“ I Heard the Voice . I Felt the Presence ” : Prayer , Health and Implications for Clinical Practice

Research concerning the relation between physical health and prayer typically employs an outcome oriented paradigm and results are inconsistent. This is not surprising since prayer per se is not governed by physiological principles. More revealing and logically compelling, but more rare, is literature examining health and prayer from the perspective of the participants. The present study examines the health–prayer experience of 104 Christians in the United States. Data were collected through recorded video interviews and analyzed by means of content analysis. Results show that prayer is used as a context nuanced spiritual tool for: dealing with physical suffering (spiritual-religious coping); sustaining hope and spirituality via a sacred dimension; personal empowerment; self-transcendence. These findings demonstrate that practitioners primarily engage prayer at a spiritual rather than a physical level, underscoring the limitations of a biomedical or “Complementary and Alternative Medicine” perspective that conceptualizes prayer as a mechanism for intentionally improving physical health. In clinical practice, regarding the medical, psychotherapeutic, or pastoral, the challenge is to understand prayer through the framework of the practitioner, in order to affirm its potential in healthcare processes. OPEN ACCESS Religions 2015, 6 671


Introduction
Studies have demonstrated that in the Western world, many people turn to religion in difficult times, especially when facing illness [1,2].According to an American survey on use of prayer (N = 2055), 35% of respondents used prayer for health concerns; 75% of these prayed for wellness, and 22% prayed for specific medical conditions; of those praying for specific medical conditions, 69% found prayer very helpful [3].What is not at all clear from this or similar work, is the extent of the respondents' histories of prayer practice.If, for instance, this 35% represents a group of people trying prayer for the first time as a "last resort" the interpretation of the findings would be radically different that if the group had a lifetime discipline of fervent prayer.
In other words, understanding the relation between prayer and health appears deceptively simple if one has in mind solely that prayer has been shown in research to be one of the main religious coping strategies within the health-illness context.However, prayer is much more than merely a tool for promoting "positive religious coping".According to Ladd and Spilka, prayer is a way of connecting with the self, others, and the sacred [4].These connections can occur in a variety of ways.For instance, they concluded that in relation to the self, prayers may evoke deeply troubling concerns (tears) or they be more linked to broad evaluations (examination).Some people pray for others to receive support (intercession), or for themselves to actively become the support for others even though it will be a great challenge to endure (suffering).On occasion, prayers can be very forceful, stating one's personal position (radical), or requesting tangible forms of assistance (petition), while at other times, the prayers are seeking peace and stillness (rest).Still other prayers are often linked to traditional texts (sacrament) ( [5], p. 59).
In sum, prayer is multi-faceted and therefore will be useful to people in a wide variety of ways when it comes to dealing with difficulties, whether chronic or acute.In addition, the quality and conditions of the context matter because prayer can have both negative and positive effects; however, the multi-faceted negative aspects of prayer have been minimally explored with regard to coping [6].
To discuss more comprehensively the relation between prayer, health, and clinical practice, it is necessary to shed light on the varied roles of prayer in one's life and the quality of the relationships it allows one to establish.Thus, the discussion of this topic will be based on a study of the prayer experiences reported by 104 participants and will present several considerations regarding the relation between prayer, health, and clinical practice.The purpose of this discussion is not to delineate all the possibilities and/or risks of integrating prayer into the clinical context, or even to address the effects of prayer on specific health outcomes.Rather, the aim is to contribute to the theoretical studies on the psychology of prayer, taking into consideration what the participants themselves state about their prayer experiences, beyond the utilitarian question effects of prayer.
Initially, some aspects of the relation between prayer and health revealed by major studies on this topic will be discussed.Then, the results of the above research will be presented and, finally, some implications of the relation between prayer and health for clinical and pastoral practice will be indicated.In the concluding paragraphs, suggestions for further studies will be provided.

Prayer and Health: A Tenuous Relation
In a recent review of the literature about prayer and health, Ladd and Spilka [6] raised the question of why one should assume there is any relation between these two topics.The authors argue that the expected relation between prayer and health is ambiguous and certainly cannot be taken for granted based on any theological presumptions.From both a theological and a clinical perspective, there is not necessarily a consistently predictable relation between prayer and its results.Most religious traditions state only that the deities will hear the prayers, and no specific consequences, whether positive or negative, are absolutely guaranteed from the practice of prayer.Ladd and Spilka [6] caution that studies drawing the conclusion that there are positive relations between faith and health can have the unintended consequence of implying that those who do not experience positive benefits from prayer are somehow personally at fault; likewise it is imperative to avoid framing of the potential effects of prayer on health in terms of divine response, as this goes beyond the scientific nature of studies on prayer.These authors [6] also observe that studies correlating prayer and cardiovascular diseases, cancer, spirituality and health outcomes studies often failed to consider other variables that may have affected health outcomes not directly related to prayer, but relate to a broader context, such as lifestyle, work, etc.With regard to intercessory-type prayer and health in particular, the authors are adamant about the disappointing state of the literature.
The observations of Ladd and Spilka [6] and other authors [7,8] who have criticized the relation between spirituality and health are relevant.It is also apparent that the basic theoretical foundation of many studies is unclear (or not presented in any substantive fashion), just as the notions of health and prayer used in such studies often are unclear.
Given the above caveats, we believe that exploring the perceptions of practitioners on their own personal prayer experiences may represent a useful subject matter for further research.It may also support reflections concerning the possible implications of prayer in clinical practice.By delving into practitioner's stories, we may extract clues concerning how and why prayer is employed in dire circumstances.This approach will help us at least partially determine the extent to which the ideas of researchers and participants align.

The Practice of Prayer from the Perspective of Practitioners
The data presented here were collected between 2009 and 2011.A set of 104 participants, 73 women and 31 men, with an average age of 51 years (ranging from 17 to 79 years), mostly Americans, but also Latinos and Africans, residing in various regions of the United States were interviewed on video.As part of a larger study about prayer practices, participants answered the following request: "If you feel comfortable doing so, please describe in as much detail as you can do, one of the most powerful experiences you have had with prayer." The participants interviewed represented ten faith communities distributed as follows: three Roman Catholic churches (44 participants representing 42.31% of the sample), five mainline Protestant churches (43 participants: one Anglican church, one Presbyterian church, two United Methodist denomination churches, and a Seventh-Day Adventist church, totaling 41.35% of the sample), and two Pentecostal churches (17 participants from the Assembly of God, representing 16.34% of the sample).With regard to economic class, 9.5% participants belonged to the lower class, 24.2% to the lower middle class, 17.9% to the middle class, 21.1% to the upper middle class, and 27.3% to the upper class 1 .As for the level of education of the study group, only 1% reported having dropped out of high school; 10.2% completed high school; 25.5% attended but did not complete higher education; 6.1% completed technical school (two-year technical degree); 22.4% completed higher education; and 34.7% completed graduate school.
Based on the Content Analysis 2 [9,10], the material was organized into four categories to describe the use of prayer by these practitioners.For the participants of this sample, prayer was used as a spiritual tool to deal with suffering (religious/spiritual coping strategy; 64.5%); as an access channel to the sacred (discipline which keeps the spirituality alive; 15.3%); as a way of strengthening relationships (technique to promote mutual empowerment; 8.6%); and as a means of self-transcendence ("turning point" in the existential process; 13.4%).We next employed the Ladd and Spilka [6] framework to identify different ways of praying that were prevalent in each of these four categories.
Although the data presented here have been used in a previous study published in Portuguese by the authors [11], the current analysis focuses a different and not yet explored angle: the relation between prayer, health and its clinical implications.

A Spiritual Tool to Deal with Suffering-Prayer as A Religious/Spiritual Coping Strategy
Of all participants, 62.5% reported prayer experiences that characterize its use as a religious-spiritual coping method.Coping here refers to the behavioral and cognitive efforts to dominate, reduce, or tolerate internal and/or external demands originating from stressful operations [12,13].For example, Lazarus and Folkman [13] note that after a cognitive appraisal of a stressful event, people often have two major types of coping responses: emotion focused coping strategies or problem oriented coping strategies.
Pargament [14] applied the coping theory of Lazarus and Folkman to the sphere of religion, thereby creating the notion of religious coping.For this author, religious/spiritual coping refers to the introduction of sacred elements in responding to stressor events, in which religious coping methods can be "positive" or "negative".Positive coping encompasses a secure relationship with God, the belief that there is meaning in life, and the sense of connection with others.It consists of a pattern of the following positive coping methods: benevolent religious appraisal; collaborative religious coping; and a search for spiritual support, life transformation, etc.In contrast, negative coping is characterized 1 The American reference for the classification of economic class is as follows: lower class: annual income of less than $32,000; middle class: annual income between $32,700 and $45,000; and upper class: annual income of more than $45,000.The Content Analysis aims to critically understand both the sense of communications as well as its explicit and implicit content [9].Bardin [10] suggests three phases in the process of content analysis: 1. pre-analysis: where the material is organized in order to make it operational by systematizing the initial ideas; 2. material exploration: defining categories (coding system), identifying recording units (content), and identifying the context units; and 3. processing of results, inference and interpretation (moment of intuition, of reflective and critical analysis).by a less secure relationship with God, a fragile and threatening worldview, and spiritual conflicts in the search for meaning [15].
In situations when the practice of problem-focused coping is not feasible, (mourning, for instance), religious-spiritual coping assumes significant importance.
The current participants described experiences of profound stress and suffering and how prayer helped them face the following situations: divorce; the mourning process for the death of friends and family; various physical illnesses; family relationship problems; problems at work or unemployment; difficulty in forgiving; anxiety of various origins (situational or as an individual disorder); abuse; spontaneous abortion; and material needs.In this category, the types of prayer employed were those of Petition and Tears.The connectivity modalities that are benefited by this type of prayer are inward and upward.
Ladd and Spilka [16] identified the following content in Tears prayer: bereavement, loss, and agony, which are typical in situations of personal turbulence, characterizing a form of inward prayer to alleviate personal feelings of unrest and agony.In several interviews, participants reported that prayer was used as a successful coping method to deal with this sort of personal, intense suffering.Approaching God via prayer enables the transformation of emotion, especially in uncontrolled or irreversible situation, such as the death of a significant person and other similar situations.Through Petitionary or even Tears prayer, the participants describe their experience as the care and comfort received from God.
I have come to pray when a horrible, horrible, horrible thing happened to my family and it was going to get worse, as a result.And I went to the chapel at my church (…) where we have Blessed Sacrament exposed.(…) And normally you would spend an hour there.But it was my lunch hour and I couldn't work...and I went in there because I was just...it was such a horrible thing that happened...and it was so fresh that I couldn't sort through it yet (it had to do with my brother and different things that happened) and I went in there and-and knelt in front of the Blessed Sacrament, cause I knew there was nowhere else I could go…and just said "Lord, I don't have an hour.I have five minutes.That's all I have that you've got to take this terror away from my stomach, cause I can't function.I have a family and I have to work.I need help right now and I could just immediately feel it all just drain away.All of it drained away, and the situation did not change...which it wasn't going to, I just needed to be able to be present...so that I could function whatever way I was supposed to in this situation.And I'll never forget that, cause it was an immediate response.And I'm sure I've had immediate responses before.But I remember that one very, very, very, very well.The power of prayer (...) it's just the strongest there is (Female Participant 710123).
Several studies have demonstrated that in situations of poor health, one of the main religious coping strategies is prayer.In such contexts, prayer is not restricted to requests for restoring physical health.It is also used as a source of strength to deal with the suffering, as a coping strategy focused on emotion, as exemplified by one of the current participants: Almost ten years ago, I was diagnosed with breast cancer…and sitting in the surgeon's off-office, and-and he said to me: "Mrs.[X] your left breast is fine, but we found cancer in your right breast."...and I said to him: "don't say anything else to me, talk to him."My husband was with me, and I didn't say a word…from then, we got in the car, we drove home, he turned to me, and said: "are you alright?" and I flung open the door and I said, "hell no: I'm not alright!I have breast cancer!" and I went just tearing down our driveway (we live in the woods, thank goodness), I went out into the woods, and screaming and running around.I was an absolute crazy woman and at some point, I was: "you're alright.It will be alright."and you know, it wasn't a Pollyanna, kind of thing.There was...I heard the words, I felt the presence (…) that was, for me pretty powerful.(Female Participant 07086133).
The respondents reported using prayer not only when their physical health was impaired, but also as a way to maintain physical and mental health, as stated by this person: I believe my day-to-day life is guided by God.And if I miss a day or I don't talk to God, I feel like I'm lost.And most of the times, even when I'm going through problems, or frustrations, just like the experience of my father-it was more frustrating distress.You're angry, everything every emotion runs through you, you're not happy but uh, the minute I pray, it enables me to lift off and take the load off my shoulders and I feel relieved so I believe that every day, if I don't talk to God, even through (my experience) whether I'm happy or not, whether I'm sad or not, I'll be the most depressed person on Earth because I would not have anybody to help me carry through the whole thing or walk with me (Female Participant 07091636).
Such reports exemplify the use of positive religious coping.The participants have no doubts about the benefits of prayer in their emotions in daily life, and its use as a coping tool.Despite the fact that such situations are not modified by the practice of the petitionary-type prayer, or even when the person reports a lack of an immediate response from God, the benefit is perceived to be manifested as a change in the emotion as a result of the consolation.
However, prayer does not only favor positive coping.The interpretation of an answer to prayer may lead to a negative coping outcome, manifesting as the presence of some type of spiritual conflict: Well recently I asked God for something for some help, and well a year ago probably for some help and the direction I was going, and then I had a major life change and I think I've been upset ever since…so I'm trying to, to figure it all out, but I think it's connected and I'm trying to seek what it is.It was just the beginning I think, the changes that occurred, I think it's all related to my request.So.… (Female Participant 0710125).
Empirical studies show there is a strong relation between spiritual conflict and distress, including poorer psychological functioning and more debilitated physical health [17].The interview above indicates a spiritual conflict involving beliefs and feelings about God, such as anxiety and fear.Pargament [18] notes there are three types of spiritual conflicts: interpersonal, intrapersonal, and divine: "(a) interpersonal struggles involving conflicts and tensions with family, friends, clergy, or church around spiritual issues; (b) intrapersonal struggles that focus on internal questions and doubts about matters of faith, as well as intrapsychic conflicts between higher and lower aspects of oneself; and (c) divine struggles that involve negative emotions toward God, such as anger, anxiety, fear, and feelings of abandonment" ( [17], p. 265).
Although the example above indicates the presence of spiritual conflict as resulting from the use of prayer as a negative coping method, most practitioners reported decreased anxiety and improved overall functioning capacity.They also reported a search for more assertive behavior and the realization of a more meaningful life.

An Access Channel to the Sacred-Prayer as a Discipline to Sustain Spirituality
Rest-and Sacramental-type prayers (Sacred Traditions) are predominantly upward, directed toward a divine listener.Thus, in addition to a coping mechanism, prayer is a channel for connection with the sacred, a form of spiritual discipline with a view to spiritual maturity: When I pray I relax.It's important for me to relax my body so I can be more attentive...and so I can hear better...I do body relaxation meditation.I walk into complete darkness...and the darkness is the presence of God that surrounds me.So God surrounds me in the darkness (...) a powerful experience for lack of a better word...I'm enveloped by that mystery...and so darkness for me is not is a negative thing (Male Participant 0710167).
Ladd and Spilka [16] characterize the prayer of Rest as stillness, tranquility, serenity, and silence in search for connecting with the sacred.A total of 15.3% of the participants interviewed conveyed experiences that can be interpreted as having a purpose of spiritual connection: It's more like a daily thing for me though sometimes I forget…so it's like if I forget like something goes wrong…and I need to pray or something so, it is like I'm attached basically.That's like my way of more like comfort after...(Female Participant 07091631).
The German theologian, Heiler [19] states that the effort to strengthen, enhance, and improve one's own life is the reason that leads people to pray.For him, this is the reason behind all prayer, "but the discovery of the deepest root of prayer does not disclose its peculiar essence.In order to get to the bottom of this, we should not ask for the psychological motive of prayer; we must rather make clear the religious ideas of him who prays in simplicity, we must grasp his inner attitude and spiritual aim, the intellectual presuppositions which underlie prayer as a psychical experience" ( [19], p. 355).The theologian argues that the person who prays makes a vital spiritual exchange with the divine and that there are three elements that form the internal structure of the prayer experience: faith in a personal God, faith in his real immediate presence, and a real communion in which the person enters into relationship with God-conceived as a presence ( [19], p. 356).
For me prayer is communicating with God.So and-and after you connected with God spiritually,...has to have communication.In every relationship where there's no communication that relationship dies.Even a husband and wife, if the husband is not communicating with the wife, that relationship cannot hold.So it's the same with me and God, so if-if I stop praying, I feel that I have broken a relationship with my creator...and if I'm not connected with him through communication, I won't understand what he want to tell me to do on a daily basis…because I believe he made me and he has purpose certain thing for me (in my life), so I have to keep connection with God.So, prayer to me is being in connection with God, being communication with God...so I anytime I'm not praying, I feel that I'm not in communication with God, and that my life is on my own, and I don't want to be on my own.(Male Participant 07091637).
While the prayer of Rest is more personal, held in a private context, and allows for a direct connection between the individual and the sacred, Sacramental-type prayer generally, though not exclusively, occurs in the collective space of worship, and employs religious traditions to establish this form of connectivity.Some people seem to identify more with the structure, the teachings, and the environment the institution provides.As argued by Heiler, the prayer rituals, liturgical hymns, and the liturgical prayers that are commonly used by worship institutions are the crystallization of phenomena that formerly occurred in personal life, but may subsequently morph into an objective, impersonal, and routine form ( [19], p. 354).However, even in the most institutionalized form of prayer, as is characteristic of sacramental prayer, the individual frequently performs it with the clear intention to keep the spiritual dimension alive: I should say that some of the best-loved hymns of the church have had fragments that have had an impact on my own prayer life, in regard to confession and affirmation, and commitment, fellowship.(Male Participant 9091004).As an access channel to the sacred, prayer is also commonly practiced as a discipline to maintain personal spiritual health, with potentially visible downstream effects on general health as a whole.In addition to the absence of disease, health concerns the creative process of a meaningful existence and a life worth living.From this perspective, prayer is perceived by its practitioners as vital to maintaining healthy spirituality and in a continuous process of maturation.

A Way to Strengthen Relationships-Prayer as A Technique of Mutual Empowerment
For 8.6% of the sample, Intercessory-type prayer was the most significant prayer experience.Predominantly outward and upward, intercessory prayer is one of the most studied prayer types in the United States of America.Ladd and Spilka [4] cite four reviews about the link between intercessory prayer and health, concluding that "…the empirical evidence that intercessory prayer has an effect on the health of those for whom the intercessory prayer was held is minimal" ([4], p. 299).Masters and Spielmans ( [7], p. 332), advise researchers interested in studies on the effects of prayer on health to avoid this type of study and it likely that a substantial number of "file drawers" are filled with similar projects that failed to show significance and hence did not go forward to publication or presentation [20].
Moreover, from a theological point of view, intercessory prayer is inherently confusing.The theologian Vincent Brümmer [21] points out the dilemma brought forth by this type of prayer: a God who is perfectly good could not depend on the intercession of human as a necessity to exercise his benevolence.However, if one denies that the benevolence of God toward some person or situation depends on the intercession of others, what would be the point of intercessory prayer anyway?Even to argue that intercession somehow influences the otherwise independent action of God presents significant theological challenges: Why would one prayer influence God but another prayer not?A full discussion of this theological conundrum is beyond the scope of this paper, and we have noted in another study [11], "from the standpoint of physical health, this type of investigation could lead the researcher into a difficult situation.If we consider the self-reported appraisal on the benefits of intercessory prayer they point out the mutual care and empowerment as the greatest benefit they have from this intercessory prayer" ( [11], p. 647).
From the perspective of the participants who pray, intercessory prayer both enables the practice of mutual care and has an empowering effect on the parties involved, with a significant impact on the spiritual dimension.
Recently having a prayer time with one of my members of my church, and they were struggling with their uh terminal illness, struggling with their sense of prayer, and their relationship with God, and I remember having a moment where we were praying that if their condition could be reversed that would be what we'd pray for, that's what we would desire.But if that physical condition could not be changed, then their need FOR that healing to be changed, so that what we were really praying for is that if healing could happen, that's what we pray for, and if healing was not physical healing was not to come, then to be healed of the need to be healed.And I found both of us found that to be, powerful moment.(Male Participant 09091010).
As noted by Brümmer [21], intercessory prayer activates the role of cooperation of the believer seeking God's benevolence."God acts through the actions performed by us", states the theologian ( [21], p. 65).For this author, the person who intercedes on behalf of a person or cause stands available as a "secondary cause" through which God could act in answer to the prayer.In other words, "'intercession is a cooperation with that transcendent will of God which is none the less immanently at work in and through man's relationships with one another', and therefore involves both God and the petitioner as partners in realizing what is being asked."( [21], pp.65-66).Thus, for the believer, petitionary-prayer on behalf of others seems to be understood as a way to enter into God's purposeful activity [21].
Beyond just an individual context, "…corporate prayer is more effective than individual prayer, not because it brings more pressure to bear on God but because it enlists more people in the realization of God's will" ( [21], p. 66).One of the interviewees expresses himself in terms that are aligned with this type of understanding: I believe that prayer does work and it works much more in groups, sometimes, than it does individually, but it-prayer does definitely work.(Male Participant 09091003).
Another aspect expressed by intercessory prayer is empathy for the suffering of another.Consequently, prayer in favor of another does not only create bonds of fellowship among those who pray.It is, for its practitioners, a community access channel to the sacred: Just standing there with the family or without the family and praying for that person, I just feel like that it is bringing God closer to me, and closer to them even though God knows that they're there.(Female Participant 0710174).

A Self-Transcendence Route-Prayer as Turning Point in the Existential Process
This category consisted of 13.4% of the sample.The participants reported the following outcomes of prayer: Conversion, Calling, and Movement of the Spirit.The set of these three types of prayer characterize a phenomenon in the subjective process we can name as epiphany.From the Greek, the word epiphaneia means an appearing, a remarkable manifestation.The term has its origin in religion and refers to revelation-for example, the revelation to the wise men about the incarnation of Christ as son of God; the revelation of the Holy Spirit who descends upon Jesus during his baptism by John; the Pentecost (descent of the Holy Spirit reported in the biblical book of Acts); the work of the spirit in the process of awareness and recognition of the human being on its state of alienation from God.
The sense of epiphany is not restricted to the boundaries of the religious sphere and can be also found in secular contexts such as Brazilian literature.The term indicates a sudden moment of enlightenment, a new understanding, a new perception of a state of affairs, and a profound change in the subjectivity of those who experience it.Sometimes, such experience may be marked by a great spiritual distress.
The description of this experience by the participants in this study suggests the character of "occurrence" at the time of prayer.Unable to explain "how" or "why" this occurred, the participants realized such experiences as extraordinary or unusual.Referred to as "conversion", "calling", "glossolalia" (speaking in tongues) or as a "movement of the Spirit", these experiences have in common a sense of revelation, enlightenment, joy, hope, trust in God, or excitement.Above all, the individuals reflect on this experience as something that has no obvious initiative in their inner selves, or in their minds, but as something that comes from outside, from a more distant dimension and fulfill them, gives them direction and insight, gives them a new meaning and purpose in life.This experience is, therefore, understood as originating in the sacred dimension, as a divine initiative ( [11], p. 650).
Thus, the types of prayer described above feature a connection experience that is distinct from the previous (inward, outward, upward), as such initiative originates from an exogenous dimension towards the person who prays.For one who believes, Conversion prayer represents a return to God.It is the acceptance of salvation offered by God [It] is when I felt a need to pray to God for myself to forgive me for my sins and how that burden was totally lifted, so it's called conversion…Which you may be aware of, so to me that's the most powerful experience I've had when I knew that my life had been totally changed in a moment when God did what He promised to do...when I confessed my sins, when He forgave me for them and when they were thrown into the depths of the sea and when I didn't have that burden to carry around anymore and that truly gave me the lightheartedness, a pep in my step when I knew that nobody could ever down with anything from my past (Female Participant 07091243).
Prayer as a Calling is characterized by a belief in a divine calling to engage, and to devote oneself to religious work.
My daughter was six to nine months old.I was got into the habit of praying for her each evening...I always prayed for (...) God watch over her: help her to grow happy, healthy, and strong.One evening while praying that I heard the voice (...) "I have her, but I wanted you."And, that like, really scared me, but it was a very powerful experience, and, it was something that'll, stay with me for the rest of my days.(Male Participant 09091008).
The "Movement of the Spirit" type prayer refers to the strong experience that is revealing in character, whether or not accompanied the phenomenon of glossolalia (the Angel's language or speaking in tongues): (…)When I was praying, the Lord dropped me to my knees, the Lord dropped me to my knees.I wasn't gonna, I-I forgot all about that, um the Lord dropped me to my knees twice in that week, I didn't get on my knees just like that, the Lord dropped me to me knees and I mean, felt like an earthquake when He dropped me to my knees, I mean it was forced, I mean then I started crying out to God and I won't say what I said, I don't remember at all what I said, but just the Lord dropped me to my knees.(Male Participant 07091628).
It seems that the epiphanic experience of connectivity (described above) activates a sort of "mystical psychological function", in order to promote a sense of human unity with what one considers sacred.It triggers a subjective transformation process where participants report positive effects on spiritual and mental health.It marks a turning point loaded with deep meaning and purpose in life, joy, and subjective wellbeing-a discovery.The practitioners understand such experience as being part of a theophany (manifestation of God) in their existential process, and it becomes clear that the existential reorganization from such experience has effects on mental health and spiritual dimensions, especially when one considers the theological notion of health as advocated by Tillich [22].For this theologian, health has to do with healing and salvation.In this sense, health is a state of self-integration of the being with the ultimate foundation of existence ( [22], pp.408-23).

Prayer and Health-Implications for Clinical Care Practice
The analysis of the prayer experience from the point of view of practitioners leads one to reflect on several issues regarding the relation of prayer to health/illness, as well as its possible implications for clinical practice in its variety of contexts: medical, psychotherapeutic, or pastoral.

Need to Understand Health beyond a Biomedical Perspective
The main revisions in the literature about prayer and health [4,[6][7][8] indicate a lack of a consistent theory to sustain the quantitative research studies on prayer and health.It is often assumed that everyone knows what is being discussed when one refers to health and prayer.One forgets that such notions are always related to the current mode of knowledge construction.Presently, with the predominance of the biomedical model, "health is understood as the absence of disease, and health care, therefore, it focuses on disease, diagnosis, drug therapy, with an emphasis on the biological aspect, and with health management that reaches the sphere of a political government of life itself" ( [11], p. 634).An understanding of health that fails to take into account the environment, the family, social relationships, and the potential of the individual restricts the notion of health to the absence of symptoms and to the physical sphere.Winnicott [23], a highly influential British psychiatrist between the 1960s and the 1980s, assumes a notion of health as necessarily related to the maturational process and the ability of the person to create his/her own style.Tillich, an existential theologian who advocates a theology emanating from the process of existence, supports the idea of health as a process of self-integration of the being in all dimensions of existence (physical, chemical, biological, psychological, mental, spiritual, and historical).In addition, as it is socially produced, the notion of health is not static.Instead it varies according to the normative processes that define the normal and the pathological.In the biomedical model, one easily forgets that the dimensions of mental and spiritual health are as important as physical well-being and the absence of symptoms.In this sense, a clinical practice from a holistic perspective, as proposed Hefti [24,25], favors the approach of religious and spiritual matters in a more integrated manner.
Hefti [24] expands the three-dimensional clinical practice proposed by George Engels, the Biopsychosocial Model, suggesting the inclusion of a fourth dimension: that of religion and spirituality.Assuming that religion and spirituality influence both mental and physical health, Hefti argues that "the 'Expanded Biopsychosocial Model' explains that a holistic approach to mental health has to integrate pharmacotherapy, psychotherapy, sociotherapy and spiritual elements" ( [24], p. 612).The clinical application of the Expanded Biopsychosocial Model takes into account the spiritual history, the support for religious beliefs, and the practice of the spiritual care model (interdisciplinary and subject-centered care-with needs/spiritual resources).Hefti argues that religion can be a causative, mediating, or moderating factor in any biological, psychological, or social outcome, as exemplified by the physiological reaction to psychological stress ( [25], p. 121).In this sense, the author points out that one cannot overlook the potential influence of religion and spirituality on disease progression, the doctor-patient relationship, and the treatment process itself.Therefore, spiritual needs and conflicts, as well as the distress and resources of the patient, should be accessed by taking a spiritual history in order to integrate them into the treatment plan ( [25], p. 121).
The emotional and spiritual well-being practitioners experience through prayer is evident in the overall perception of practitioners regarding their personal health and well-being.In other words, the effectiveness of prayer does not necessarily reside in the positive outcome of a petitionary (or intercessory) prayer for physical healing.Healthcare professionals could better assist their patients, beyond the biomedical model, by considering religious and spiritual matters during the process of diagnosis and treatment.

Prayer Cannot Be Seen Simply as Complementary and Alternative Medicine for Improving Physical Health
From the practitioner's point of view, prayer is a spiritual tool used for spiritual purposes.However, even though its practice promotes mental and spiritual well-being, understanding it as "complementary medicine" is at least a misconception.Even in situations when Petitionary-type prayer is used, what is most important for the practitioner is not the divine response to the request made, but what it enables as a connection with oneself, with others, and with what they consider sacred.In other words, prayer is a means of transcending the physical world, not necessarily "fixing" it.Indeed, participants claimed that "prayer always works!"I pray more for good health and understanding, you know, (…) some good friends of ours lost a son thirty years old, you know, to cancer and, you know, you pray about those things.I feel that prayer is a conversation with God, and he does respond to us not necessarily immediately, and so you know, that's-that's just my life experience is a continual thing and again it seems to be tied into the health, it's how long are we here?You know, and prayer is sorta what keeps us-what keeps us going while we're here, you know so (....) (Male Participant 0710102).I was on massive drugs because of a back problem and could not get doctors to really address the issue, everybody seemed to think it was in my head until I finally found a sports-medicine doctor but that's way beside the point.When I was deeply involved in the drugs I felt unable to pray.Not because I didn't think God was there but just I couldn't-I couldn't get to that place inside of me where I had the assurance that God even heard me anymore...and I ask faith people around me to pray for me for that issue not for my health because that was even more important than my health to me.(Female Participant 0710177).
Studies that examine the issue of whether prayer works-in a solely biomedical perspective of eradicating disease-suppose an understanding of prayer that does not match the use of those who practice it.This discrepant understanding of the role and meaning of prayer should give pause to scholars regarding such investigations.As mentioned above, the studies on the effectiveness of prayer (especially intercessory prayer) with regard to effecting physical healing are not supported in a consistent fashion.Although prayer is known to be an influential factor in the overall health of practitioners, as can be seen in this study, its role as an alternative physical medicine lacks firm empirical support.The integration of a spiritual dimension into clinical practice is intended to provide better care to patients.This goal can only be met by developing a thorough understanding of the patients' perspectives.
Beyond the biomedical context, understanding prayer as a spiritual tool with a spiritual purpose requires a psychotherapist to position him/herself regarding matters related to spirituality and clinical practice.If the psychotherapist assumes that spiritual issues not only constitute the subject's subjectivity, but also affect his/her emotional and mental health, the clinic may represent a privileged space to investigate and work with the patient on the positive and negative effects arising from his/her spiritual-religious understandings.
For the pastoral counselor, it is also important to understand the way in which the individual uses this prayer resource in order to ascertain religious beliefs that lead to potential emotional and spiritual struggles, such as: "God has forsaken me"; "This is punishment from God."Such interpretations are typical of a negative religious coping style, which is characterized by spiritual conflicts and predicts symptoms of depression and anxiety [17].

Conclusions
The reflection on the relation between prayer and health and the implications for clinical practice leads one to realize just how much advancement is still needed in the studies on the topic.The practice of prayer is a living and dynamic reality in the existential process of the person who believes in God or some form of a higher power.It offers several elements that express the subject's psychic and behavioral functioning.In this sense, a consistent analysis of the experience of prayer described by the individual may indicate not only the healthy or symptomatic functioning of the subject, but also offer clues for clinical intervention and point out aspects to be addressed in the practice of holistic health care.
The volume of research on religiosity/spirituality and prayer, and their use in clinical practice, is still small [26].The present article only mentions various aspects, which deserve an in-depth investigation, with an aim to further our understanding of the religious experience of the contemporary subject, and to discuss the validity, necessity, and challenges involving the integration of religious/spiritual dimensions into health care and clinical practice.A key issue that warrants investigation is the development of theory-based intervention models beyond the biomedical model that consider the influence of spiritual struggles, attachment behaviors, and religious-spiritual coping, particularly in countries other than the United States and Europe.
Research on these topics, especially from an interdisciplinary perspective with the participation of experts in medicine, nursing, sociology, psychology, and theology, can contribute greatly to a more refined understanding of contemporary subjectivity and health care practices, as well as the way and degree to which the religious/spiritual dimension acts upon these processes.
Prayer can be a powerful spiritual resource available to health care professionals (psychologists, physicians, nurses) and pastoral counselors in the assisting of people who seek health care: "I'd be lost without prayer [...] peace and strength are two major things that I get from my life of prayer" (Female Participant 0710173).Listening attentively to the way a person who believes in a higher power experiences and recounts his/her practice of prayer is necessary for a holistic-care-based clinical practice.Prayer can be a means of expressing a person's psychological dynamics, as well as an ally in the process of clinical interventions that seek to use this important dimension of human life-spirituality-for the promotion of holistic health."Hearing the voice and feeling the presence" does not have to be a statement that is exclusively spoken by believers regarding their prayer experience; it may also be an expression used by health professionals and pastoral counselors when describing how they listen to their patients and feel their presence as a whole (in all its dimensions) in the exercise of a clinical practice focused on the affirmation of life and health processes.

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It's hard to say just one experience [Editor: constitutes prayer].Every Sunday I go to church and I receive communion.That's really powerful.(Female Participant 0710168).