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Strength, resilienceParticipation in religious communityInner peace, comfort, supportHopeFaith (trust)TranscendenceOpen in a separate windowThe 3 H’s encompass cognitive (head), experiential (heart), and behavioral (hands) aspects of the human spiritual experience. The phrase “head, heart, and hands” is used widely in other contexts68–71 but is applicable here. The cognitive, or existential, (head) aspects include search for meaning and purpose, and values and beliefs most important in one’s life. The experiential (heart) aspects encompass the human need for love, inner peace, resilience, and connection. Finally, the behavioral (hands) aspects pertain to the outward expression of spiritual beliefs and needs, such as life choices, behavior toward others, rituals, and practices. These dimensions of spirituality are applicable to all human beings irrespective of culture or belief system, whether secular or religious.In the medical context, spiritual issues pertaining to the head include such questions as why is this happening to me (or my loved one), what will happen after I die, are these treatments consistent with my beliefs, and if God exists, where is God now? Spiritual issues related to the heart include the experiences of feeling connected vs alone when ill; feeling peace vs turmoil when facing death; or feeling hope vs despair when dealing with chronic illness. Finally, hands aspects can manifest in the medical context in a variety of ways including spiritually based treatment decisions by patients or families; patients’ requests for specific rituals, prayers, or diets; or physicians’ own needs for spiritual rituals or prayer when dealing with stressful situations.Go to:RELATION BETWEEN SPIRITUALITY AND RELIGIONPeople differ widely in the way they view the relationship between spirituality and religion. For some, these terms refer to the same thing; for others, they are overlapping concepts; and for yet others, they are vastly different.64–67,72One practical approach is to envision spirituality as addressing universal human questions and needs, and religion as providing specific (and often differing) answers to those questions, and ways of meeting those needs. Human spirituality, therefore, is often expressed in the specific language of religions or other world views. For example, to the question of what happens after death, Christianity might discuss heaven and hell, whereas Buddhism will refer to karma and rebirth. To the question of how to feel more connected and at peace, Islam might suggest specific prayers and the reading of the Koran, whereas Hinduism might recommend specific Vedic chants and mantras. Regarding how to lead a good life and make good choices, Judaism might point to the Ten Commandments and Talmudic discussions, whereas an atheist might point to certain basic human societal values to guide life’s many decisions. The questions and needs are universal, but the answers and approaches vary.In Figure 1▶, organized religion is listed under social factors (S) that influence the individual. Because the combination of religious background, culture, family, and past experience shape the individual’s spirituality, members of similar religious backgrounds may have different spiritual beliefs and needs. Huston Smith asserts that in every religious community, a variety of “spiritual personality types” exist, ranging from atheists, to polytheists, to monotheists, to mystics.73 In a Jewish family, for example, one brother may be orthodox in his practices, whereas another brother may describe himself as a secular Jew; each will have different needs related to health care. Personal religiosity, therefore, is an aspect of a person’s spirit in Figure 1▶ (the 3 H’s) and interacts to varying degrees with organized religion.Go to:SPIRITUAL SUFFERINGSpiritual suffering can occur in any of the 3 dimensions outlined in Table 1▶ (head, heart, hands). A mother whose child has just died may wonder whether this is divine punishment for something she did earlier in life, thus experiencing spiritual suffering in the head dimension. A patient who is dying of cancer and has noticed family and health professionals withdrawing from him may be suffering in the heart dimension. Finally, a recent immigrant, without access to family or religious community, may be unable to perform important rituals that sustain him, thus suffering in the hands dimension. It is important to note that these 3 dimensions are closely related; thus, suffering may occur in all 3 dimensions simultaneously. The mother who is struggling with meaning (head), in the example above, may also feel disconnected from God (heart) and find herself unable to pray for help (hands). She needs assistance from someone specifically trained to address all of these issues.Because suffering has physical, mental, and spiritual aspects, therapeutic options should be available at all of these levels. Relief from spiritual suffering can be provided by spiritual self-care and 2 levels of therapeutic options: specialized and general spiritual care (described below). Figure 2▶ illustrates therapeutic approaches at the body, mind, and spirit levels (arrows f, g, h, i). Given the complexity of human suffering, multidisciplinary teams are increasingly needed to provide appropriate therapeutic interventions.Figure 2.Secular version of the BMSEST model for whole-person care: the physician-patient relationship.BMSEST = body, mind, spirit, environment, social, and transcendent; PT=physical therapy.Arrow a = interactions between body and mind.Arrow b = interactions between mind and spirit.Arrow c = interactions between body and spirit.Arrow d = interactions between environmental factors and the individual.Arrow e = interactions between social factors and the individual.Arrow f = therapeutic approaches at the body level.Arrow g = therapeutic approaches at the mind level.Arrow h = therapeutic approaches at the spirit level (specialized spiritual care).Arrow i = therapeutic effects at the spirit level (general spiritual care).Go to:SPIRITUAL CARESpiritual Self-CareSelf-care of the body and mind, such as by healthy diet, exercise, and social support, has long been encouraged. Spiritual self-care can take the form of self-understanding and inquiry regarding beliefs and values, or methods for bringing peace and tranquility, such as prayer, meditation, nature walks, church attendance, or yoga. With the growing interest in the efficacy of self-management in the treatment of chronic illness, the role of spiritual self-care in health is fertile ground for exploration.Specialized Spiritual CareFor specific struggles with head issues or hand needs, such as specific prayers or rituals, the most appropriate approach involves consulting a professional trained in spiritual care, such as a chaplain with clinical pastoral education (CPE) training or a community religious leader.74–76 In much the same way as social workers or psychologists provide the mental health components of whole-person care, chaplains are also integral to the health care team. To maintain high-quality patient care, it is critical to attend to the boundaries of role and training between physician and specialist in providing this specialized spiritual care.74–76 Physicians can identify the need and provide simple modifications in the treatment plan to accommodate specific beliefs. Chaplains, however, are trained to provide in-depth counseling and access to religious rituals and prayers (interaction h in Figure 2▶). In addition, it is essential for all professionals to cultivate self-awareness to avoid interference of personal beliefs and biases in ethical, patient-centered care.76General Spiritual Care—Being a HealerSpiritual care also attends to the heart needs (interaction i in Figure 2▶). The health care setting can be impersonal, leaving patients feeling vulnerable and disconnected from their usual sources of strength. This state of spiritual distress is easily overlooked because no clear religious struggle or need is articulated. The therapeutic intervention at this heart level is at once both simple and extremely difficult. It requires that health care professionals bring their humanness to the medical encounter. Elements include compassion, presence, true listening, and the encouragement of realistic hope, which have been articulated as critical elements of spiritual care.77 Unlike head and hand issues, these elements do not require doing, but rather being. These interventions do not require inquiring about specific beliefs and take no more time than a clinician’s usual duties. Rather, they require that health care professionals augment their everyday activities with presence, compassion, and positive intention. This definition of spiritual care overlaps considerably with the concept of physician as healer,1,2,78–81 who cures, relieves, and comforts always. Balint82 refers to the doctor as a potent medication, and Hippocrates2 said, “Some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician.” Some of these concepts are also addressed in the literature on mindfulness83 and professionalism79 in medicine, and in the research being done on listening,84 altruism and compassion,85 and the placebo effect.13Importantly, general spiritual care does not involve emotional entanglement. There are clear distinctions between being engaged vs enmeshed. Osler, in his famous speech “Aequanimitas,”86 describes the value of clinical detachment, the “mental equilibrium of the physician…,” but advises striving for this “without at the same time hardening ‘the human heart by which we live.…” More recently, Fricchione87 describes the middle ground between separation and attachment in his neurobiologic modeling of human development and spirituality.To achieve this critical balance, physicians need to attend to their own health and well-being, including their spiritual health. Doing so is challenging in today’s health care environment, yet is essential in the quest to be a healer and scientist. Figure 2▶ reminds us that every physician is also a whole person—a product of his or her own culture, family, and social institutions (including the medical industry). It also reminds us that at the level of general spiritual care, the therapeutic association (arrow i) is bidirectional—physicians have the potential to heal and be healed through their clinical interactions, as clearly illustrated by numerous physician stories.88–90Go to:BMSEST MODELS—CULTURAL AND RELIGIOUS VARIATIONSFigure 2▶ illustrates the physician-patient relationship with therapeutic options at body (B), mind (M), and spirit (S) levels within the context of environmental (E) and social (S) factors; however, many who examine this figure will argue that no discussion regarding spirituality is complete without a discussion of the transcendent (T). The figure displays a secular version of the BMSEST model, which may resonate most readily with secular humanists or atheists. In this model, spiritual factors are entirely contained within the human being, and prayer and meditation are likewise human phenomena. The transcendent, in this model, may refer to the set of societal values and needs that transcend the individual’s needs, thus guiding complex ethical decision making.When one studies the world’s religions,73,91–96 2 major conceptual models of a divine transcendent emerge, giving rise to 2 BMSEST variations—the duality model (Figure 3▶) and the unity model (Figure 4▶). Both models exist to some degree in all the major religions; however, the duality model predominates in western religion, and the unity model predominates in eastern thought and the mystic traditions of many religions.Figure 3.Duality version of the BMSEST model for whole-person care.BMSEST = body, mind, spirit, environment, social, and transcendent; PT=physical therapy.Arrow a = interactions between body and mind.Arrow b = interactions between mind and spirit.Arrow c = interactions between body and spirit.Arrow d = interactions between environmental factors and the individual.Arrow e = interactions between social factors and the individual.Arrow f = therapeutic approaches at the body level.Arrow g = therapeutic approaches at the mind level.Arrow h = therapeutic approaches at the spirit level (specialized spiritual care).Arrow i = therapeutic effects at the spirit level (general spiritual care).Arrow j = interactions between the individual and the Transcendent.Figure 4.Unity version of the BMSEST model for whole-person care.BMSEST = body, mind, spirit, environment, social, and transcendent; PT=physical therapy.Arrow a = interactions between body and mind.Arrow b = interactions between mind and spirit.Arrow c = interactions between body and spirit.Arrow d = interactions between environmental factors and the individual.Arrow e = interactions between social factors and the individual.Arrow f = therapeutic approaches at the body level.Arrow g = therapeutic approaches at the mind level.Arrow h = therapeutic approaches at the spirit level (specialized spiritual care).Arrow i = therapeutic effects at the spirit level (general spiritual care).Arrow j = interactions between the individual and the Transcendent.In the duality model (Figure 3▶), God is seen as separate from human beings but able to affect us on all levels. God is seen as a father or mother, and our relationship with other people is that of brothers and sisters. Prayer and meditation are methods of communicating with and attuning oneself to God, and all healing and moral guidance ultimately come from God. A variation of this model is applicable to polytheistic religions.In the unity model (Figure 4▶), Maslow’s triangles are turned upside down. Here, the body is just the tip of the iceberg, and on a spiritual level, we are all one. In this model, we are part of God, as a wave is part of the ocean, and our relationship with other people is akin to limbs on the same body. Prayer and meditation are methods to connect with “God within” or the “Oneness of the universe,” and healing and ethical decisions arise from connecting with that oneness.These 3 BMSEST models provide insight into the various ways people view spirituality and the transcendent, thus paving the way for more meaningful communication. They also emphasize that, in the clinical arena, the approaches to patient care (arrows f, g, h, i) are the same, regardless of the model variation most resonant with physician or patient. The choice of the most appropriate specific therapeutic intervention for the patient varies depending on the patient’s belief background.Go to:SPIRITUALITY, SERVICE, AND ADVOCACYThe individual’s role in the health care system does not stop at the physician-patient relationship. The BMSEST models also illustrate the 2-way interaction between the individual and social and environmental factors (arrows d and e). Ideals and values (head), energized by inner strength and resilience (heart), can lead to profound action on a systems level (hands) to benefit the health of others. History abounds with examples of individuals, such as Mahatma Gandhi, Mother Teresa, and Martin Luther King, who harnessed spirituality to improve the social environment, with effects on many people’s health and quality of life. Research on altruism is beginning to elucidate some of the factors that influence this aspect of human experience.85Go to:FINDING COMMON GROUNDFor patient care, education, and research to successfully incorporate spirituality into whole-person care, it is essential that human spirituality be understood in universal terms, just as the human body and mind are considered universal. From the universal, we can appreciate normal variations, and from there, identify factors that affect health and well-being.The 3 H’s (Table 1▶) provides a framework for understanding common spiritual themes. These themes are both explicitly and implicitly present in patients’ narratives and actions. By recognizing and responding to patients’ cues, we can allow patients to provide us with the language of spirituality that best suits them—whether religious or secular.The BMSEST models (Figure 2▶, 3▶, 4▶) provide a theoretical framework for understanding the role of spirituality in whole-person care, applicable to all people. They also remind us of the existence of considerable variations in world views and images of God, while emphasizing the common therapeutic approaches available at the body, mind, and spirit levels. Optimal patient care requires a multidisciplinary team approach to navigate this complex system.However, the true common ground and foundation for integrating spirituality into medicine lie in the healing attitude and self-awareness of the professional. Adopting a patient-centered approach, reflecting “spiritual humility,” akin to “cultural humility,”97 together with an attitude of service and advocacy, will likely yield better understanding and thus better therapeutic options than simply following established spiritual history protocols.98,99 In addition, unlike questions in other areas of medicine, many spiritual questions are unanswerable. Thus, it is often in the appreciation of the questions, rather than the provision of answers, that healing occurs.Go to:CLINICAL AND EDUCATIONAL APPLICATIONSThe BMSEST models and the 3 H’s have many practical clinical and educational applications. The former remind clinicians of the layers of complexity in their patients’ experience of illness, and the latter provide a means for bridging cultural differences in spiritual beliefs and practices.Example 1. Medical students can use the BMSEST framework (Figure 2▶) to develop a holistic diagnosis and treatment plan. For example, when learning about domestic violence, rape, and incest, they can visualize potential effects on patients’ physical health (eg, bruises, sexually transmitted diseases, chronic pain); mental health (eg, posttraumatic stress disorder, depression); spiritual health (eg, search for meaning, conflicts between beliefs and treatment options); social relationships (eg, disruption of family ties, contribution of alcohol and drugs, police and legal issues); and environment (eg, safety/emergency housing). Therapeutic options may include medications for sexually transmitted diseases (arrow f) or posttraumatic stress disorder (arrows f and a); counseling by a psychologist for anxiety (arrow g); procurement of housing in a homeless shelter by a social worker (arrow d); counseling by a clinical chaplain regarding treatment options for a pregnancy resulting from rape or incest (arrow h); and a safe, compassionate, therapeutic relationship (arrow i).The 3 H model proves a useful tool for spiritual assessment during a medical encounter, as an alternative to existing tools.98,99 It helps clinicians recognize spiritual themes in their patients’ narratives and offers a common vocabulary for open-ended questions that can reveal the specific language of spirituality that a patient uses (religious or secular).Example 2. A 59-year old hospitalized patient with metastatic lung cancer is struggling with the decision between hospice vs more chemotherapy. Her physician is struggling to control her severe pain because the patient is reluctant to increase the amount of pain medication. A picture of Jesus on her table cues her physician to learn more about her beliefs. The 3 H’s remind him to start with general spiritual questions. He learns that although the patient believes in God as Jesus, her specific language of spirituality is from the 12-Step recovery community. Because the physician has a compassionate, respectful attitude (BMSEST arrow i), she tells him more. She believes in the afterlife and that things happen for a reason (head), and she feels loved by God and does not fear death (heart); however, she is struggling with the hospice decision and pain management (hands) because of a conflict between her fear of pain and symptoms vs her fear that taking narcotics is against the beliefs of her spiritual community. She worries that she will lose her community and die alone, “addicted” to pain medications. These concerns needed to be addressed directly, with the help of her 12-Step community, in order for her to peacefully transition to hospice care. At the end of her life, her physician realizes that attention to his own spiritual 3 H’s gave him the strength to visit her bedside, when nothing was left to do except provide his presence.Medical students and residents in the United States have diverse spiritual beliefs, ranging from devoutly religious (in different religions), to atheist, to undecided. The 3 H’s offer the opportunity for all learners to sit at the table when discussing spirituality and medicine.Example 3. Educators (a physician and chaplain team) have successfully used the following small group exercise as an introduction to spirituality and medicine in required medical school clerkship sessions41 and resident education43: (1) ask learners to define spirituality, (2) organize their answers using the 3 H model, (3) using small group facilitation skills, provide a safe and respectful environment for students and residents to learn from each other about the variety of world views present in their own learning community, (4) expand the conversation to stories from learners about patient encounters in which spiritual issues played a role, and (5) facilitate a conversation regarding challenges and approaches. This technique introduces the concept of spirituality as a universal human experience and promotes cross-cultural discussion.The 3 H and BMSEST models can also be used to nurture health care professionals’ self-understanding. These models help professionals clarify their own world view and provide tools for traversing cultural differences in spiritual beliefs and practices.Example 4. A medical student, visibly shaken, tells her advisor about an upsetting experience in her community mentor’s office. Her mentor, whom she respects, started praying with a patient while the student was present. She was taken by surprise and felt trapped, confused, and scared. Her advisor can use the 3 H and BMSEST models as tools to debrief her experience by encouraging self-understanding regarding her response (she is undecided about her beliefs, and her family has experienced religious discrimination); facilitating her understanding of the positive experiences of the patient and her mentor in this situation; and exploring strategies for responding to prayer in the clinical setting. In addition, the advisor could use the BMSEST models as training tools in cross-cultural communication for clinicians interested in including spirituality in their work.The 3 H and BMSEST models can also help promote physician self-care by acting as springboards for physicians to discover (and rediscover) their ideals, values, and purpose, and to explore methods to rejuvenate and sustain themselves during a challenging career. These methods, aimed at reenergizing the spiritual heart, can vary widely, depending on the individual physician, from religion-based activities, to secular activities, such as nature walks, dancing, and laughing with their children. Workshops regarding spiritual self-care have been valuable additions to medical education.42,43Go to:RESEARCH APPLICATIONSThe 3 H and BMSEST models also have research applications. Elements of these models can be tested. A variety of methods might be used to evaluate the universality of the 3 H dimensions of spirituality and the extent to which current areas of research/study have a home within the BMSEST model. BMSEST homes for published studies include the following: meditation and health (arrow a, b, c, or j)4,5,13,17,52,56; religion and health (arrow b, c, or e)8,11,12,14,16,36; compassion and altruism (arrow i, d, or e)85; biologic mediators of spirituality (arrows b and c)17,46–55; consciousness studies, in the areas of mind and spirit (arrow b)32,33,45; and human energy systems (body, arrows a and c).57–59 The BMSEST models can also help identify which of the 6 components and 10 relationships (a to j) need further study.The various subthemes within each of the 3 H dimensions of spirituality can be used to develop scales for measuring spiritual health, well-being, and need (for use in biomedical research). The 3 H’s can add to existing scales (reviewed elsewhere26,65) by providing a framework for ensuring that measures for each dimension are included in comprehensive scales and that studies regarding the relationships between various sub-themes (eg, effects of love, hope, forgiveness, meaning) can be conceptualized in a logical way. Future research could also elucidate the contributions of physical, mental, and spiritual health to overall quality of life.Finally, because the BMSEST models include consideration of the transcendent, which is frequently defined as being outside the realm of the physical world, they raise the question of whether effects directly related to the transcendent (eg, arrow j) can be adequately studied using methods typically used in biomedical research. Many have debated this issue.100–102 Perhaps a deeper understanding of these effects can be gleaned only through direct experience and indirectly through qualitative methods, the arts, and the humanities.In conclusion, the 3 H and BMSEST models provide a conceptual basis for approaching spirituality as a universal human phenomenon, essential to understanding whole-person medicine. Given the complexities of the human condition, future study regarding whole-person care will require innovative multimethod research and a multidisciplinary approach, encompassing science, social science, and the humanities. Although challenging, many opportunities exist for finding common ground between differing world views and discovering better ways to provide cure, relief, and above all comfort to suffering patients.Go to:AcknowledgmentsI thank the many medical students, residents, and colleagues who, over 11 years, have engaged in frank conversations about spirituality and health. I thank Denise Leclair, MD, Roger Mennillo, MD, the Brown Family Medicine Scholarship Promotion Committee, Jeffrey Borkan, MD, PhD, and Kohar Jones, MD, for reviewing this manuscript.Go to:NotesConflicts of interest: none reportedGo to:REFERENCES1. Lown B. The Lost Art of Healing. New York, NY: Ballantine Books; 1999.2. Dixon DM, Sweeney KG, Pereira Gray DJ. The physician healer: ancient magic or modern science? Br J Gen Pract. 1999;49(441): 309–312. [PMC free article] [PubMed] [Google Scholar]3. Murray CJ, Lopez AD. Global mortality, disability and the contribution of risk factors: global burden of disease study. Lancet. 1997;349(9063):1436–1442. [PubMed] [Google Scholar]4. Benson H, Malvea BP, Graham JR. Psysiologic correlates of meditation and their clinical effects in headache: an ongoing investigation. Headache. 1973;13(1):23–24. [PubMed] [Google Scholar]5. Kabat-Zinn J. 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