According to the World Health Organization (WHO), the ideal model for understanding human health is the biological, psychological and social model, which is articulated in three basic dimensions. However, numerous scholars-including academics, spiritual counselors and psychiatrists-advocate the importance of including a fourth dimension, that of spirituality, thus transforming the bio-psycho-social model into a bio-psycho-socio-spiritual model. This debate, which began within the World Health Organization as early as 1948, continues to this day without reaching a definitive conclusion.
Over the years, a number of task forces have been established to explore the issue further. Among them, a particularly significant one was led in the late 1990s by psychiatrist Shekhar Saxena, who placed special emphasis on the spiritual dimension. Saxena, while a psychiatrist, strove to separate the concept of spirituality from mental health, which until then was often identified exclusively with emotional well-being and brain functioning. This very “functional” view was too limiting compared to the broader and more complex nature of spirituality.
Saxena’s work led to the creation of the “WHOQOL Spirituality, Religiousness and Personal Beliefs (SRPB) Field-Test Instrument”, which explores variables related to, among other things, religious belief. It is crucial to note that religion and spirituality, while they certainly have areas of interconnectedness, do not always coincide: while religion is based on sacred texts, laws, rituals and fixed beliefs, spirituality embraces a more personal and universal dimension. As highlighted in Cook’s (2004) definition, spirituality includes a sense of interconnectedness with the present, with the transcendent (where present but not mandatory) and with our surroundings-people, nature, animals. It is related to the search for peace and serenity for the soul, for meaning and reprioritization, especially in times of fragility.
A central element of spirituality is the search for meaning, which results in deep questions such as, “What can I do? What is my role? What is the meaning of this earthly passage of mine? Why me?” This quest goes beyond the rational mind and involves more mysterious dimensions that we can call “soul,” without necessarily linking it to a specific religion.
But what does this have to do with Narrative Medicine? Although WHO’s position on the inclusion of spirituality as a structural dimension, to date, is still unclear (this is also evident from Simon Peng Keller’s very interesting Report analyzing this issue from 1946 to 2021), the narratives of patients and caregivers instead highlight the profound relevance of this dimension. Spirituality emerges prominently from the stories of life and caregiving, especially in times of difficulty. Among the most recurring aspects we find: the sense of interconnectedness among people (family members and even friends), when in a moment of fragility or after an inauspicious event one seeks “the other” and asks for help; the ability to feel a sense of wonder, joy and amazement even in small things, enjoying every moment of the “here and now.”
Illness, by shrinking the boundaries of life, often leads to new discoveries and a reorientation of priorities: work gives way to affections, the remaining time is devoted to loved ones, and a greater awareness of the present develops.
Certainly there is also a religious component that emerges from the narratives: people who find comfort in prayer, who, for example, after awakening from a pharmacological coma recognize prayer, in addition of course to the work of doctors and nurses, as an instrument responsible for their salvation.
Everyone, then, has his or her own hidden garden, a secret garden: some cultivate the immanent, some the interconnections, the soul, the meaning, the “why to me”; some begin to write their own autobiography or Illness Narrative (story of illness), to leave a mark, because of tomorrow it is not given to know, in this so impermanent world. In this sense, storytelling goes precisely to fill the need to leave a trace, to build a lasting memory.
Or, as reported earlier, there are those who prefer the intercession of their saints of reference to all this, to have healing or simply for the time that remains.
Even in the most difficult situations, such as requests for terminal sedation (gentler and slower than euthanasia), deep ethical implications related to spirituality emerge. Many believing people reject it, preferring a gradual end, because they wish to live fully until, as they often say, “God will come for me.” These deep, ingrained visions that accompany us throughout our being require great sensitivity on the part of health care professionals, who are called upon to respect and integrate them into the course of care.
Just as it is often the case that one changes in the course of one’s existence (sometimes, in times of greatest need, one prays, while when things are going well, one becomes more contemplative), health and illness are also not realities separated by a clear boundary, but are part of an existential continuum that runs through our lives.
These were some small reflections that underscore how spirituality turns out to be deeply related to Narrative Medicine. Listening to the stories of sick, frail and vulnerable people is an act of great responsibility: it is not just about “fixing” a body, but accompanying a soul in its search for meaning and peace. Then again, caring, as delicately and elegantly defined by one part of WHO, is itself an act of the deepest spirituality. For this we are truly grateful to all caregivers who continue to dedicate themselves to others at this time, ensuring some health and salvation even during the Christmas holidays. So, a heartfelt thank you and invaluable wishes to everyone.
