religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

8
Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study GAVIN YAMEY{§ and RICHARD GREENWOOD{* { BMA House, Tavistock Square, London, UK { Regional Neurological Rehabilitation Unit, Homerton University Hospital NHS Trust, London, UK Accepted for publication: December 2003 Abstract Purpose: To explore the religious beliefs that patients may bring to the rehabilitation process, and the hypothesis that these beliefs may diverge from the medical model of rehabilitation. Methods: Qualitative semi-structured interviews with repre- sentatives of six major religions—Islam, Buddhism, Christian- ity, Judaism, Sikhism, and Hinduism. Representatives were either health care professionals or religious leaders, all with an interest in how their religion approached health issues. Results: There were three recurrent themes in the interviews: religious explanations for injury and illness; beliefs about recovery; religious duties of care towards family members. The Buddhist, Sikh, and Hindu interviewees described beliefs about karma—unfortunate events happening due to a person’s former deeds. Fatalistic ideas, involving God having control over an individual’s recovery, were expressed by the Muslim, Jewish, and Christian interviewees. All interviewees expressed the fundamental importance of a family’s religious duty of care towards ill or injured relatives, and all expressed some views that were compatible with the medical model of rehabilitation. Conclusions: Religious beliefs may both diverge from and resonate with the medical rehabilitation model. Understanding these beliefs may be valuable in facilitating the rehabilitation of diverse religious groups. Introduction The relationship between religion and health is a subject of increasing research interest. A systematic review of over 1100 studies on this relationship showed that religious involvement is associated with better physical and mental health, and lower use of health services. 1 Two other systematic reviews and a meta- analysis have confirmed that religious activity is an epidemiologically protective factor, 2–4 whilst religious involvement may improve the quality of life of elderly patients. 5 Rehabilitation practitioners have begun to realise the potentially important role played by religion in the rehabilitation process and in the ongoing lives of people with disabilities. 6 Rehabilitation professionals serve an increasingly multicultural patient group, and so they need to understand how patients’ religious beliefs might influence therapy. The importance of religion and culture in vocational rehabilitation is well described, 7, 8 and cultural beliefs about disability are also well documented. 9 – 11 However, little is known about how religious beliefs may apply to physical and cognitive rehabilitation early after injury or illness. One US conference on this topic recommended that we should examine the background experiences that patients bring to early rehabilitation, ensure the comfort and willingness of health professionals to address patients’ religious needs, and adapt the curriculum content of rehabilitation programmes to help meet these needs. 12 In a survey of patients discharged from a reha- bilitation unit in Baltimore, USA, 54% of responders reported that their religious beliefs were important, and 45% felt that there had been inadequate attention paid to their religious needs. 13 If rehabilitation professionals fail to acknowledge their patients’ religious beliefs, they may be expecting them to engage in a medical model of rehabilitation that conflicts with these beliefs. In the UK this model origi- nated in the period after the First World War and it involves training patients to adapt to change. 14 The * Author for correspondence; Regional Neurological Reha- bilitation Unit, Homerton University Hospital NHS Trust, Homerton Row, London E9 6SR. e-mail: Richard.- [email protected] § GY was a registrar in rehabilitation at the Regional Neurological Rehabilitation Unit, Homerton Hospital at the time of the study. DISABILITY AND REHABILITATION, 2004; VOL. 26, NO. 8, 455–462 Disability and Rehabilitation ISSN 0963–8288 print/ISSN 1464–5165 online # 2004 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/09638280410001663021 Disabil Rehabil Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 11/01/14 For personal use only.

Upload: richard

Post on 08-Mar-2017

217 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

Religious views of the ‘medical’ rehabilitationmodel: a pilot qualitative study

GAVIN YAMEY{§ and RICHARD GREENWOOD{*{ BMA House, Tavistock Square, London, UK{ Regional Neurological Rehabilitation Unit, Homerton University Hospital NHS Trust,

London, UK

Accepted for publication: December 2003

Abstract

Purpose: To explore the religious beliefs that patients maybring to the rehabilitation process, and the hypothesis thatthese beliefs may diverge from the medical model ofrehabilitation.Methods: Qualitative semi-structured interviews with repre-sentatives of six major religions—Islam, Buddhism, Christian-ity, Judaism, Sikhism, and Hinduism. Representatives wereeither health care professionals or religious leaders, all with aninterest in how their religion approached health issues.Results: There were three recurrent themes in the interviews:religious explanations for injury and illness; beliefs aboutrecovery; religious duties of care towards family members. TheBuddhist, Sikh, and Hindu interviewees described beliefsabout karma—unfortunate events happening due to a person’sformer deeds. Fatalistic ideas, involving God having controlover an individual’s recovery, were expressed by the Muslim,Jewish, and Christian interviewees. All interviewees expressedthe fundamental importance of a family’s religious duty of caretowards ill or injured relatives, and all expressed some viewsthat were compatible with the medical model of rehabilitation.Conclusions: Religious beliefs may both diverge from andresonate with the medical rehabilitation model. Understandingthese beliefs may be valuable in facilitating the rehabilitationof diverse religious groups.

Introduction

The relationship between religion and health is asubject of increasing research interest. A systematicreview of over 1100 studies on this relationship showed

that religious involvement is associated with betterphysical and mental health, and lower use of healthservices.1 Two other systematic reviews and a meta-analysis have confirmed that religious activity is anepidemiologically protective factor,2 – 4 whilst religiousinvolvement may improve the quality of life of elderlypatients.5

Rehabilitation practitioners have begun to realisethe potentially important role played by religion inthe rehabilitation process and in the ongoing lives ofpeople with disabilities.6 Rehabilitation professionalsserve an increasingly multicultural patient group, andso they need to understand how patients’ religiousbeliefs might influence therapy. The importance ofreligion and culture in vocational rehabilitation is welldescribed,7, 8 and cultural beliefs about disability arealso well documented.9 – 11 However, little is knownabout how religious beliefs may apply to physicaland cognitive rehabilitation early after injury orillness.

One US conference on this topic recommended thatwe should examine the background experiences thatpatients bring to early rehabilitation, ensure the comfortand willingness of health professionals to addresspatients’ religious needs, and adapt the curriculumcontent of rehabilitation programmes to help meet theseneeds.12 In a survey of patients discharged from a reha-bilitation unit in Baltimore, USA, 54% of respondersreported that their religious beliefs were important,and 45% felt that there had been inadequate attentionpaid to their religious needs.13

If rehabilitation professionals fail to acknowledgetheir patients’ religious beliefs, they may be expectingthem to engage in a medical model of rehabilitation thatconflicts with these beliefs. In the UK this model origi-nated in the period after the First World War and itinvolves training patients to adapt to change.14 The

* Author for correspondence; Regional Neurological Reha-bilitation Unit, Homerton University Hospital NHSTrust, Homerton Row, London E9 6SR. e-mail: [email protected]§ GY was a registrar in rehabilitation at the Regional

Neurological Rehabilitation Unit, Homerton Hospital at thetime of the study.

DISABILITY AND REHABILITATION, 2004; VOL. 26, NO. 8, 455–462

Disability and Rehabilitation ISSN 0963–8288 print/ISSN 1464–5165 online # 2004 Taylor & Francis Ltdhttp://www.tandf.co.uk/journals

DOI: 10.1080/09638280410001663021

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 11

/01/

14Fo

r pe

rson

al u

se o

nly.

Page 2: Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

medical rehabilitation model emphasizes the activenature of rehabilitation and its educational basis, andthe model is goal driven. A characteristic of rehabilita-tion is that it requires the active engagement of thepatient with the rehabilitation team with the aim ofachieving a number of chosen goals. These goals ofteninvolve aiming for greater independence. Medical reha-bilitation differs from a medical care model, in whichservices are supplied to a patient who is a passive recipi-ent of care.

The medical rehabilitation model, then, emphasizesthe importance of fostering autonomy in patients—yetthere is evidence that Eastern cultures may sanctiondependence on others in the context of illness.15 Inextended Asian families, religious duties of care by apatient’s family may conflict with the aims of the reha-bilitation team.16, 17 A patient’s injury or illness may beviewed by some religious groups as a family problem,rather than just an individual problem, so that healthprofessionals may believe that the family is ‘overin-volved’.18 We have witnessed such conflicts betweenrehabilitation professionals and patient’s families inour own rehabilitation unit.

We therefore performed a pilot interview-based studyto explore the religious beliefs that people might bring torehabilitation early after neurological damage. Wewished to examine the hypothesis that there are conflictsbetween the medical rehabilitation model and thesebeliefs.

Methods

Religious ideas and experiences constitute phenomenathat may not be amenable to traditional scientificstudy,12 and qualitative data collection is the approachmost likely to yield information that can be used toguide further research efforts. Qualitative methods areparticularly effective in investigations of health beliefs,and can serve as powerful reminders of their complex-ity.19

In this pilot study, qualitative semi-structured inter-views were held with representatives of six majorreligions—Islam, Buddhism, Christianity, Judaism,Sikhism, and Hinduism. The representatives were eitherhealth care professionals or religious leaders, all ofwhom had an interest in how their religion approachedhealth issues. The Muslim and Hindu representatives aregeneral practitioners and the Christian representative isa clinical psychologist. The Jewish representative doescommunity liaison work with orthodox Jewish patientsat our hospital. The Buddhist and Sikh representativesare community leaders.

We found the interviewees in a variety of ways:through our hospital (Jewish representative), througharticles they had published on religion in the medicalliterature (Muslim representative), or through recom-mendations from other interviewees (Sikh, Buddhist,Hindu, Christian representatives). These six representa-tives were purposively sampled for their authoritativeviews.20

We recognize that these views could not have beenentirely representative of the six different religions—the views are likely to have been shaped by the intervie-wees’ own personal beliefs and experiences. But we feltthat an initial inquiry through these individual inter-views would be a useful starting point for gaining someunderstanding of how religious beliefs may relate tomedical rehabilitation.All respondents were fluent in English and all

happened to be male. Interviews were face-to-faceand each lasted approximately 1 h. Before each inter-view, respondents were sent three case scenarios, inorder to present real life clinical situations (Appen-dix 1). The first case illustrates the rehabilitation of apatient after a single incident neurological injury, thesecond after an acute relapse of a deteriorating condi-tion. The third case describes a situation in whichexcessive care of a patient by his family leads to atherapeutic stalemate.For the interviews, we wished to understand how

each religion would view and understand the casescenarios. We used a semi-structured interview guide(Appendix 2) involving nine questions that werebased around the clinical vignettes. One of us (GY)conducted all six interviews, and used the questionsas prompts to guide the interviews. He did notalways ask all nine questions to all interviewees—for example, if an interviewee spontaneouslydiscussed his religion’s explanations for recovery, he(GY) did not specifically ask the question ‘How doesyour religion explain recovery?’ He asked additionalquestions to probe respondents’ views in greaterdepth.We derived the clinical scenarios and the list of ques-

tions by discussion between ourselves, and by our read-ing of the influence of religion on health, disability, andvocational rehabilitation.6 – 18 We tape recorded andtranscribed the interviews. One of us (GY) looked forrecurring themes in the transcripts by manual coding.21

The three broad themes that emerged were largelydetermined by the themes that we covered in the semi-structured interview guide.All interviewees gave their written consent to publica-

tion of direct quotations from the transcripts.

G. Yamey and R. Greenwood

456

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 11

/01/

14Fo

r pe

rson

al u

se o

nly.

Page 3: Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

Results

There were three broad themes in the respondents’views.

RELIGIOUS EXPLANATIONS FOR INJURY AND ILLNESS

Religious explanations for injury or illness mayimpact upon the subsequent rehabilitation process,and are therefore relevant to rehabilitating people fromdifferent religious backgrounds.

The Muslim interviewee explained that in Islam, ‘lifeis seen as an examination’, or a test of faith. Injury orillness are seen as part of this test. The intervieweeexplained that a key aspect of Muslim theology is theconcept of, ‘predestination of divine will, or fatalism’.Hence ill health is seen as being predestined by God.

The Buddhist interviewee explained his belief that apatient’s injury or illness may be, ‘a result of his owndeeds done in the past’. The patient may not, however,be aware of these former deeds. The interviewee saidthat an accident happens ‘because that person must havedone something very bad in the past . . . perhaps thatperson may not know about it’. Buddhist illness explana-tions are based on a humoral theory, as the intervieweeexplained: ‘In our religious language, we say our body isgoverned by three main things to keep it healthy—air orwind inside our body, bile and phlegm. As long as theseare in balance, one is healthy. Any ill balance, then theperson becomes sick’.

In orthodox Judaism, explained the Jewish inter-viewee, it is believed that, ‘nothing is happening withoutGod’. Injury or illness are therefore seen as God-given,and may be God’s way of punishing an individual fordoing harm. The reasons behind God’s actions maynot be clear: ‘we don’t understand why these things arehappening. Sometimes people are being punished, andsometimes it is difficult to understand’. This perspectiveextends to chronic disabling conditions where, ‘God, inhis wisdom, feels that this human being has to suffer’.

A Sikh perspective, explained the Sikh interviewee, isalso that an injury or illness is God’s will. Karmictheory is invoked in disease explanations. The inter-viewee said: ‘I tell my children, ‘‘Don’t do that, that’sbad for you, and you will suffer, in this life and the nextlife’’ ’. Karma, he said means, that, ‘you’ve got to bearit [your suffering], you’ve got to live with it’. A Sikhperspective on chronic, deteriorating illnesses is that,‘One day this body will deteriorate. Nobody is going tolive forever, and we must accept it, with our open mind,open heart. It is bound to happen. This body is bound todecay’. There is therefore a sense of the inevitability of

physical deterioration, which is God’s will and which ispredestined by karma.

The Hindu interviewee also discussed injury andillness as being predestined: ‘the patient will try to bearhis miseries, that, well, I was destined, this was destinedfor me and I’m suffering, but he will not blame anybody’.He also invoked karmic explanations: ‘we believe thatwhatever we enjoy in this life—happiness or misery—thatis the fruits of our past deeds’.

The Christian interviewee described two variant posi-tions on injury and illness within Christianity. The firstview holds to the idea of, ‘an all powerful God who hasabsolute control over our lives’. Those holding such afatalistic or deterministic view, when faced with injuryor illness, would feel that it is God’s will. But a secondvariant would see suffering as an opportunity for spiri-tual growth. The implication here is, ‘not to say thatGod wants us to have multiple sclerosis, but in fact theway in which we respond to disability may have profoundimplications’. He also contrasted Old Testament withNew Testament thinking on the question of whetherinjury or illness are a form of punishment. An OldTestament view might be that God is punishing thepatient, but in the New Testament, ‘Jesus said, ‘‘thesepeople are not ill because of their sin, it is not their faultthey are like that’’ ’.

BELIEFS ABOUT RECOVERY

The medical rehabilitation model assumes thatpatients will strive for independence. It relies on apatient believing that he or she can influence the recov-ery process, but there are varying degrees to whichdifferent religions hold to this view.

The Muslim interviewee explained that in order tosucceed in the face of a loss, such as injury or illness,Islam promotes two driving forces. The first is to main-tain religious faith: ‘one level of success is that you, whenfaced with that difficulty, retain your belief in God and youtrust God and you maintain your relationship with God’.Muslims, he explained, believe that they are being testedwhen they are ill, and maintaining faith is part of thetesting process. There is a fatalistic belief that, ‘if Godwants to cure him [the patient], he will’. Hence it wouldbe usual for a Muslim to pray for recovery, and to asksomeone else to pray for them, and there is a belief infaith healers. The second motivation is a striving to dothings for the better. This, explained the interviewee, isbased on the statement of the prophet Mohammedwho said that, ‘for every illness there is a cure, exceptone, and that’s old age’. Seeking conventional medicalhelp would be part of this striving, so that prayer and

Religious views of the medical rehabilitation model

457

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 11

/01/

14Fo

r pe

rson

al u

se o

nly.

Page 4: Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

medicine are seen as complementary rather thanconflicting. If recovery does occur, then, ‘that doctorwas an instrument of God’. In applying these conceptsto the notion of rehabilitation, the interviewee said:‘on the whole people within Islam would be encouragedto use whatever means are provided to rehabilitate them-selves, to live as equal a life as possible’. In situationsof non-recovery, they would be encouraged to practice,‘patience, resilience, fortitude and also maintain that senseof gratitude to God’. Non-recovery is therefore seen as anadditional test or examination of faith.

The Buddhist interviewee explained that individualscan have some influence over their own recovery byadopting, ‘positive thinking, rather than having negativefeelings’. This would be combined with seeking medicalhelp to obtain, ‘proper remedy and the proper attention ofothers’. In rehabilitating someone whose illness is due tohumoral imbalance, it is believed that recovery canoccur. But the Buddhist interviewee explained that,‘there are other types of sicknesses caused by his ownactions, that is the only thing that cannot be corrected.If it is the result of his own deeds in the past, you can’trecover [sic] that person’. Non-recovery is thereforethought to be pre-destined, and in this situationBuddhist patients would accept their karmic fate. Thiskarmic theology is not, however, an excuse for therapeu-tic nihilism: ‘whatever the action, whatever the cause, wemust not neglect the person, we must not leave it todestiny’.

In Judaism, explained the Jewish interviewee, recov-ery from injury or illness is explained in several differ-ent ways. Central to recovery is that, ‘nothing is ableto be done in this world without God’. Furthermore,there is a biblical duty to seek medical help: ‘God infact asks people to obtain help. There is in fact a [Bibli-cal] version where it says that ‘God is our healer’, andthe interpreters of that say that from here one can seethat one should be obtaining the treatment of a doctor’.In emergency medical situations, even the Sabbathrestrictions can be broken in seeking help. Personalmotivation is considered just as important: ‘there isa need for human beings to put their efforts into it,otherwise, just because there is a God the person wouldbe sitting back and doing nothing’. In Orthodox Juda-ism, there is thought to be an element of luck inwhether a person can influence events, which wouldextend to their control over recovery. There is also abelief in miraculous recovery. Prayer and good deedscan assist the recovery process.

In Sikhism, recovery is explained through a combina-tion of religion, will power, and modern medicine. Inaddition, ‘willpower comes into it. A weak person will

recover; probably it will take a long time. But a personwith a strong will will contribute a lot’.The Hindu interviewee expressed very similar ideas

about an individual’s recovery. There is a key belief thatGod will give a patient strength at times of crisis, so thatreligious faith and prayer are seen as central to recovery.The support of medical agencies is also considered to beimportant, as is an individual’s will power.Recovery and healing in Christianity, explained the

Christian interviewee, occur as part of God’s createdorder. The variant traditions within Christianity, heexplained, place different emphasis upon how muchindividuals can influence their recovery. Those holdingto a fatalistic or determinist view would believe thatrecovery only occurs, ‘if God wills it’. Those with thisview would see prayer as a way of aiding recovery,and sin as a hindrance. But another Christian traditionsees recovery as occurring through the integration ofseveral processes: natural recovery, external medicalintervention, patients’ own views and interpretationsof their illness or injury, and their own spirituality.

RELIGIOUS DUTIES OF CARE AND THE ROLE OF THE FAMILY

IN THE REHABILITATION PROCESS

All the six representatives in our study expressd theimportance of familial duties of care towards patients.In Islam, there is a powerful duty of care towards

family members, particularly during times of crisis.The interviewee explained that, ‘after service to God,the next level is to parents’. He felt that this level of devo-tion towards parents could be at odds with the goals ofthe rehabilitation team.There is also a Buddhist responsibility towards family.

The interviewee explained that the Buddha himself said:‘looking after a patient is like looking after Buddha; if yourespect me, you respect the patient as well’. To illustratethis point, the interviewee told a story about TheBuddha visiting a monastery where ‘there was a monk,an elderly monk, covered with his own urine because hehad been neglected by others. Having seen that, he [TheBuddha] immediately called another monk and askedhim to bring some warm water, and he [The Buddha]washed him and dried him with a cloth. Afterwards he saidto the monks, ‘you look after each other’’ ’. The intervie-wee also discussed how caring for a family memberbenefits both the patient and carer: ‘Looking after[family] is considered as one of the highly beneficial actsa person can do . . . it benefits the doer as well as the recei-ver’.In the Orthodox Jewish community, ‘one tries to help

each other and especially close family’. The family, he

G. Yamey and R. Greenwood

458

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 11

/01/

14Fo

r pe

rson

al u

se o

nly.

Page 5: Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

said, ‘are in fact very anxious to try to be with the patientas much as possible’. One reason for being with thepatient, he said, was so that ‘they [the patient] shouldknow that they have their own people—who they’ve beenused to all the time—around them and supporting them’.

It is a part of Sikh culture to look after relatives: ‘it isthe duty of relatives to look after the sick person, anddevote as much time as possible’. The interviewee saidthat if you are a Sikh you would be expected to, ‘do asmuch as you can for your family’.

The Hindu interviewee discussed how his parentslooked after him as a child, so that, ‘when they growold, and when they are incapable to do [sic] their normalfunctions, it is my duty to look after them, and that isbasic’. He said, ‘We [Hindus] have got a united familysystem’. The family has a duty to, ‘give him [the patient]comfort’.

The parable of the Good Samaritan, explained theChristian interviewee, informs a Christian duty to helpthose who are suffering. This duty, ‘will not just be thephysical caring, the Good Samaritan binding up thewounds’, but also involves helping patients to makesense of their pain, discomfort, and disability. There isa Christian duty, said the interviewee, to ‘actually helpthose who are oppressed or suffering’.

Discussion

This study provides individual perspectives on themedical rehabilitation model by religious representa-tives. We recognize that such representatives may holdviews that are not generalizable to patients and carersof the same religious group, but we feel that ourapproach is a useful initial enquiry to inform furtherlarger scale research efforts.

The process of sample selection may have contained anumber of biases, including male gender, level of educa-tion, and English fluency. We purposively sampled theserepresentatives because of their scholarly theologicalknowledge. We are aware that a minority group’sprominent citizens may be more ‘Westernized’ andmay as a result be more ready to dismiss traditionalbelief systems.10

Since interviewees were from varying religious groups,we felt unable to apply a comparative analytical methodto the emerging themes, such as the constant compara-tive method used to derive a grounded theory in qualita-tive research.22 This lays our method open to thecriticism that our results are simply individual narra-tives. Nevertheless, we believe that these narratives givean initial insight into the religious beliefs that patientsmay bring to early rehabilitation.

Our results suggest that some religions have healthbeliefs which conflict with the principles of the medi-cal rehabilitation model. These dissonances representaspects of the model that may be rejected by somepatients, and they could therefore guide us towardsa ‘universal, transcultural understanding of rehabilita-tion’.6 They could also be an important source ofincompatibility of goals between patient and thera-pist.

FATALISM, KARMIC THEORY, AND GOD-GIVEN PUNISHMENT

Fatalistic ideas, involving God having pre-destinedcontrol over an individual’s recovery, were expressedby the Muslim, Christian, and Jewish interviewees.The medical rehabilitation model relies on a patientbecoming an active participant in the therapeuticprocess,14 but it is possible that some patients may notengage in therapy due to such fatalistic beliefs. Theorthodox Jewish notion of luck and a belief in miraclesmay also contribute to adopting an external locus ofcontrol over recovery.23

A belief that God has absolute control over ourlives, including over recovery from injury or illness,may play a role in the greater degree of resignationto one’s illness that has been demonstrated in Easterncultures.24 Trill and Holland have compared the differ-ent responses of Western and Eastern cultures towardsillness and recovery.25 In the West, man has beenexpected to gain mastery over nature, and Westernpatients are expected to struggle against and overcometheir injury or illness. This is not true of Easternsocieties where man has historically not been asconcerned with gaining mastery over his environmentas he has been with living in harmony with it. Thisstance may perhaps lead to greater passivity in theface of illness.

Buddhist, Sikh, and Hindu interviewees describedkarmic theory—that unfortunate events happen dueto a person’s former deeds. The Buddhist intervieweefelt that deteriorating conditions like multiple sclero-sis are the result of a patient’s former deeds, as aresome cases of non-recovery from injury or illness.In Sikhism and Hinduism, karma is invoked in illnessand injury attribution. The Jewish intervieweedescribed a belief system in which injury, chronicillness, and non-recovery are all knowingly given byGod and may be seen as punishment. All of thesebeliefs might disempower patients in rehabilitationand could in theory engender feelings of guilt, shameor hopelessness, leading to non-adherence to a ther-apy regime.

Religious views of the medical rehabilitation model

459

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 11

/01/

14Fo

r pe

rson

al u

se o

nly.

Page 6: Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

RELIGIOUS DUTIES OF CARE

All interviewees expressed the importance of afamily’s religious duty of care towards a relative inthe context of injury or illness. This study providessome evidence of how powerful this religiously moti-vated obligation of care may be in influencing beha-viour in the context of rehabilitation. Loyalty andself-sacrificing behaviour are recognized in Asianextended families, particularly by children towardstheir parents.16 Many Asians are members of extendedfamilies with a complex hierarchy in which oldermembers are revered and younger ones protected. Filialpiety is the cornerstone.

In a rehabilitation setting, these duties of care byfamilies may be at odds with the view of the multidisci-plinary team who constantly encourage patients to dothings for themselves. If clinicians adopt a goal-drivenmedical model that cherishes independence, they maybe prone to demonize a family’s ‘over-involvement’.Visiting relatives in hospital is clearly a religious dutyfor many people. In treating patients with mental healthproblems from non-Western cultures, involving thefamily enhances patient compliance26 and this may applyto a rehabilitation setting. One way to do this is to askfamily members if they wish to attend and watch ther-apy sessions.

BELIEFS THAT RESONATE WITH THE MEDICAL

REHABILITATION MODEL

All interviewees expressed beliefs that resonate withaspects of the medical rehabilitation model. These repre-sent common ground which could be therapeuticallyimportant, and which may be a useful starting point innegotiation and compromise.

Individual motivation is considered to be a corner-stone of the medical rehabilitation model, and all reli-gious representatives in this study expressed theimportance of a patient’s positive outlook in the recov-ery process. There were notions of personal responsibil-ity in all religions in this study.

Furthermore, all respondents had some faith inmodern medical intervention into injury and illness.None felt that religious beliefs were incompatiblewith medical help seeking behaviour. Hence in Islam,prayer and medicine are seen as complementaryrather than conflicting. This integration of beliefswas a recurring theme of our study. For example,the Buddhist interviewee talked of combining positivethinking with medical treatment. Modern medicalrehabilitation units should also ideally be ‘holistic’

in addressing patients’ physical, psychological,emotional, and vocational needs. To this we shouldbegin to add some of the religious needs identifiedin this study.

RELIGION, REHABILITATION, AND COPING

Religious belief can provide a framework for a patientto understand their losses. Making sense of the question,‘why has this happened?’ may play a role in protecting apatient from depression in the face of injury or illness.For example, the use of religious coping skills by olderpatients who are acutely or chronically disabled is asso-ciated with a diminished risk of incurring depression andincreased likelihood of recovery if depression occurs.12

The Muslim interviewee stressed the notion in Islam ofthe inevitability of difficulty and loss. He felt that thispreparation provides comfort when difficult eventsoccur to a person. This is similar to the Sikh belief thatphysical decline is predictable. The rehabilitation teamshould be aware of these religious coping mechanisms,which could be encouraged where appropriate. Theyare likely to be underused resources in the rehabilitationprocess.Prayer is central to all religions represented in this

study, and all interviewees discussed the role of prayerand religious faith in assisting recovery. Most formalrehabilitation units are not structured to meet theneed for prayer by patients and their families. InIslam, for example, the daily prayers play a pivotalrole in everyday life and an even greater role in timesof suffering and distress.27 Muslims pray towardsMecca, which is to the south-east of Britain, and forimmobile patients it would not be difficult to positionthe bed in this direction if requested. A compass andprayer timetable, available from local mosques, wouldalso be useful, as would the provision of a prayerroom for visitors.28

Conclusion

These individual perspectives provide an insight intohow religious beliefs may diverge from and resonatewith a medical rehabilitation approach. Incompatibilityof goals between patient and therapist may originatefrom a dissonance in beliefs. The rehabilitation teamadopts a medical model based on Western ideals of inde-pendence and gaining mastery over illness, which mayconflict with Eastern beliefs about karma, fatalism andthe duty of the family towards caring for the patient.More often, however, there may be an opportunity forresonance between the two approaches, with conflict

G. Yamey and R. Greenwood

460

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 11

/01/

14Fo

r pe

rson

al u

se o

nly.

Page 7: Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

resulting from misunderstanding rather than a disso-nance of beliefs.

We now wish to conduct a larger study involvingfocus groups of patients from different religions, to seewhether the beliefs elicited in this present study arewidely held and how they may impact upon early reha-bilitation. Our study suggests areas in which the medicalmodel may be inappropriate to meet the needs of cultu-rally diverse patients, and highlights the uniqueresponses by different religious groups to injury, illnessand recovery.

Acknowledgements

We thank the two anonymous peer reviewers for their valuable

comments about our paper and the interviewees for agreeing to take

part in this study.

References

1 Koenig HG, McCullough M, Larson DB (eds) Religion and health:a century of research reviewed. New York: Oxford University Press,1999.

2 Larson DB, Pattison EM, Blazer DG, Omran AR, Kaplan BH.Systematic analysis of research on religious variables in four majorpsychiatric journals, 1978 – 1982. American Journal of Psychiatry1986; 143: 329 – 334.

3 Ellison CG, Levin JS. The religion-health connection: evidence,theory, and future directions. Health Education Behavior 1998;25(6): 700 – 720.

4 Witter RA, Stock RA, Okun MA, Haring MJ. Religion andsubjective well-being in adulthood: a quantitative synthesis. Reviewof Religious Research 1985; 26: 332 – 342.

5 Reyes-Ortiz CA, Ayele H, Mulligan T. Religious activity improvesquality of life for ill elderly. Clinical Geriatrics 1996; 4: 102 – 106.

6 Banja JD. Ethics, values and world culture: the impact onrehabilitation. Disability and Rehabilitation 1996; 18(6): 279 – 284.

7 Harley DA, Feist-Price S, Alston RJ. Cultural diversity: A contentanalysis of the rehabilitation literature. Journal of AppliedRehabilitation Counselling 1996; 27(2): 59 – 62.

8 Gordon RP, Patterson JB. Ethnic content in rehabilitation journals.Journal of Applied Rehabilitation Counselling 1996; 27(3): 26 – 29.

9 Scheer J, Groce N. An anthropological perspective on disabilities.Journal of Society Issues 1987; special edition.

10 Groce NE, Zola IK. Multiculturalism, chronic illness, anddisability. Pediatrics 1993; 91(5 Suppl 2): 1048 – 1055

11 Ingstad B, Reynolds S (eds) Disability and Culture. University ofCalifornia Press, 1995.

12 Underwood-Gordon L, Peters DJ, Bijur P, Fuhrer M. Roles ofreligiousness and spirituality in medical rehabilitation and the livesof persons with disabilities. American Journal of Physical Medicineand Rehabilitation 1997; 76(3): 255 – 257.

13 Anderson JM, Anderson LJ, Felsenthal G. Pastoral needs andsupport within an inpatient rehabilitation unit. Archives of PhysicalMedicine and Rehabilitation 1993; 74(6): 574 – 578.

14 McLellan DL. Introduction to rehabilitation. In: BA Wilson, DLMcLellan (eds) Rehabilitation Studies Handbook. CambridgeUniversity Press, 1997; 1 – 19.

15 Gregory RJ. Disability and rehabilitation in cross-cultural perspec-tive: a view from New Zealand. London: Chapman & Hall, 1994.

16 Cheng LL. Cross-cultural and linguistic considerations in workingwith Asian populations. ASHA 1987; 29(6): 33 – 38.

17 Nilchaikovit T, Hill JM, Holland JC. The effects of culture onillness behaviour and medical care. General Hospital Psychiatry1993; 15: 41 – 50.

18 Smart N. Attitudes towards death in eastern religions. In: AToynbee, AK Mant, N Smart (eds) Man’s Concern with Death. St.Louis: McGraw Hill, 1969; 122 – 131.

19 Pfeffer N, Moynihan C. Ethnicity and health beliefs with respect tocancer: a critical review of methodology. British Journal of Cancer1996; 74(suppl. XXIX): S66 – S72.

20 Curtis S, Gesler W, Smith G, Washburn S. Approaches tosampling and case selection in qualitative research: examples inthe geography of health. Social Science and Medicine 2000; 50:1001 – 1014.

21 Strauss A, Corbin J. Basics of Qualitative Research: GroundedTheory Procedures and Techniques. London: Sage, 1990.

22 Green J. Commentary: Grounded theory and the constantcomparative method. BMJ 1998; 316: 1064 – 1065.

23 Littlewood R, Dein S. The effectiveness of words: religion andhealing among the Lubavitch of Stamford Hill. Culture MedicinePsychiatry 1995; 19(3): 339 – 383.

24 Adams D. The monkey and the fish: Cultural pitfalls of aneducational adviser. In: L Riddick Lynch (ed) The Cross-CulturalApproach to Health Behaviour. New Jersey: Fairleigh DickinsonUniversity Press, 1969; 436 – 444.

25 Trill M, Holland J. Cross cultural differences in the care of patientswith cancer. A review. General Hospital Psychiatry 1993; 15: 21 –30.

26 Kinzie JD. Overview of clinical issues in the treatment of SoutheastAsian refugees. In: TC Owan (ed) Southeast Asian Mental Health:Treatment, Prevention, Services, Training, and Research. Washing-ton DC: National Institute of Mental Health, 1985; 113 – 135.

27 Sheikh A. Death and dying – a Muslim perspective. Journal of theRoyal Society of Medicine 1998; 91: 138 – 140.

28 Sheikh A. Quiet room is needed in hospitals for prayer andreflection. BMJ 1997; 315: 1625.

Appendix 1

CLINICAL CASE SCENARIOS

Case one

A 50 year old bank manager is involved in a road traf-fic accident in which he is a pedestrian crossing the road.He suffers injury to his brain and a brain scan shows ablood clot. The clot is surgically removed and he spends1 week on the intensive care unit before transfer to asurgical ward. One month later he is admitted to a reha-bilitation unit. He has weakness of all four limbs andmoderately impaired intellectual abilities, but retainsexcellent language skills. On admission to the unit hecan feed himself but depends on others for transferringin and out of a wheelchair, washing and dressing. After6 months of rehabilitation he is independent in all ofthese activities. He is able to walk short distancesindoors although he still uses a wheelchair for longerdistances. He is unable to return to work but is selfcaring. In the long term he takes on part time voluntarywork for a charity.

Religious views of the medical rehabilitation model

461

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 11

/01/

14Fo

r pe

rson

al u

se o

nly.

Page 8: Religious views of the ‘medical’ rehabilitation model: a pilot qualitative study

Case two

A 34 year old woman has had multiple sclerosis for10 years. She experiences two to three relapses peryear, involving difficulty with her speech, vision,balance and mobility. She is admitted to a generalmedical ward with a further deterioration. She is givena 3 day course of steroid injections and her functionalabilities are starting to improve. She is admitted to arehabilitation unit with slurring of her speech, weaklegs and poor balance. She is incontinent of urine.On the unit she becomes mobile in an electric wheel-chair and she can transfer from her wheelchair intoher bed or on to the toilet independently. A long termurinary catheter is inserted and she becomes able toempty the catheter bag herself. She returns to aground floor adapted council flat and is able to useher electric wheelchair indoors. She can also use anoutdoor wheelchair to access shops and localamenities independently. She receives disability livingallowance.

Case three

A 55 year old man is admitted to hospital with astroke. He was previously employed as a taxi driver.After 4 weeks on a general medical ward, he is admittedto a rehabilitation unit with left sided arm and leg weak-

ness and poor balance. His intellectual capabilities areintact and his speech is unchanged. His wife and 3 chil-dren are keen to do as much for him as possible. Onemember of the family is present at all times during theday. They feel that it is their responsibility to care forhim, taking him to the toilet, feeding and dressinghim. After 4 months, he is still not walking and heremains dependent for most of his daily activities. Therehabilitation team is unable to generate furtherimprovement and he is discharged home into the careof his family.

Appendix 2

SEMI-STRUCTURED INTERVIEW QUESTIONS

How does your religion view the ‘Western’ rehabilita-tion model? Does it conflict with your religion’s theolo-gical principles? How does your religion explain theinjury or illness of cases one and two? Are they thoughtto be divine in origin? How does your religion explainrecovery? Where is control over recovery thought tolie—is it within or outside the patient? Is it with God?Are there religious explanations for non-recovery? Incase three, if this family belonged to your religiousgroup, would their actions be directed by any religiousbeliefs?

G. Yamey and R. Greenwood

462

Dis

abil

Reh

abil

Dow

nloa

ded

from

info

rmah

ealth

care

.com

by

SUN

Y S

tate

Uni

vers

ity o

f N

ew Y

ork

at S

tony

Bro

ok o

n 11

/01/

14Fo

r pe

rson

al u

se o

nly.