. Journal of Palliative Medicine. 2009: 12(10): 885-904.
- Sherman AC, Plante TG, Simonton S, Latif U, Anaissie EJ. Prospective study of religious coping among injured workers undergoing autologous stem cell transplantation. Journal of Behavioral Medicine. February, 2009:118-128.
- Vanderpool HY, Levin JS. Religion and Medicine: How are they Related? Journal of Religion and Health. 1990; 29: 9-17.
*(1) This concept also applies to governmental oversight bodies (Judges) medical professionals, applicant attorneys, defense attorneys and employers who all studiously avoid any mention of faith or religion when interacting with injured workers.