Spirituality and Practice

I'm a Social Worker on a Palliative Care Unit and have been working with dying patients and their families for the past 20 years.  The average length of stay on our Unit is approximately 14 days, and we have over 200 patients die on our Unit every year.

Prior to working in palliative care, I never thought about spirituality, as part of my social work practice.   I don't remember it being discussed or explored during my undergraduate or graduate school education. 

I was raised in the Catholic faith, attended Catholic schools, and believed in a Catholic God.  For me religion and spirituality were one and the same.

Because I framed my spirituality within the context of religion, I felt that it was something 'personal' and that as a professional Social Worker, I should not discuss or share it.   I was very conscious of maintaining my objectivity and a professional relationship with my patients.  The Code of Ethics for the Ontario College of Social Workers and Social Service Workers emphasizes the importance of Social Workers distinguishing their needs and interest from those of their client, to ensure that, within professional relationships, clients' needs and interest remain paramount.

My strict interpretation of this made me uncomfortable discussing my spirituality or religion with patients who asked me about it.  I usually tried to redirect the conversation back to the patient, or suggest that I get our Chaplain to see them.  It wasn't until I began to work in palliative care that I realized that spirituality was something more, something that wasn’t limited by the confines of religion.  I learned this from my patients, who introduced me to a whole range of spiritual beliefs.

I came to appreciate and understand the spiritual context of social work and that spirituality affects all aspects of our life: the psychological, emotional, physical, and social.  I discovered that spirituality has to do with who we are as people, and our need to know that our lives have value and meaning.

Harry van Bommel (Family Hospice Care: Preplanning & Care Guide, 1999 page 153) said it well when he stated: “We are connected to each other as members of a living community.  Most of us share a belief in a power or force greater than ourselves.  We may define that force as nature, God or gods, the collective human spirit, the Creator, or a higher power”.

Our spirituality often comes to the forefront during a crisis, or times of distress, which is why you find it at the centre of the hospice/palliative care movement.

‘Spiritual’ is the only word that begins to describe the ”connectedness” I experience with a dying patient when I've had the privilege to journey with them and to share in the intimacy of their dying.  Helping a patient explore and express their spirituality can help them achieve a sense of internal healing or wholeness.  This process of spiritual exploration can provide a new sense of hopefulness and understanding, that allows a patient to die in peace.

Providing Palliative Care is a spiritual experience, particularly in its efforts to support and guide a Person's search for meaning.  The diagnosis of a life threatening illness inevitably raises spiritual questions regarding mortality, life after death, and the meaning of suffering.  Working as a Social Worker in palliative care, and dealing with death on a daily basis, has forced me to explore similar questions and to explore my own spirituality.  Questions like:

·        Who am I?

·        What am I?

·        Does my life have meaning?

·        What is my role and purpose in this world?

These questions touch upon intensely private thoughts and feelings, and the answers help us articulate an understanding of who we are at the very core of our being, our soul/spirit.

As Social Workers we can't tell the patient who raises questions about the meaning of their life, to "Hold that thought, while I run and get the Chaplain".  We need to be able to respond in a supportive way that reflects our focus on the whole person.

What matters is our willingness to be fully open to that person, and to accept them as they are, unconditionally.  If we are willing and able to respond in this way, the dying person is able to experience a sense of closure.

You don’t have to be a Chaplain to do spiritual counselling. Spiritual counselling utilizes the interpersonal and listening skills that we've acquired in our social work training.  It requires a comfort, and a willingness to be ‘present’ with the dying.  Listening to the story of the Dying Person can help them define their spirituality and what they need.  Every time we listen to another person's life story, we are involved in "spiritual caregiving"

When we provide spiritual caregiving, we are more than Social Workers, we’re ‘Healers’.  An important gift of the healer is to listen, to care and to be able to go into the dark, desperate places that some of our patients live spiritually.  The Dying invite us into spiritual encounters.  It is our willingness to enter into those encounters that constitutes spiritual care.

The patient who first invited me into this type of spiritual encounter was a man who was HIV positive, and had been admitted to our Unit to die.  This was in the 1980's, at the height of the AIDS crisis, and the beginning of my social work/palliative care career.

This patient had limited social supports in his life.  His family disowned him when he told them he was gay, and his partner had already died of the disease.  In obtaining a social history, and developing a therapeutic relationship, this man shared with me a tragic life of abuse and persecution.  He had been raised Catholic, and had attended Catholic schools.  He struggled with his homosexuality because the Church denounced it as sinful and inherently evil.  When he later contracted AIDS, he felt that this was punishment from God.    He worried that he would go to Hell when he died, and felt an incredible anger toward the Catholic Church.  In sharing his story, he sought my opinion on the spiritual issues/questions that he struggled with.

Given this man's feelings and issues with the Church I didn’t feel I could refer him to our Chaplain.  His spiritual conflict was intertwined with his psychosocial issues, and were not easily separated.  In addition, he had opened up to me and had put his trust in me.

This patient challenged my sense of professional boundaries.He invited me to connect with him as another human being, and at a spiritual level. I recognized that our relationship was at a pivotal point.  If I maintained my professional objectivity I would likely miss an opportunity to help this man achieve a sense of peace and resolution in his dying.  If I shared a part of myself and engaged in this spiritual encounter I felt I risked crossing a line in terms of my professional conduct.

I must admit that my personal outrage at how this man had been treated made it easier for me, but I still struggled initially.  I eventually shared with this man my belief that God is not a punitive God, and that he is a loving and forgiving God.  Some might argue that this was inappropriate and unprofessional but my efforts to reframe his view of God seemed to reduce some of his fear and anxiety.

I helped him discover a spirituality within himself that was not confined to the religion he had been raised in. A spirituality based in accepting and loving one's self.

Despite my efforts, I could not address his anger at the Catholic Church.  After much discussion, this man agreed to meet with a Catholic priest I knew who allowed my patient to vent all his anger and just stood there and 'took it'.  In the end this priest apologized for all the hurtful things that the church had done to my patient.  Although he wasn't personably responsible, this priest recognized that as a representative of the Catholic church, he needed to take responsibility for the emotional/spiritual pain that had been caused.

I'm convinced that the combined efforts of this priest and myself allowed this man to die in peace.  Had I not been willing to enter in this spiritual encounter with this patient, he may have died an angry, frightened, man.

This spiritual encounter and subsequent others have enriched my spirituality and in turn, enhanced my practice as a Social Worker

These encounters have made me more aware of the spiritual issues that my patients experience and with each encounter my comfort in journeying with the dying has increased. These encounters have also helped me realize the importance of continually exploring and nurturing my own spiritually. Given the multiple losses and spiritual pain that I deal with, I have learned the importance of caring for my soul to prevent, what Kelly Walker termed "loss of soul". I've learned to be aware of how and where I experience my spirituality, and recognize that I need to build it into my life, each and ever day.  I need to nurture it, and reconnect with it on a regular basis.

I believe that spiritual care lies at the heart of social work, and we need to acknowledge it's place in our practice. We all have a spiritual dimension, which we should not be afraid to explore and express.