Introduction
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
illness,
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
walking.
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
family.
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
Janice.
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.