Excerpted from: SPIRITUALITY AND OCCUPATION
SPIRIT AND OCCUPATIONAL THERAPY – SOME PRACTICAL ISSUES
Should occupational therapists be concerned with spirituality?
Studies by Blain & Townsend (1993), Enquist et al (1997), Taylor et al (2000). Farrar, (2000) indicate that spirituality is important for client’s health and rehabilitation, but occupational therapists are unsure how to address spirituality. Many occupational therapists do not feel adequately trained to address spiritually, and many feel spirituality must be addressed by clergy (Enquist1997, 173). Taylor found that most therapists feel that spirituality is a fundamental human aspect; spirituality influences health; disease and disability affect clients’ spirituality; and that knowledge of spiritual beliefs and practice is essential for occupational therapy practice (Taylor et al, 2000, 421). Farrar’s (2000) pilot study fundamentally corroborated this. Farrar states that occupational therapists are obligated to consider spirituality: “Occupational therapists must design treatment plants that are relevant to the client’s culture, values, morals and priorities,”(77). Farrar claims this is a matter or ethics as the occupational therapist has a fiduciary relationship with the clients and “is obligated to develop treatment plans that are meaningful and engage or motivate the patient’s spirit.” Urbanowski & Vargo (1994) state that “meaningful therapeutic activities are selected effectively when these address values which motivate the client’s spirit, thereby enhancing the possibility of return to independence.” Clearly therapists feel that spirituality is important, but remain uncertain about how to integrate into practice.
The following discusses some practical considerations towards grounding the therapist’s interest and concern about spirituality into occupational therapy work.
- Assessing spirituality
When we address the issue of “How important is this?” and ask the client about his perspective about a need or goal or role or performance area to be addressed, we are asking about the meaning of that to him/her. Therapists, simply by asking the question and inviting reflective response, may discover meanings of occupational roles or life activities. One OT assessment tool which includes this importance dimension, is the client-centered Canadian Occupational Performance Measure (COPM)(Pollock, McColl, Carswell, 1999). The client’s spirituality and religious life is perceived by Canadian client centered practice model as the basis for meaningful occupational therapy intervention. The COPM can be used for an individual or for a community or organization, i.e., a group of clients could have a shared occupational performance problems (111). In the COPM the client identifies the area of concern, not the therapist. Therapists who are more accustomed to the client centered model are more comfortable with this assessment tool, whereas those who are accustomed to working from a more professional driven model have difficulty using it (109).
A spiritual assessment tool which is brief but which generates “spiritual” information helpful for healthcare (non clergy) workers, is a tool introduced by Christine Pulchalski MD (2000). Called by its acronym the FICA, it provides 4 questions, which cover areas of:
Faith (What do you believe in that gives meaning to your life?);
Importance/Influence (how important is your faith–or spirituality–to you?);
Community (are you a part of a religious or spiritual community?);
Address/Application (how would you alike me to address these issues in your health care?).
Dr. Pulchalski stressed this takes only a few minutes, and can reveal a wealth of information. These questions are brief in the asking but usually generate helpful responses to patient and therapist. While the questions are asking about faith practices, the therapist can ask the question about roles and experiences. E.g., what is it that you do, or what is the role that you have, that is most important to you, or that troubles you in light of the current disability? Other spiritual health care assessment options are described and highlighted by Dr. Harold Koenig (2002).
In psychosocial, mental health, wellness and health promotion program settings, time and presence may be dedicated to spirituality through self-reflection and discussion process. In Wellness and Lifestyle Renewal: A Manual for Person Change, which Rosenfeld (1993) says is written for “the worried well,” he offers a self-reflection process that can be used in community based health promotion programs. Questions require client self-assessment of physical, emotional, mental and spiritual being. Exercises clearly stimulate reflections of a spiritual nature. The facilitator as well as the client may feel drawn into wellness programs discussions where more of a partnership and equal footing relationship is established with clients.
- Accessing Spiritual Meaning—Life History Approaches—the Use of Narrative
Narrative is a suggested way to access spirituality in our clients. Narrative refers to a telling of a story, of describing life experience with all its meanings. Many recent professional articles discuss the use of narratives in therapy (Clark, 1993; Frank, 1996; Helfrick & Keilhofner,1994; Larson and Fanshiang,1996; Peloquin, 1993; Spencer1996). Kirsh and Welch (2003) discuss at length the number of way in which narrative captures spirit:
“Narrative is a soul-searching, meaning-making process through which life’s values and lessons can be realized and expressed.” Within the occupational therapy process, “eliciting narrative, or facilitating the ‘emplotment’ of one’s life, is an approach directed at the individual as a whole—his or her feelings, thoughts, perceptions and beliefs—rather than the pathology itself. It places the narrator or client at the center of the process, empowering self-expression as he or she chooses” (p 175).
Addressing the client’s spirit means to understand and discern the meaning in the client’s story. This require interactive clinical reasoning skills such as active listening, authenticity nonjudgmental observation, perceiving the client’s story” (Mattingly, 1991) and presence, i.e., the therapeutic use of self. Clark et al (1993) describes occupational storytelling as a powerful therapeutic tool that enables people to weave together the themes of meaning that are salient within their lives and possibly use this process of reflection as a springboard for envisioning a future they wish to secure.
This writer worked for several years with clients from a specific section of urban Philadelphia in a state psychiatric hospital. Multiple problems brought these clients into the state mental health system including poverty, learned attitudes, joblessness, jail sentences and drug use as well a mental health problems. In our group sessions and community meetings, there was often a group identity or story that had “an urging” to be told. These stories were doorways to understanding what was really important for the group. Finding or allowing ways to bring these stories to expression, was a relationship step of great value. So much energy went into the telling of the story, the sharing with staff and others, that the importance of this for the storytellers was obvious. That we listened and heard, made a difference, and a trusting and healthy relationship was formed. Eliciting and hearing the story can be facilitated by the use of projective methods, employing arts and crafts, as follows.
- Use of Projective Approaches and Creative Activities
Projective techniques and creative activities can be used to stimulate the client to tell his story, revealing psychological and emotional dynamics and often issues of spiritual meaning. In both her mental health OT practice, and in community wellness work, this writer has found the use of creative artistic and musical activities helpful in engaging clients in spiritually reflective discussion. Activities such as mandala making, pinch pot clay, mask-making, leather tooling, journaling, poetry, plant growing, flower arranging, song-writing and many others, can be used to enable conversations about oneself, including sharing of meaningful life experiences and issues, within a group and aided and bolstered by the group. Guided or free association of thoughts accompany these activities, e.g., “imagine the mandala is a picture of you…what is it saying?” Projective activities not only enable rumination about the conscious self, but also tap the imagination and subconscious and spiritual part of man. Swarbrick and Burkhardt (2000)
Note that “certain media have symbolic or transcendent component such as art, humor, music and nature activity and may support communication on a spiritual level.”(2).
“Creative” may refer more to a way or process or style rather than a specific activity. Toomey (in McColl (Ed.) 2003, 183) says “creativity itself is not an occupation; rather, creativity is how an occupation is pursued or performed.” Making a meal or gardening can be routine tasks, but preparing a meal for a guest or special occasion or creating a landscape is creative. Creativity can be described as a playful process, with ingenuity, imagination, new associations and arrangements in the discovery of new ways to doing things, even problem solving life’s problems. Therapists can put together an environment that invites creativity. Hasselkus (2003) discusses the surroundings that support creativity: “one’s physical environment acts like a birth mother, providing the host entity and sustenance that enable creativity to be born and to flourish.” (117). Such an environment can provide an “optimum fit” for the individual or the group. The social environment also affects the likelihood of creativity to happen, e.g., some workplaces do not reward thinking “out of the box.”
Some activities, such as the opera mentioned in the beginning of this paper, allowed for the group stories loaded with spiritual meaning for the children, to be expressed as the obvious (written, acted, danced) content of the activity. The more subtle therapeutic aspects of the activity (e.g., having a significant role, importance to the group, esteem, contribution, pride, cooperation, friendships, accomplishment, group esprit, having fun) were also important and meaningful, inspired by and part of the creative process and the creative doers. The task and setting, social and physical, invited the creative process to happen. When novel, appropriate and useful to the task at hand, creativity is felt to be inspired, which is to say, infused with spirit. While we cannot guarantee that creative occupation will happen, we can offer an environment that supports creativity and provides fertile soil for inspiration and healing to take seed.
- Respect Rituals and Faith Practices
Ritual is a means by which activities and symbols with spiritual purpose are shared and celebrated by community or family. Rituals involve occupations laden with spiritual meaning that may be supportive of health and may included in the occupational therapy process. An example might be the occupation of a wedding or holiday celebration, or a prayer liturgy, such as a candle light prayer vigil, or use of prayer rugs, prayer beads or healing practices of a certain form. If the client offers invitation to his spiritual practice (which in this case is also a religious practice), and if the therapist is comfortable to do this, this can be of very health affirming impact. Responding to an invite to be part of a spiritual or personal or community religious practice is a positive action and respects the client’s meaning and importance he holds for that ritual. It may support his hopefulness and recognize his need for attention to spiritual caring; it also may convey respect to his family, culture, religion and community. Music, dance, art, food choices and ways of preparation, dress and adornment, may be part of this. In a setting which is home or community for those living with a certain disability, or a for which there is community felt identification, respect for these meanings opens doors to trust and communication.
- Healer: Heal Thyself
There is abundant discussion of therapeutic relationship, the art of therapy and use of self is the primary mode of reaching out, caring for and inspiring others in occupational therapy literature. (Egan and Delaat, 1994, Urbanowski & Vargo, 1994, Peloquin, S (1993), AOTA,1995), Swarbrich and Burkhardt. 2000). Sulmasy (1993) in The Healer’s Calling, addressing healthcare professionals, discusses some aspects of spirituality on the therapist’s or healer’s side of this relationship. “The therapist as a ‘healer’ in his spiritual depths longs for a sense of transcendent meaning in their own work, and a consideration of the spiritual aspect of care with their patients.” Effort on the part of therapists to clarify and cultivate their own spirituality will be of benefit to clients.
Therapeutic presence is the capacity to enter into “fellow feeling” and interact from the space of genuine shared emotion (Davis 1997, 10). To do this, a therapist needs to be self-accepting, self-forgiving and self-affirming: this is the basis of compassion. “Fellow feeling” is conveyed by compassion, by one who understands by virtue of his being a co-suffering and still–in-process-of-healing human being. A client who feels accepted and understood is empowered. The therapist learns and feels from him what are his hopes and dreams, his fears and his shortcomings, in consideration of the reasons he came to us. Working from the heart, the therapist works not in a problem orientation, but rather in a whole person orientation: the focus is on the client and what he tells us is important for being and for function, for quality of life, within his story, considering his past history and his future hopes. Our purpose is to help him go forward, building on the strengths that he brings to the challenge before him. We offer therapeutic presence, and we offer compassion, as well as knowledge and skills in the relationship.
The clearer we are in our own process, the more whole and authentic we can be in our relationship with our clients. This involves clear intention, self-awareness and reflection in personal process, competence, experience and maturity.
- Whole Person Focus—Maximize the Positive
Spirit builds in strength when surrounded by the energy of care, encouragement and optimism of others, engendering hope within our clients. We affirm, build on strengths, maximize the positive, and create a positive environment. Our focus is on the client, his important life roles, his strengths, his hopes and desires. We offer experiences, exercises, and activities for adjustment, growth, adaptation, healing, development and change. In wellness programs, we offer complementary therapies that are now occasionally seen in hospitals as well. For instance, we suggest that clients make time for “Affirmation Breaks” during the day to uplift the spirit. These positive thoughts and feelings can be introduced through inspirational stories, imagery, imagery with music, visualization, hypnosis and other means. These positive repetitions or images of desired states of being are constructed or selected just for the individual and can be part of “relaxation breaks” suggested below, Through mechanisms understood through PNI research, positive changes in self esteem, attitudes and beliefs take hold at subconscious levels, which ultimately impact on the immune system, and the body, emotions and mind,
- Promote Living A Healthy Lifestyle
Occupational therapy, with its emphasis on quality of life and the activity balance of self- care, work, leisure, rest, can assume the driver’s seat in promoting the healthy effects of balanced and satisfying lifestyle. (See Wellness is a Way of Life, Appendix B).
Mind/body/spirit are interconnected. Making healthy lifestyle choices, including nutrition, exercise, balance of work and play and self-care, relates to spiritual as well as physical, emotional, mental and relational health. Making healthy choices is “work” for those who have perhaps developed habits and patterns that have contributed to disease or disability. Occupational therapists offer education to help clients become aware of the need for change, and offer options, activity choices, opportunities, group experiences including inspiring testimonies, to help the client “do the work” of the change of habits and patterns of a lifestyle. Group or peer support is powerful tool of lifestyle change. Heart-resonating stories of the group members can inspire listening clients and help them make positive changes. Sometimes therapeutic roles include teaching, modeling, coaching, partnership, facilitating the group, creating environment for change, or positive regard. Linda Gutterman (1990) in her work with persons with AIDS in the Village day treatment program, states that occupational therapists can stimulate, or inspire, the client towards self actualization and insight by teaching or providing opportunities for learning and self-healing techniques (236).
Essential to lifestyle wellness and mind/body/spirit health is the “relaxation response” (Benson, 1996). Relaxation is stimulated through many complementary healing methods and options, including yoga, qigong and pilates, bodywork and biofield therapies, nutritional and spiritual practices such as prayer and meditation. Essential oils and flower essences have beneficial effects and may be of interest to some. Time in nature and ways to manage stress within a daily routine are important. For some, it requires only a reminder to resume favorite activities (avocations) which have been forgotten in the quickened pace of everyday living. Relaxation “time out” breaks in a daily routine can benefit the whole person. Providing wellness education to groups often engenders enthusiasm and peer support for lifestyle modification as well as furthers and bolsters the individual’s perseverance with initiated changes. Ultimately the responsibility for making health lifestyle choices and doing the “work” remains with the client, but we educate, create the climate, set the positive tone, and provide support in community and relationship.
- Bring to Others Awareness to The Relationship of Health and Spirit
While spirituality is gaining increasing attention in healthcare, there are hospitals and clinical settings which eschew spiritual practices. This is old behavior passed down from the era of separation of spirit from medicine. There is need to educate to bring about desired change. This is not a neutral area. For example, many counseling therapists are apprehensive when it comes to “discussing God” with their clients. Yet, a recent Gallop (1993) poll found that nearly two thirds of American surveyed said they would prefer to receive counseling from a therapist who is religious. This means we must consider the meaning of the therapist’s spiritual affiliation or practice to the client. Clients are seeking consideration of their spiritual needs. The meaning and impact of this in psychotherapy and mental health practice is also receiving more attention as the importance of spirituality is increasingly realized.(Kahle & Robbins, 2004). Books mentioned in the above section on Spirituality and Health by Harold Koenig, Jeffery Levin, Dale Matthews are good choices for imparting this information to healthcare audiences.
- The Call to Deeper Meaning
Illness can be a wake-up call to spiritual life. Spirituality helps people cope when living with illness or disability. A person may undergo a change from the experience of an illness and be propelled into spiritual growth. Life can be seen as a spiritual journey with the meaning of illness and loss as part of that journey. McColl (2003) explores six different spiritual perspectives on disability, derived from the literature and from her original research on the interpretations and meanings of illness to clients. These perspectives include: disability as an expression of divine will, as an opportunity for redemption, as a mission, as punishment for sin, as a reminder of embodiment, as a condition of life. Disability is also seen as an opportunity for spiritual change, reconciliation, transformation, and a call to higher consciousness or deeper meaning. (McColl 2003, Ch 2, 19-30).
In Living with Illness or Disability, Gutman (2005) addresses the heart of the matter. She tells the story her own father’s response to a lengthy but terminal illness when she observed him to change meaningful ways. This led her to view closely the life stories and personal narratives of occupational therapy clients whose lives were transformed by the experience of illness, and to glean from their stories common spiritual themes, or “lessons.” Perceiving life as a spiritual journey, experiencing self acceptance, learning compassion, are among the ten themes that emerged. Gutman offers a blending of eastern and western practices, ways of thoughtful refection, to help clients and therapists find spiritual meaning, to hear the messages of illness and through compassion, to be able to help themselves and others in positive ways.
Everyday Heroes relates true life stories of how tragic events and life challenges within the lives of young people in troubled school or family circumstances provide stimulus to life style change, including vocational choices and occupational roles. The obstacles include poverty, racism, abuse, neglect, illness, drugs and violence. These everyday heroes, coming from unfortunate life experiences serve to inspire and make a difference for others through their stories of courage, heart, hope, determination and “inner fire.” (Johnson, 1996).
In the midst of challenge or disability or misfortune, we can help a client take a bird’s eye view of life, asking themselves some questions about meaning and importance. Perhaps courage, hope, steadfastness, trust, goodness, love, contribution, beauty, patience, family, kindness, gentleness, joy, peace, gratefulness, simplicity, sharing and other such qualities come to mind. If life and all its challenges are a spiritual journey, maybe these are the deeper spiritual meanings it is all about. A deep spirituality, whether religious or not, gives courage and strength and meaning, and enables transitions, even that of death.
- See and Affirm the Spirituality of the Community.
Be ready to see and to utilize the therapeutic benefits of spiritual community. Meyers (1993) discourses on the benefits of such community: caring, helping one another to cope with losses and struggles, providing a framework of hope, delighting in others’ conditions—to rejoice or to mourn together. Community offers a deep sense of purpose—attachment to something larger than oneself and broader sense of life’s purpose and impact on self and others. One’s community offers ultimate acceptance and this can be love or acceptance despite shortcomings; community sets the stage for giving, encouraging and supporting others; and for faith and hope. Spiritual (and religious) community may be a significant strength when addressing community health and wellness issues such as we see in poor, urban and troubled neighborhoods. Church, synagogue, school—wherever there is heart felt community center—may be considered as potential settings of “optimal fit,” identification and trust.
- Other Traditions Healing Occupations: Can we learn from these?
This writer has been involved with holistic health and wellness practices since 1994. During this time, I have been exposed to the richness and variety of healing rituals and occupations in other cultures. For instance, medicine wheels, sound chambers, sweat lodges, dancing, drumming, chanting, sand paintings, labyrinth walks, nature walks, ancestral feasts, and candlelight vigils are all part of healing which is a most significant human occupation. Many cultures openly embrace spirituality as part of healing. Healing occupations express individuality, family, culture and meaning through symbol, activity, ritual and work. There is much about holism missing in our western health care. There is so much more that we could do, if holism was our guide, and these healing and spiritual occupations were embraced as part of what we do.
There are some exceptions to this absence, of which I will mention a few:
The Chalice of Repose Project (initiated at St. Patrick’s Hospital in Missoula, Montana) offers a way for a dying person to be held in sacred space. Music thanatology, offers whole “contemplative” presence, harp music and chanting, prayer and ritual. This approach derives from eleventh century monastery infirmary practices. Remarkable, almost miraculous changes occur, such as marked pain relief without morphine as well as emotional, mental and spiritual release (Schroeder-Sheker, 1994). This writer has seen added to this, spiritual healing practices of touch, anointing with sacred oils. This healing occupation of care of the dying holds in sacred space the whole human being.
The Prison Ashram Project (in connection with the Human Kindness foundation) is a prison-based spirituality program that addresses the spiritual needs—and whole needs, mind/body/spirit—of prisoners, even those on death row. Here lifestyle is altered, spirituality and meditation become part of daily life. Expressive artwork and letters tell prisoners’ stories and meanings derived from this insertion of spiritual activity. (Lozoff, 1984).
Religious groups have spiritual practices that are specifically healing, such as the Kabalistic healing of immanence and Christian laying-on-of-hands. These we rarely see in most hospitals, but just as complementary health practices are coming in to healthcare, we hope to see the opportunities for individuals to experience spiritual healing practices that are their religious choice.
A beautiful holistic healing artful expression of spirit is the AIDS memorial quilt which is created by loving and caring hands, shares a mourning and grieving process, offers heart felt messages from friends and family, supports community education about AIDS, and continues over many years to grow and reach out to others. http://www.aidsquilt.org
A program does not need to look “spiritual” to be spiritual. A striving or behavior that is accompanied by motivation, energy, emotion, meaning, endurance of suffering, hard work or perseverance, may very well be “spiritual.” Realizing one’s potential, developing one’s innate abilities, is a spiritual quest for therapists and for their clients. Expressing and utilizing talents and sharing gifts in the service of the world—i.e., manifesting our own spirits in our work for the benefit of others—is a quest of deepest spirituality.
Spirit ultimately flows into the clay pot, writes the poem, toils in the vineyard, goes to work every day, and puts food on the table. Spirit is grounded by occupation, like a lightning bolt piercing from heaven to the earth. It makes all the sense in the world for the occupational therapist to develop the vision to see the spirit within the mundane, the energizing force behind one’s own call to duty, and the call to heart.