Spirituality, not always linked to a religion, has the ability to modulate the patient's behavior in the face of adversity, such as illness, manifesting itself through Positive Spiritual Religious Coping, which most of the time results in a better prognosis, or Negative Spiritual Religious Coping, characterized by discontent in relation to one's belief, reflecting in interpersonal conflicts and with oneself, resulting in the worst coping with the moment and the ongoing pathology. From this perspective, the World Health Organization recognized Spirituality as an intrinsic aspect of the human being, including the term in the new concept of health. The observation of the significance of S/R for the way patients view their illness and treatment was the object of discussion in this study, with reflections on the phenomenon of Positive and Negative Spiritual Religious Coping, as well as the consequent impact of coping on patients' health and quality of life. This is a descriptive study, of the experience report type, whose characteristic is the description of the experience of situations from the first to the tenth period of the medical course, in which the connection between spirituality and the circumstances of the patient and the observer were observed during the moments of consultation. These observations reinforce the need for updating in the area and for debates among the clinical staff on how, in medical practice, health professionals should see the patient holistically and understand beliefs, dogmas and values to provide the best care and achieve the best outcome for the patient, welcoming the patient beyond the disease.

Keywords: spirituality, spiritual religious coping, health, humanization

Spirituality and Religiosity (S/R) have been shown to be an extremely important factor in the outcomes of individuals' health and illness processes. Spirituality is understood as something intrinsic to the human being and of profound relevance to the patient's biopsychosocial nature, seeing it beyond the pathology installed, while Religiosity is present through practices or rituals of faith, necessarily linked to a religious institution,¹ which can reinforce existing Spirituality.

This tenuous relationship between S/R and its influence on the patient's behavior in the health scenario has been pointed out in the literature as one of the main forms of coping in chronic clinical conditions through a process called Spiritual Religious Coping (SRC), which can be positive (PSRC) or negative (NSRC),² bringing the health professional's gaze to care beyond the organic.

PSRC, for example, is mentioned as a protective factor for destructive behaviors, such as addictions to cigarettes and illicit drugs;^3,4 alcohol abuse,⁴ suicidal thoughts.⁵ These data are already the result of S/R's focus on the search for meaning, self-control, spiritual comfort, closeness to God and other members of society, as well as a change in behavior⁶ to organize a routine that provides a better quality of life.

Attitudes linked to PSRC include prayer, a way of asking for help from God's care in relation to some situation,⁷ as well as practices related to religions such as Buddhism, Taoism and Shamanism⁸ affiliation; frequency of activity and attendance at religious meetings.⁹

On the other hand, in NSRC the patient has attitudes of victimization, a passive conduct that goes hand in hand with a history of guilt or judgment for going through difficult times. Among the consequences can be seen the loss of hope through treatment, exclusive imputation to the Divine for the resolution of problems, looking at one's own clinical condition as something of God's will or the result of karma. Another very common view associated with religion is that of a punitive God, with illness being a punishment for sins committed during life,¹⁰ which can worsen the patient's outcome.

Once PSRC has been observed, the health professional can remain indifferent, respecting the patient's speech, even if such reports are not part of their core beliefs, and reinforcing, in a welcoming way, the benefits observed for the patient during treatment. On the other hand, once NSRC is in place, it can be responsible for some of the destructive feelings that accompany the debilitated individual, such as abandonment, hopelessness, denial of medical care and therapy, whether pharmacological or surgical, believing that only faith will bring a cure. Therefore, the presence of NSRC is a strong sign of the need for therapeutic intervention in the field of Spirituality associated with clinical practice, which requires care and attention from the professional, especially the doctor - whom the patient has as a reference for guidance and health care.¹¹

Based on this scenario, in 1998, the World Health Organization (WHO) included the term 'spirituality' in the concept of health, referring to issues such as the meaning and sense of life, and not limited to a specific type of religious belief or practice. Thus, health is currently characterized as the whole of the patient's physical, social, mental and spiritual well-being and not merely the absence of illness or disease.¹²

As these are two extremes that interfere with the way patients deal with their health, impacting on their quality of life and prognosis, S/R presents the need to disseminate the tripod of spirituality, health and science. Both in periodic and ongoing follow-up, the observation of the significance of S/R for the way patients view the disease and treatment was the subject of discussion in this study, with reflections on the phenomenon of PSRC and NSRC, as well as the consequent impact of coping on patients' health and quality of life.

This work is a descriptive study, of the experience report type, which is characterized by accurately describing a given experience that is relevant to a particular area of activity. To this end, a professional experience, successful or not, is polished by the author(s) towards building a source of discussion, exchange and proposition of ideas for improving healthcare.¹³

The report was written in the first semester of the year 2024, describing issues observed about spirituality, health and science throughout the academic career of a medical student in a city in the interior of Minas Gerais (Brazil), with a time frame from the second semester of 2019 to the year 2024.

The basis of the description was the student's perception of the approach to the subject in practice, according to his experience in these settings during his undergraduate medical internships, between the 1^st and 10^th terms. During the internships, consultations were carried out in Primary Care (PC), in Basic Health Units (BHUs), Outpatient Clinics (Secondary Care - SC), and in Hospital Emergency Care Units (HECU) (Tertiary Care - TC). Each practical scenario, experienced in a different time and space, provided diverse observations on patient behavior associated with routine health care and S/R.

In both periodic and ongoing follow-up, the significance of S/R for the way patients deal with their health care in the face of diagnosis and treatment was observed, based on the influence of S/R based on coping. There was also a brief discussion of how health professionals deal with this situation.

In relation to the extrinsic link between human beings and S/R, it can be said that the existence and practice of faith is of great importance for maintaining health by modulating attitudes such as reducing risk behaviors like the use of tobacco, alcohol, risky sexual behavior, violent situations and illicit drugs,¹⁴ a better relationship with diets and/or improved nutrition.⁶

According to Rezende-Pinto, Moreira-Almeida,¹⁵ S/R can act as a protective factor against drug and alcohol abuse by providing meaning to life and suffering, valuing life, inserting people in social environments where they don't use substances, prayer and other religious practices. In a study on tobacco use in Rio de Janeiro (Brazil), Verona et al.¹⁶ found that individuals belonging to the evangelical religion had a lower prevalence of tobacco use compared to the "no religion" group, which had the second highest percentage of smokers. The Spiritist doctrine had the highest number of adherents who gave up smoking. In the study, there was a correlation between high religious attendance and a lower prevalence of smokers, which suggests a positive behavioral modulation when assessed by the difficulty of overcoming an addiction, especially to the chemical substance "tobacco" and the act of smoking itself.

In addition, one study suggested that S/R can serve as a protective and resilience factor in adolescence, acting to maintain psychological well-being, as well as to develop character and reduce risk behaviors such as early sexual exposure, multiple sexual partners throughout life, alcoholism, and depression. According to results, religious groups can act as stress reducers and encourage good practices such as prayer, meditation and the exercise of forgiveness, as well as inserting the individual into social groups away from harmful habits.¹⁷

Throughout the course of my degree in medicine, I realized, from the first contact with practice, the relevance of S/R in the patient's life, whether through common words when saying goodbye, such as "Stay with God", "God bless everyone who works here", "I'm going to pray for the Lord"; or through objects and symbols of faith, such as leaflets related to religious institutions, bibles, necklaces and rosaries, or even by changing behaviors and attitudes through suffering and signifying the moment.

However, these issues are traditional and have been widely addressed since the beginning of the history of medicine, when science sought its space amid the religious domain of knowledge to unravel the disease, studying man and everything that made up the environment around him.¹⁸ The gap that needs to be filled is the understanding of the impact of S/R on the patient's health and the mechanisms by which this axis shapes the patient's behavior, directing the prognosis.

Based on this millenary heritage regarding the influence of Spirituality on man, it is important for health professionals to be up to date on research into the influence of Spirituality on the processes of health and illness, so that they can approach the subject when taking an anamnesis and constructing clinical thinking in the face of illness.¹⁹

Despite not yet having a specific subject to discuss the S/R and science tripod, discussion points have been introduced throughout the undergraduate course in subjects that work on humanization in health, through scientific articles or updated guidelines, such as that of the Brazilian Society of Cardiology (2020), which proposed S/R as a therapy, even requesting that the doctor address the topic during the care and clinical follow-up of patients with hypertension and other heart diseases.²⁰

One of the ways of screening a patient's Spirituality during a consultation is through anamnesis, a process in which the doctor conducts an interview with the patient, in order to collect data to point to a probable diagnosis, through the use of questionnaires such as the "FICA" directed by the questioning points: (F) - faith and belief, (I) - importance and influence, (C) - community, and (A) - action and treatment; which will indicate the importance of the patient's Spirituality and its best approach, adding spiritual values and resources, and thus the best outcome in clinical management.²¹

From this perspective, attracted by the importance of the topic and by my curiosity to see how this comes about in practice, throughout my internships I began to observe how patients present themselves in relation to religious beliefs and their respective health and illness processes. When I analyzed the frequency of cases in which religious beliefs were included in medical consultations daily, I came up with the idea of highlighting the main observations, due to the frequency with which they occur and even the naturalness with which they are presented, with the aim of inserting the debate on the subject into the academic environment. Table 1 provides a summary of these findings in the various practical scenarios experienced throughout the course.

In one of consultations at a Family and Community, corresponding to PC, a patient presented with intense psychomotor agitation, disorientation, asthenia, weight loss and confused thoughts. At the time of the anamnesis, it was noted that she had interrupted her treatment for hyperthyroidism due to guidance from her spiritual leader, resulting in exacerbated signs and symptoms of the pathology. This is a clear example of NSRC, in which the individual, due to issues related to S/R, abandons the established therapy, placing faith as the only measure for improvement.

According to Foch, Silva and Enumo²², NSRC corroborates the worsening of quality of life, psychological well-being, reduction in pain and the reduction in the search for better techniques to improve the clinical condition. According to Panzini and Bandeira⁹, when patients renounce their own will to the detriment of God's will, the course of the disease is transferred to the Divine, which can lead to abandonment of the therapy already in place.

In addition, Tostes, Pinto, Moreira-Almeida²³ point out that, after establishing a good doctor-patient bond, it is important to have a conversation to suggest and request the patient's authorization for possible contact with the religious leader, not in a conflictual way, but in order to establish a joint treatment and better care for the patient, associating the issues of S/R in the clinical condition evaluated.

In a study carried out with health professionals at a BHU about the approach to S/R in consultations and its relationship with treatment, perceptions were cited of how religion influences the way individuals take care of their own health, such as NSRC, to the detriment of religion being placed ahead of the therapeutic approach, preventing or hindering procedures with a view to healing specifically through faith. The positive influence of religion on health has also been observed, for example through adherence to treatment due to hope and faith in a cure, affirming the existence of PSRC among individuals.²⁴

In relation to the observation of the patient in the Rural Internship I carried out, related to PC and Family Health care, the presence of objects associated with the faith and beliefs of the patients was notorious, such as the presence of rosaries, leaflets, blouses, religious books, necklaces of religions of African origin, among others. Phrases such as "God bless", "God willing", "I pray for the Lord's life", "Sunday I went to Mass", "Stay with God" (when saying goodbye), and other things were commonly noticed. These were present not only in the PC, but also in the SC and TC, demonstrating how faith accompanies the patient in the process of health and illness, justifying the extreme importance of health professionals addressing this issue during consultations.

From this point of view, studies have shown that among users of health centers, beliefs and values go beyond religious concepts and are associated with the patient's way of living, and it is of great value that the professional knows the concepts of SRC to better approach and bond with them. This care can be based on the practice of welcoming patients regarding these issues in order to stimulate them and also the ability to provide a care plan that involves these concepts, suggesting that the doctor and the entire health team have a clear understanding of this area, with respect for the patient's beliefs, dogmas and autonomy.⁶,¹⁴

It is therefore important to compare the experience of practice with the literature to understand what to do to benefit the patient and how to make changes. The importance of the issue for the individual's life demonstrates the need for health professionals to understand the patient's faith and explain the importance of medication without undermining their beliefs and values, bypassing the situation and explaining the indispensability of resuming drug therapy.

In relation to SC, which includes internships in specialty outpatient clinics such as psychiatry, cardiology and rheumatology, we witnessed a consultation at a Psychosocial Care Center (PCC), where a young woman wearing necklaces and pendants linked to the Roman Catholic religion was accompanied by her husband and a priest. The patient had sought medical help complaining of hearing voices of spiritual beings suggesting actions such as self-flagellation and aggression towards her husband, and as a result, she had difficulty sleeping or staying at home alone.

From this perspective, Cardoso and Seminotti²⁵ point out that many individuals seek relief from their suffering in other types of services such as churches, spiritual centers and other religious practices, to improve their anguish before seeking a specialized mental health help service. In relation to the way of life and healthy religious practice, Koenig²⁶ mentions that the religious experience becomes negative when the patient shows dysfunctional behavior towards themselves or socially, such as legal problems with the police or suicidal or homicidal threats.

The author also points out that although the field of psychotic disorders and their relationship with religion is still in need of further study, it is of great value for the health professional to carefully investigate the patient's spiritual history during the consultation and consider the necessary interventions.²⁶

Linked to the Psychiatry outpatient clinic and the management of people giving up drink and illicit drugs, we saw the help of therapeutic homes or rehabilitation centers linked to religious institutions as a way for patients to move away from environments that favor substance abuse to a new place, promoting a healthy way of life for future reintegration into society.

Associated with the theme of rehabilitation centers, a qualitative study carried out with drug users in the slums of Manguinhos, Rio de Janeiro (RJ), pointed out ways of recovering from addictions linked to a practice of faith. In the study, evangelization was provided as a form of religious treatment and, as a therapeutic method, prayer, Bible reading and participation in meetings, such as cells for holding prayers, moments of praise and prayer for the "expulsion of demons" that once led to drug use. However, it was pointed out as a criticism that some of these institutions lacked technical training and focused only on spiritual treatment as a form of healing.²⁶,²⁷

In addition, a study carried out on former drug users showed that one of the main factors linking drug addicts to religion is the welcome provided by these groups, because when the patient arrives in a broken physical, moral and emotional state, they are welcomed without prejudice and with dignity, demonstrating behaviors that raise the self-esteem of newcomers and make them worthy of God's love, which gives the marginalized a sense of belonging and self-worth.²⁸

While working in hospitals in the region, in the context of Urgent and Emergency Care, both related to TC, a patient was admitted in a state of drowsiness, unable to move and requiring the use of a wheelchair. During the clinical examination, she presented with inaudible blood pressure (BP) and hyperglycemia. After a few moments, the patient went into cardiorespiratory arrest. Her daughter, who had been praying for her mother's improvement since early morning, approached the doctor in an apprehensive state and was taken into a private room to be informed of the death. Her reaction was to cry out in pain, questioning God for having allowed this to happen. Stoppa and Moreira-Almeida²⁹ pointed out how NSRC can manifest itself through the idea of a "punitive God" or spiritual discontent, which leads to a worsening quality of life.

Regarding grief, the study by Biancalani et al.³⁰ shows that many family members used the mechanism of faith, beliefs and spirituality to overcome the loss of their loved ones. PSRC was used as a way of strengthening their resilience and coping with the moment of grief; however, there are reports of individuals who, due to the instability and uncertainty caused by the death of their family members, created an aversion to the concept of God, thus developing a state of revolt with the sacred due to the feeling of divine abandonment.

In this sense, it is understood that Spirituality can provide strategies for human beings to face situations such as death, because through it there is a re-signification of the process as a finitude of existence for a possible eternal life or passage to another plane. Such a conception can bring the family member liberation and alleviation of suffering and a way of acquiring peace and tranquility in the face of the situation that affects them, because through the RSC there will be ways of overcoming or enduring the event.³¹

From this perspective, when observing the case of a pregnant woman who arrived at the hospital (TC) due to pre-eclampsia, which was serious for her and her child, it was possible to see that while she was waiting to be taken to the room where the procedure to extract the baby would be carried out, the patient began a moment of praying aloud, quoting names referring to her religion. As she was led into the room, the pregnant woman increased her prayers and reinforced the name she was praying to. Her prayer continued with moments of gratitude and tears as she heard the newborn's cry.

Ferreira Nascimento et al.³² cited that many women reported pregnancy as a time of physical, spiritual, and sentimental changes for the pregnant woman, requiring a holistic approach that encompasses the woman and her family. On this subject, a study carried out with pregnant women in Portugal pointed out that among some pregnant women there is the belief that God determines the sex of the child, as well as the thought that pregnancy prevents them from going to places such as funerals or cemeteries, as going there could cause spiritual illnesses to the fetus.³³

 These and other reports justify the great value of the S/R debate during pregnancy, since SRC can impact the lives of pregnant women in many ways, depending on their socioeconomic, religious and cultural conditions. In addition, it is important to note that the S/R axis has the capacity to encompass multiple atmospheres of the puerperal woman's life, such as her insecurities, fears, uncertainties and challenges from the gestational period, childbirth and the puerperium. The boundary between spiritual and emotional care is tenuous, because through the inseparability between the spheres, caring for the spiritual provides comfort and courage and generates emotional support.³⁴

During the period in question, an elderly woman accompanied by her daughter was seen in a hospital. During the anamnesis between the beds, they both emphasized their faith in God and the elderly woman's hope of going home to carry out her daily chores, such as looking after her home and attending Mass. The elderly woman carried objects that referred to her faith, such as phrases related to her belief in God's care for her life. After being diagnosed with pneumonia, it was noted that she needed to be hospitalized to continue her care. In the scenario of care for elderly individuals, a study covering the geriatric population showed that the fine line that unites S/R has positive characteristics for coping with the reality of life, because through reports of contact with God, the elderly are able to overcome obstacles such as distance from family, routine and, in addition, it provides a new perspective on hospitalization.³⁵

According to Duarte and Wanderley³⁵, elderly people who took part in a survey reported that their religious beliefs underpin their lifestyle as the practice of going to mass and exercising their faith in the community or individual religious practices such as Bible reading, prayers. In addition, they link S/R as a means of greater social support and psychological health in the elderly. Given the doctor's daily need to see the patient holistically, it is of the utmost importance to consider their religious-spiritual aspect, as this will improve the care of human beings in states of health and illness, respecting them as an integral being.

In view of this scenario, it is understandable to note the lack of medical training on the approach to Spirituality and its integration during consultations, partly due to the absence of this topic in undergraduate courses and the lack of knowledge of the insertion and recognition of the topic during consultations. In the literature, Banin et al.³⁶ pointed out that a minimal proportion of doctors had previous training or instruction to approach the subject during consultations, showing a lack of specific knowledge and skills about Spirituality in medical care as satisfactory training for an adequate approach to the subject with patients. In addition, fear of imposing the professional's religious point of view on the patient, lack of training and lack of knowledge were pointed out as reasons for not approaching the subject, demonstrating that the literature corroborates the practice experienced.³⁷

On the other hand, a study carried out by De La Longuiniere and Yarid³⁸ pointed out that health students, during the collection of data for a research project related to spirituality in populations undergoing chemotherapy, developed reflections on the subject and improved a global view of the patient beyond the disease. In addition, the result was the start of productions for congresses, scientific writing and the creation of an academic league on Spirituality and Health. In this sense, the introduction of the theme into the construction of medical knowledge can provide reflection on the topic and deepen the subject in the student sphere as well as in clinical practice.

Looking at the literature, we can see the evolution of S/R in research and its integration into medicine, which points to a possible advance of the subject in the academic sphere and in clinical practice. In Brazil, Moreira-Almeida and Lucchetti³⁹ cite that Brazil ranks 5^th in publications on the subject in Medicine, Psychology and Nursing in the last five years, with Medicine having the largest number of publications (139 articles), pointing to the importance of the subject for medical training and a possible indicator of progress on this axis in academic settings, offering better preparation for future health professionals.

Reginato et al.¹⁸ cite that Spirituality has been debated as one of the pillars to be considered in the patient's health-disease process, pointing to the need to include the topic in academic fields, as well as the insertion of a discipline to deal with clinical protocols with the student within the curriculum of health courses.

Furthermore, according to Dal-Farra and Geremia⁴⁰, in the United States, in 2008, 100 out of 150 medical schools offered some activity linked to Spirituality in their courses and, in 75 of these, it became part of the regular undergraduate program. Nowadays, in the Brazilian scenario, there is a growing interest in the subject in universities, such as the Federal University of Juiz de Fora (UFJF), Brazil, which has a Research Center and Postgraduate Program in Health (NUPES), with branches of study on topics related to Spirituality.¹⁵

Given this importance, it is essential to include Spirituality in the academic context and to debate the conduct of health professionals in their work environment and how to manage the patient in situations of NSRC and encourage them in a way that is favorable to treatment, often as an adjunct to SRC.

In order to move forward with the proposal for greater dissemination of the topic and a practical approach, Correa, Batista and Holanda⁴¹ propose a multidisciplinary approach, not just limited to the academic or research scenario, but also in practice, aiming to multiply the significant impacts of the use of SRC on the quality of life and increased levels of well-being of patients, providing a new perspective through diagnosis, treatment and the unpredictable losses.

The observations made during the practical activities of the medical course allowed us to understand the dimension of S/R for the patient in the health scenario, reflecting on the insertion of the holistic view, which provides an understanding of the patient as a person who has religious beliefs and dogmas that accompany them, and it is extremely valuable for the doctor to investigate and insert the subject in consultations.

Both in the PC and in the SRC and TC, religious habits and objects on display were observed, as well as the acceptance or not of the medical conduct adopted, paying attention to culture, as well as the NSRC's analysis of the attribution of psychiatric disorders to the spiritual, the SRC's view of mourning and the loss of loved ones. The PSRC was present at times of childbirth with complications and when the geriatric population was hospitalized due to lung problems.

This highlighted the need for debate in academia about the importance of integrating spirituality, religion and heath and how it permeates medical practice. There was a notorious lack of knowledge among academics and professionals about how to carry out a spiritual/religious anamnesis and, above all, how to intervene in practice if signs of SRC are observed in the patient, whether negative or positive.

None.

The author declares there is no conflict of interest.

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