The Spiritual Dimensions of Working 
With Families in a Medical Setting

Suzanne R. Engelman

Published in: S. Engelman (Ed.), 
Confronting life-threatening illness: mind-body approaches.
New York: Irvington Press, 1993

Working with families in a medical setting provides the 
health care team with ample opportunity to witness the diverse 
influences that impact individual patients under their care. 
One frequently overlooked dimension of family experience in 
medical settings is the "spiritual" - both as a family experience 
before injury, and as a factor that emerges spontaneously in 
response to illness. It is the purpose of this paper to explore 
some of the ways in which these spiritual experiences may 
occur and be utilized in the process of working with patients in 
a medical setting. 

Any discussion about spiritual matters is potentially con- 
flicting due to the different ways writers use the term. Clarifi- 
cation of the definition of spirituality used in this paper will 
therefore precede further discussion. 

Perspectives of spirituality offered by spokespersons of 
Transpersonal Psychology provide good working definitions of 
spirituality for the purposes of this paper. Singer (Note 1) sees 
the transformation of "ego, from the center of consciousness to 
an organic part of the larger whole" as an essential ingredient 
of spiritual experience. Bloomfield (1980) cautions that spirit-
tuality is not the same as mysticism and the occult, referring 
to spiritual experiences as ones that "lead to wholeness and 
integration, irrespective of religious belief or affiliation" (p. 
125). The synthesized meaning of the term spiritual used in 
this paper refers to experiences which lead one to expanded 
levels of awareness through a process that shifts one beyond 
ego boundaries to a larger, more encompassing whole, whether 
this whole is the collective unconscious, the family, culture or 
the cosmos. The process by which this shift occurs may include 
dreams, prayer, second-order learning, dealing with crisis, or 
working with one's family genogram to evidence the invisible 
links to earlier generations. These processes will be the focus 
of this paper, and it is important to distinguish spiritual 
experiences as used in this text to be different from traditional 
religious practice. 

Patients and their families undergoing the shock of physi- 
cal trauma leading to a spinal cord injury or catastrophic 
illness such as cancer, are in a state of crisis. At these times 
when we would expect individuals and their families to retreat 
and tend to their wounds, could we possibly assume spiritual 
experiences occur? Observations by this author (Engelman, 
1986) and others (Jung, 1972; Firman & Vargiu, 1980) suggest 
that although spiritual experiences may arise as part of a 
natural, orderly developmental search for greater meaning in 
one's life, these experiences may have other emergences that 
are less harmonious and potentially devastating. Spiritual 
upheaval may come as a result of a major disruption in the 
person's life such as terminal illness (Bahnson, 1984), death of 
a loved one, divorce, or other "violent and destructive interven- 
tions of fate" (Jung, 1972, p. 164). Conceptually, a model for 
thinking about how these spiritual upheavals may occur in 
patients coping to serious illness is as follows: 

Normally, families carry on their lives in a way that is 
molded to fit the ideals of the particular family in its cultural 
context. Families have concrete, physical roles that they play 
out according to unacknowledged family rules, alliances and 
coping strategies. Considering individual dynamics. this more 
superficial level of self-definition is what Jung refers to as the
"persona level of experience" (Jung, 1972, p. 161). This "per- 
sona" level is present in the family dynamic and disguises two 
less obvious, unconscious levels of influence. 

The first unconscious level is the transgenerational family 
level, which contains the unconscious patterns of behaviors 
that have been experienced in generations preceding the 
current family and levels of family awareness that cannot be 
understood by linear means (Taub-Bynum, 1985). These fam- 
ily patterns are unconsciously passed down and may include 
specific symptoms, unconscious family myths, roles and the 
less understandable phenomenon of paranormal family 
dreams and experiences. The experiences and feeling of a 
particular family have been repeated over many generations to 
form an archetypal context that is unconsciously "transmit- 
ted" to the current family generation, even though the family 
member may not have even known his predecessors (Bahnson, 
Note 2). 

The second and deeper unconscious level is what Jung 
calls the "collective unconscious," or the repository of experi- 
ences that underlie all of humanity, including the intensely 
horrible and beautiful images and feelings that arise during 
times of spiritual crisis (Jung, 1972, p. 160). Out of this level 
emerges a living picture, "containing pretty much everything 
that moves upon the checkerboard of the world, the good and 
the bad, the fair and the foul" (Jung, 1972, p. 148). 

Patients who are undergoing severe disabling and life 
threatening trauma appear to be catapulted into a crisis 
situation. Pain, unfamiliarity with strange people and equip- 
ment, side effects from strong medication and fear, all accom- 
pany the crisis of the immediate illness can lead to a break- 
down of the persona level of functioning. This "persona break- 
down" may produce a state of disequilibrium that parallels a 
psychotic disturbance, yet differs from psychosis only from the 
fact that "dissolution of the persona leads in the end to greater 
health, while the latter leads only to greater destruction. It is 
a condition of panic, of letting go in the face of apparently 
hopeless complications" (Jung. 1972, p. 161). 

With the persona somewhat dismantled, forces burst out of
the collective psyche and have a confusing and blinding effect. 
the plunge into this state may be unavoidable whenever the 
necessity arises of overcoming an extreme stress in life (Jung 
1972). It is at this time of intense and frequently overwhelming 
crisis that spiritual dimensions and bizarre behaviors can
simultaneously emerge, while patients are being treated in the
otherwise rational and organized world of the medical ward. 
The metaphors of the larger Self may emerge at this time-- 
Jesus, nirvana, prayer, nature, omniscience, and the ultimate 
truths about life may be revealed with the upsurge of the
collective unconscious into conscious awareness. Indeed, 
one physician writes of his revelations during an incurable 

My mind is more alive and vivid than ever before ... My 
sensitivities are keener; my affections strong. I seem for 
the first time to see the world in clear perspective. I love 
people more deeply and comprehensively. I seem to be 
just beginning to learn my business and see my work 
in its proper relationship to science as a whole. I seem 
to myself to have entered into a period of strong feelings 
and saner understandings (Cousins, 1983, p. 231). 

Thus, while coping to physical illness, the person IT 
experience intensely uplifting or overwhelming feelings 
chaos. How the person copes may depend on a combination 
pre-morbid personality patterns and the kind of support given 
by the health-care team. According to Jung (1972), one way in 
which the person may struggle with the spiritual crisis that 
ensues is to be overwhelmed by the collective contents, 
which case paranoia or schizophrenia may develop. A second 
way of coping with the upsurge of collective images may be to 
totally reject them, in which case the person reverts back to 
"infantile attitude." This person patches up the persona 
in order to function in the world, but does so at a level that leaves 
the full functioning of the person compromised (Jung, 1972 
162). The most ideal type of reaction would be that of critical 
understanding (Jung, 1972). In this mode of coping, the person 
does not become overly discouraged by the overwhelming 
images and circumstances, but strives to integrate them, 
continues to take healthy risks, but with a more cautious 
understanding that life presents us with challenges that are 
sometimes beyond our individual control. 

As we look into families' backgrounds, we are likely to see 
the seeds of their religious beliefs that may be contributing to 
their current coping styles. Patients who are undergoing the 
shock of serious illness frequently call upon God to relieve their 
anguish. This pattern may be a reflection of early childhood 
experiences of religion in which the family called upon God in 
times of trouble (Singer, 1973). 

Seriously ill persons experience their illnesses differently 
from one another. Many see their illness as just punishment for 
past sins (Bahnson, Note 2, p. 20), or they may feel that their 
illness happened as part of a larger pattern in which something 
is to be learned; that it is God's will. For such persons, belief 
in a higher power's ultimate plan helps them come to accept 
their pain and relieve guilt feelings surrounding their past sins 
(Power & Dell Orto, 1980). Faith in God may also assist those 
who are overwhelmed with their feelings of hopelessness and 
powerlessness. Despair has been found to be greatest when a 
person feels both hopeless and powerless. Being a patient in a 
medical setting week after week, month after month, is the 
perfect medium for developing a good case of powerlessness, 
let alone having a serious illness which further creates physical 
changes, leaving the person very dependent on others tempo- 
rarily or permanently. So although the patient may not feel like 
his or her fate can be controlled (Le., ls he feels powerless), one 
can still come to feel hopeful, by placing what happened to 
oneself in God's hands. In this way one's faith can be sustain- 
ing (Stotland, 1969). This hope, in turn, may facilitate a more 
optimistic attitude and enhance the healing process. 

Bahnson (1984) has also discussed the role of religious 
experience as it occurs with the terminally ill, as a "denial or 
nonexistence" which may be either helpful or destructive, 
dependent on whether it constitutes a flight from the solution
of urgent interpersonal problems, or whether it becomes part 
of the mosaic of security characterizing the final stage of 
acceptance of death (p. 250). 

Prayer, meditations and visualization are tools that people 
may use in putting themselves in the kind of psychological 
space that takes them away from their immediate ego and 
bodily concerns, and puts them into an altered state of 
consciousness whereby their awareness may be expanded 
(Bahnson, Note 2, p. 19). Prayer is frequently used by persons 
coping with catastrophic illness, and many of the patients with 
whom I worked have talked about the importance prayer has 
played for them in their healing process. 

Whether or not the prayers hold the conscious desire to 
obtain something or to have that something "descend" 
on ourselves or others, the upward projection of feel- 
ings has the effect of "lifting" the center of conscious- 
ness in some measure into subtler levels of the inner 
world. It is a process of elevating feelings, and desires, 
and thus transmuting them into aspirations toward 
higher goals (Firman et al., 1980, p. Ill).

This paper will now focus upon three specific instances of 
patients integrating spiritual experiences as part of coping to 
their serious illness. The genogram, which is a diagram of the 
family's three generational structure, is used to facilitate the 
patient and family's recognition of the role of transgenerational 
problems and the role of spirituality in the past. These 
genograms are included in the original publication with each
case presentation; however, they are unable to be include 
in this format.

The first case is that of Joe, a 23 year old man who 
sustained a spinal cord injury during a hang-gliding accident 
two years ago. I worked with him during his initial hospitalization 
and had the opportunity to meet with him again during a 
subsequent hospitalization for diagnosis of abdominal pain.  
Joe represents the struggle of many spinal cord injured 
persons; most, however, do not have outcomes as positive as 
.Joe’s. Prayer was a very important aspect of Joe's rehabilitation. 
Like many spinal cord injured patients, he asked and was told 
within a few days of his accident, that he would “never walk again.” 
At that time, paralyzed from the shoulders down years ago. Joe 
responded that that was unacceptable to him and he would walk 
out of the rehab center. The medical staff felt he was "in denial," 
because they had diagnosed him as a C-4 Quadriplegic, Frankel 
Class A, with a one out of one hundred chances of ever walking. 
Later he was told his chances of walking were more like one in 
one thousand. 

Like many spinal cord injured patients, Joe prayed a lot- 
24 hours a day. Joe also thought a lot about his father who at 
one time developed cancer and was bedridden for many years. 
but eventually "overcame it-I knew that if he could do it. I 
could too. So I spent a lot of time praying and thinking about 
how he did it." Especially during the first six weeks of his 
rehabilitation. before any part of Joe's body began to move. his 
feelings needed particular uplifting; but after he started getting 
movement back in his hands. then his toes. the physical proof 
was uplifting enough. 

Joe did "walk out" of the hospital to return home to live with 
his father and work on strengthening himself so he could walk 
more functionally. Most patients do not leave the hospital with 
as good an outcome. but then again, maybe most patients did 
not have the same inner experiences about overcoming illness 
and conviction that Joe had. Joe's own feelings were that his 
prayers and the optimism they engendered were what got him 

The second case study regards .Jarl, a 50 year old man. who 
came from a "long line of healers" in his family. His great- 
grandmother who lived in the Mid-West. used to do natural 
healing with herbs and laying on of hands. She was a full 
Cherokee Indian and passed her healing down to her children. 
which Jarl was very comfortable talking to me about but 
indicated, "It's the kind of stuff I wouldn't tell just anybody. and 
certainly not the doctors. They would think I'm 'nuts ... · Jarl 
talked about the time his great-grandmother walked several 
miles through the woods to tell her daughter that something 
was wrong with the oldest male child of her string of nine 
children. At that time John was fine. only to come down with 
polio two days after the grandmother's prophecy. In his own 
generation. Jarl talked about his mother's psychic abilities to 
know when her children were in trouble. She "had a feelin' 
about this accident when it happened." just as Jar! too. had 
had a feeling of expectation before he had his vehicle accident.

For the first several weeks after his accident, Jarl fought for 
his life. His injury had been so debilitating that his lungs 
stopped working on their own. He had to use a respirator, 
which breathed for him. Three times his breathing stopped 
while he was on the respirator. One of those times was due to 
the respirator malfunctioning. Because of his past history with 
"spiritual" experiences, Jarl had the inner resources to help 
him cope with the severe panic and terror of losing his breath 
and suffocating. Jarl talked about how he was able to teach 
himself to breathe again by focusing on the square I put in 
my lungs. When I focused on the square, it would gradually 
get larger and it was white light. Gradually it expanded until 
it filled my whole lungs and then I could breathe totally on my 
own. If my concentration was interrupted just the slightest, 
the square would disappear and I would have to start over 
again. On the other hand. I couldn't really fully focus on the 
square because that could interfere too. 

Unknown to him at that time, Jar! had described the 
process of meditation and passive volition in the act of focus- 
ing. Jarl was busy in his process of "inspiring" himself. As the 
psychologist working with. Jarl, I gave him much support to 
continue along the path he was on and praised him for the 
excellent way in which he worked with his own inner healer. 

Finally. I would like to end with the story of Janice. who was
a 48-year-old woman with metastatic breast cancer. Janice 
opened her life to me about nine months before she was to die. 
Her goals were to be able to have help in looking at and going 
through the process which she felt would end in death. 

Janice had been the sixth born of eight girls in the rural 
farm country of North Dakota. Life was hard on the farm. and 
her father, disappointed in not having any sons, expected his 
daughters to see to the farm work. By the time chores were 
done, Janice didn't have much time for social life. When she 
was 32, she met her future husband and they were soon 
married. While she was pregnant with their son, Dave, her 
husband developed multiple sclerosis. By the time her baby 
was delivered, her husband was going into a wheelchair. He 
gradually deteriorated and when Dave was 8 years old, his 
father died. Janice was 39 and completely in charge of bringing 
up her young son and her deceased husband's two teenage 
daughters from a previous marriage. Nine years later, Janice 
was diagnosed with metastatic breast cancer.

As we talked about these early life events, Janice explored
regrets she had.  One of the major issues for her was that she 
had never been able to talk to her husband or any other family
members in the process of his dying. Her fears were that her 
death would be an equally lonely experience. Janice wanted to 
do it differently. As hard as it would be, she wanted to bring 
family tensions, cut-offs, and other feelings out into the open. 
In particular. she wanted to know her son better. and role 
model the process of communicating for him. She was con- 
cerned about Dave's very quiet and sometimes moody nature. 

This precipitated the beginnings of family meetings. 
Throughout the course of the next nine months, we had many 
family sessions; at the times when Janice would deteriorate 
physically and her sisters would fly in from other parts of the 
country, they would be included. Janice was anxious to try 
anything that would help to alleviate her anguish in facing her 
impending death. We used hypnosis to help with the periodic 
headaches and pain; visualizations to "chart" the growth of her 
cancer at times when the physicians were unable to clinically 
diagnose its spread; and just honest heart to heart discussions 
among all the family members. Janice experienced all of these 
events as enlarging upon the quality of her life, while struggling 
with tremendous resistance to stay open to herself and her 
Previously closed to expressions or anger, Janice was able 
to really let her anger out about her progressing sickness. As 
she began to make her transition into another reality closer to 
death, Janice bitterly cried, "I can't believe this is happening to 
me." She vented her frustration with her family's difficulties 
dealing with her loss of memory and disorientation, but during 
her final days, Janice had to be reminded that her mind and 
body were turning inward and she need not be judgmental of 
her failing cognitive abilities and hair loss. In other words, I 
worked with Janice to release some of her ego concerns to look 
and act appropriately and prepare for a larger reality. 

Her resistance to death continued up until the final day. A 
hospital bed was set up in her bedroom. She tossed and turned 
in her bed, bolting upright with her small frail hands grabbing 
the rail of her bed, only to fall back again, gently into her 
depths. And finally came the day of Janice's death. Within an 
hour of her death, I arrived at her home and together with
family members, including her three children, two sisters and 
two friends, we encircled her bed. Taking Janice's hands, we 
kneeled around her bed and formed an energy circle to say our 
good-byes and talk about what we had loved about Janice, and 
had been troubled by. It was a tremendously powerful time for 
us all, leaving our everyday world to spend these last few 
moments in the sanctuary of Janice's room. as she speeded off 
into another realm. Each person said their good-byes in their 
own special ways. Our circle included Janice and respected her 
dying wishes. Just as we had met as a family together through- 
out the process of her dying, so we completed the process with 

These three case presentations underscore the importance 
of considering the whole family system within which the 
patient is embedded. The current family and previous genera- 
tions may all affect how the patient deals with serious illness. 
Spiritual experiences (as opposed to traditional religious prac- 
tice) have been overlooked as an important ingredient in 
dealing with illness, and need to be respected as part of the 
whole experience of coping to serious illness. 

Reference Notes 

1.  Singer, J. Personal communication, Palo Alto, CA, August 
2.  Bahnson, C. B. Disability in classical myth and modern 
     society. Presented at a workshop/seminar at the Woodrow 
     Wilson International Center for Scholars, Smithsonian 
     Institute, Washington, D.C., May 13, 1981.


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