The current discussions of how spirituality fits within health care can be grouped into different yet related conversations. There are conversations about the spiritual needs of people when they become patients, about how medical caregivers are becoming professionally interested in patient spirituality, and about medical caregivers' interest in their own spirituality. There is a conversation among chaplains about how an emphasis on spirituality influences who they are and what they do, one within organizations about the spirituality of leaders and employees in faith-based health care, and finally a conversation on how spirituality and ethics interact on medical and organizational levels.¹

The medical and organizational conversations are the most heated and the most visible. The give-and-take of these conversations is not limited only to professionals in health care, but on occasion includes contributions from the larger population. There are strong opinions on these issues, and these conversations are by no means over.

The medical conversation begins with questions of how to evaluate the recent research into the relationship between religiousness/spirituality and mental and physical health. Many studies show that spirituality/religiousness has positive effects on mental and physical health and is influential in both preventing and coping with illness.² However, questions abound. Is this research methodologically sophisticated? Does it warrant some of the conclusions reached? What effect should this research have on medical practice? Should physicians inquire into patients' spirituality and encourage religious practices as part of a treatment plan? If this is going to happen, what guidelines are available to structure this physician-patient conversation? Do holistic visions of health care warrant a deeper involvement of medical caregivers in the lives of patients? In terms of religion and spirituality, what do patients want from nurses and doctors and, in turn, what level of interaction are doctors and nurses comfortable with? If religion and spirituality enter into the medical conversation in a more systematic way, does this entail a new relationship with chaplains? How do medical caregivers, chaplains, and community clergy work together to provide holistic care?

This focus on the nature and extent of the interaction between the medical caregiver and the patient naturally unfolds into questions about the spirituality of the medical caregivers themselves. Does their faith and spirituality influence how they practice medicine? If spiritual beliefs were influential in their choice to become doctors and nurses, how are those beliefs maintained and how have they changed? If they are to ask questions about faith and spirituality, what type of training is necessary? Is this whole question of the religiousness/spirituality of the medical caregivers an intrusion into their personal lives?

The organizational conversation encompasses the medical conversation, but also goes beyond it. It flourishes in faith-based health care and asks how spirituality is or can be a visible feature on every level of the enterprise, from boardroom to lunchroom. How do leaders in faith-based health care systems articulate the theological values that inform the organization? Should they also have a spiritual life that is in sync with the faith-based nature of the organization? If so, how would that spiritual life manifest itself in their leadership style and how could it be measured? Also, should a health care organization that welcomes the religiousness/spirituality of patients extend the same welcome to its employees? If so, how should this be done, especially in an interfaith world? What does it mean to be an organization that welcomes the whole person—physically, psychologically, socially, and spiritually?

Into these conversations on how to integrate spirituality into health care, I would like to introduce a distinction and a perspective. The distinction, borrowed and adapted from organizational development, differentiates adaptive challenges from technical fixes. The perspective, taken from contemporary spirituality, focuses on people's experiences and work as a spiritual path. I think this distinction and perspective can illumine these efforts to integrate spirituality into medical practice and organizational life and also point to a possible next step in this process.

FROM PROBLEM SOLVING TO ADAPTIVE CHANGE
In their article "The Work of Leadership," Ronald A. Heifetz and Donald L. Laurie distinguish problem-solving approaches from adaptive change.³ When using the problem-solving approach, leaders define problems and provide solutions. In doing this, they shield people from the distress the problem is causing, clarify roles and responsibilities, and restore order. In adaptive work the leader identifies the challenges, recruits people into the work of responding, encourages the rethinking of roles and responsibilities, and does not prematurely close down conflict and change in the name of order. Leading adaptive work means facilitating a process of deep change that can involve basic identities, role definitions, and specific responsibilities. Of course, the key is to discern what situations call for problem solving and what situations call for adaptive work.

Heifetz and Laurie think organizational leaders are most comfortable in a problem-solving modality. Leaders have reached their present position of authority by providing leadership in the form of solutions, and there is no reason to call into question what has been successful in the past. Therefore, they are prone "to make the classic error of treating adaptive challenges like technical problems that can be solved by tough-minded senior executives."⁴

The tendency to approach every situation as a problem to be solved goes beyond organizational leadership. It can be extended to include medical professionals. The dominant method of the medical professional is diagnosis and treatment, which is a variation on defining the problem and providing the solution. The problem-solving mind-set, once it is firmly in place, moves to meet each new situation, sizing it up on the terms with which it is most familiar. It becomes the acceptable and predictable way of doing things.

As spiritual interests emerge in health care settings, they encounter the organizational and medical problem-solving mind-set. Spirituality is automatically appreciated in terms of the medical and organizational structures already in place and evaluated in terms of whether it fits or not. The question becomes: how can this new kid on the block be included in an appropriate way, a way that does not disturb established roles and ways of working? Leaders in consultation with experts address the situation and determine an organizationally acceptable response. In other words, under this modality the inclusion of spirituality is a problem in need of a solution.

In the efforts to integrate spirituality into health care a number of predictable problems emerge and solutions are not far behind. If a patient raises a religious or spiritual issue, here is what should be done and what should not be done. If a physician wishes to incorporate a spiritual history into the medical history, here are some guidelines and some sensitive questions to ask. If leadership wants to know whether employees and patients view the organization as spirituality friendly, here is an assessment tool to use. Depending on the outcome of the assessment, here are some procedures and programs to put in place. If, in interviewing prospective chief executive officers for a faith-based health care system, there is a need to assess their theological abilities and spiritual sensitivities, here is a way to go about it. In organizational and professional cultures that value solutions, solutions are supplied, often in the form of guidelines and best practices.

However, once solutions are in place and are regularly evaluated, another process may be triggered. The necessary stage of problem solving may be the forerunner of deeper adaptive work. Although Heifetz and Laurie draw a sharp distinction between problem solving and adaptive work, the health care example that begins their article holds the two approaches together.

To stay alive, Jack Pritchard had to change his life. Triple bypass surgery and medication could help, the heart surgeon told him, but no technical fix could release Pritchard from his own responsibility for changing the habits of a lifetime. He had to stop smoking, improve his diet, get some exercise, and take time to relax, remembering to breathe more deeply each day. Pritchard's doctor could provide sustaining technical expertise and take supportive action, but only Pritchard could adapt his ingrained habits to improve his long-term health. The doctor faced the leadership task of mobilizing the patient to make critical behavioral changes; Jack Pritchard faced the adaptive work of figuring out which specific changes to make and how to incorporate them into his daily life.⁵

Jack Pritchard's situation begins with a technical fix—triple bypass surgery and medication—and unfolds into an adaptive challenge. The adaptive challenge is a call to take personal responsibility and change ingrained habits. Therefore, the problem solving is not an end but a beginning, and not the beginning of more technical fixes, but an invitation to a deeper level of involvement. The authors spell out this deeper involvement in terms of needed behavioral changes. But the call to adaptive work often entails an inner assessment of identity and attitudes as the basis of behavioral change. In other words, adaptive work is often a journey of self-knowledge that looks inside in order to find the energy and perseverance to change the outside.

Could it be that the efforts to integrate spirituality into health care will spur deeper adaptive work? Could it be that as people—patients, physicians, nurses, leadership, and all levels of organizational health care—engage the prescribed solutions of how to integrate spirituality into health care, they will hear and accept the invitation hidden in the solution? Could it be that a patient hearing a physician say, "Is faith or spirituality important to you in this illness?" will begin a process of reflection leading down a path Rachel Remen marks out?

Through illness, people may come to know themselves for the first time and recognize not only who they genuinely are but also what really matters to them. As a physician, I have accompanied many people as they have discovered in themselves an unexpected strength, a courage beyond what they would have thought possible, an unsuspected sense of compassion or a capacity for love deeper than they had ever dreamed. I have watched people abandon values that they have never questioned before and find the courage to live in new ways. Often these ways are more soul-infused.⁶

Could it be that physicians who ask patients whether faith or spirituality is important to them also pose this question to themselves? Could it be that as leaders struggle to connect theological values to concrete business decisions they will realize no mechanical connection is persuasive, and seek in themselves a deeper, more integrated space to speak from? Solutions are the seeds of deeper work. As people engage them, they are called to more. The invitation may be ignored or accepted. If it is ignored, things go on as usual. If it is accepted, they begin to walk a spiritual path.

SPIRITUAL PATHS
There are many ways to appreciate the complex and mysterious reality that is referred to by words like "religion," "faith," and "spirituality." From the perspective of medical research this reality has been approached by distinguishing and relating religion and spirituality, by focusing on spiritual needs that are companions to physical, psychological, and social needs, and by spelling out the various domains of religiousness/spirituality, from church attendance to religious experience, in order to study them more effectively. However, from the perspective of trying to integrate faith, religion, and spirituality into medical practice and organizational life, a different approach may be helpful. Perhaps the way to proceed is to appreciate how people's experiences and activities become a spiritual path and how spiritualities—beliefs, stories, and practices—are used on this path to develop spiritual consciousness and service. It is this perspective that will illumine the individual and organizational adaptive work that might go on as a result of engaging the solutions of integrating spirituality into health care.

Activities become spiritual paths when in and through them people develop spiritually. Traditional spiritual paths would include the various activities of organized religions, e.g., liturgies, religious education, prayer sessions, etc. Many people today include activities that previously would not be considered spiritual. People say parenting is their spiritual path, or volunteering at the hospital is their spiritual path, or they name being a patient or nursing or working in human resources. All these activities have responsibilities and objectives of their own. Yet the people engaging in them are adding a dimension to what is happening. They are using these activities to awaken and develop spiritually.

How does this go on?

A story Rachel Remen tells provides some significant clues. She is working with a cancer surgeon who is suffering from depression. "I see the same diseases over and over again. I just don't care anymore. I need a new life." Remen suggests that each night he review his day by asking three questions: "What surprised me today? What moved or touched me today? What inspired me today?" He was to write his answers in a journal.

At first he came up empty. He just wrote "nothing" in the journal. Then he began recalling clinical oddities. He was surprised that a cancer had grown or shrunk or that a new experimental drug was effective. But eventually "he saw people who had found their way through great pain and darkness by following a thread of love, people who had sacrificed parts of their bodies to affirm the value of being alive, people who had triumphed over pain, suffering, even death." He was still attending to bodies and their disease processes, but now he was seeing people.

This new sight developed in stages. At first, he became aware only of what he was seeing at night, as he was reviewing the day. But gradually the time lags shortened. "I was building up a capacity I had never used. But I got better at it. Once I began to see things at the time they actually happened, a lot changed for me." What changed was how he practiced medicine. He began to share with his patients what he saw, and they responded in kind. One of his patients gave him a stethoscope engraved with his name. When Remen asked him what he would do with it, he responded, "I listen to hearts, Rachel. I listen to hearts." ⁷

A spiritual path has two interlocking elements. The first is the use of spiritualities—beliefs, stories, and practices—to facilitate spiritual awareness, to give new eyes.⁸ In the physician's story Remen gives him a practice, three questions he must ask himself at the end of each day. This practice puts him on a path, and the path becomes a counter force to his depression. As John Welwood says, "The nature of path is to lead us on a journey, and it is life's deepest urge to move forward in this way. Whenever our lives have this sense of forward momentum, we feel an unmistakeable stream of vitality flowing through us, which tells us we are on to something real."⁹ In the extravagant language of mystical traditions, the practice brought him back from death to life.

The surgeon persevered in this practice and gradually came to see more deeply. This seeing more deeply happened in stages. At first, he saw nothing. Then he saw the surprising on the physical level. Finally, the personal and spiritual came into focus. On a spiritual path there is a need for both perseverance and growth. It is not just the beliefs, stories, and practices people espouse. It is the steadfastness of their attention to these beliefs, stories, and practices. The beliefs have to be consistently entertained and integrated into the mental processes, the stories have to be told and retold to the listening heart, and the practices have to have a greater priority than sleep. Path and perseverance go together.

However, if there is only perseverance and no deepened spiritual awareness, a spirituality is not functioning well. As the story suggests, spiritualities are stethoscopes to hear the pulse of the spiritual in each experience and in every situation. Therefore, they are known by their fruits, the effects they produce in the minds, hearts, and actions of those who espouse them. Spiritualities must facilitate growth in spiritual consciousness. If they do not do this, it is time to find new beliefs, stories, and practices that will. As people walk the path, the spiritualities that illumine the path and inspire the journey often change.

The second interlocking element of a spiritual path is the dynamic interaction of realization and integration. Realization is seeing the deeper dimension of the spiritual as it suffuses physical, psychological, and social life. Integration is the struggle to act on what is seen. The physician reflects on this process.

At the beginning I couldn't talk about it and I just wrote everything down. But I think when I began to see things differently, my attitude started to change. Maybe that showed in my tone of voice or in some other way. People seemed to pick up on it because their attitude seemed to change, too. And after a while, I just began talking to people about more than their cancer and its treatment. I began talking about what I could see.¹⁰

Once again, growth continued—from not being able to talk, to suspecting that his new attitude was showing even though he was not talking about it, to finally saying what he saw. This is the movement from realization to integration. However, it is not always this smooth. In fact, it usually entails extensive trial and error with new ways of talking and new ways of acting.

In general, spiritual growth moves from the inside to the outside and back to the inside. People see or realize the presence of the spiritual as it arises in the ordinary interactions of life and, after a sufficient amount of inner work, venture out of hiding with their new realization. This movement into the outer world has to go through the conditioned mind and deal with recalcitrant and uncomprehending elements in their situations. Also, it is often unclear how this spiritual realization should be embodied. This struggle of integration necessitates a return to the realization to draw from its wisdom and strength, and then another attempt to embody the inner spiritual in the outer world. This inner-outer dynamic is the realization-integration two-step that is used by people who walk a spiritual path.

CONCLUSION
Integrating spirituality into health care is a formidable problem-solving enterprise that must take into account medical, moral, organizational, theological, financial, and legal considerations. Leaders and experts conspire to find solutions and develop time-tables for implementation. What will happen to people as they engage these solutions? Will some hear in the solution an invitation to deeper adaptive work and begin to walk a spiritual path? Will they experiment with spiritualities to guide them and live in the oscillation between realization and integration? If they do, the integration of spirituality into health care will go beyond structural adaptation into personal transformation. Also, there will be a need for different individual and organizational responses. Envisioning those responses may be the next step in integrating spirituality in health care.

NOTES
1. For a developed understanding of these spiritual interests, see John Shea, Spirituality and Health Care: Reaching Toward a Holistic Future (Chicago: The Park Ridge Center for the Study of Health, Faith, and Ethics, 2000), 21–68.