The Practice of Spiritual Health Therapy--Definig our work and profession

Defining the Practice of SPIRITUAL
HEALTHTHERAPY
Advocating for
ourWork and Professional Practice
VenerableThom Kilts, MA/MDIV, CPETeaching Supervisor,William Osler Health System

WHAT IS SPIRITUAL HEALTHTHERAPY?
WE START WITH DEFINING WHAT “SPIRITUAL” MEANS:
• Spirituality has been defined as the beliefs and practices that develop people’s
personal values and concept of meaning.
• THREE COMPONENTS: 1) making personal meaning, which may or may not be
connected to an “ultimate source.” 2) coming to an understanding of self. 3)
appreciating the need and value of connections to others.
• Spirituality is more properly connected to the meaning a person attributes to living,
while religion refers to the ways a person expresses their spiritual awareness or
journey. Spirituality speaks of inner meaning and a person’s place in the world,
while religion speaks of the rituals, practices and beliefs of a particular religious
group.

“SPIRITUAL” Defined--CONT:
• Spirituality is the life force that awakens us: to wonder, to community, to trust, to
hope, to healing.
• Informing us about: our identity (who I am?), our place (where do I belong?), our
purpose (why I am?) our values (how do I live well?).
• And inspires us: to be creative and responsible, to build mutually beneficial
relationships, to cope with change and loss courageously, to invest in the good of
all.
• Spiritual health care involves a recovery of the patient as a person, upholding his or
her beliefs and experiences and addressing matters of meaning and hope...As one
person in the service of another; spiritual health care is therefore literally
therapeutic and not an attempt to impose, intervene or control.

“SPIRITUAL” defined CONT:
• As authors of Making Health Care Whole state:
“A human being is a spiritual being. When injured or ill, human beings naturally
ask transcendent questions about meaning, value and relationship. If providing
holistic care is a moral duty, then that duty extends to the spiritual as well as the
physical. Therefore, attending to the spiritual needs of patients (persons) is not just
a moral option, it constitutes a moral imperative.”

WHAT IS SPIRITUAL HEALTH?—Well, this is what it isn’t...
• Spiritual distress, spiritual despair or spiritual crisis occur when a client is
unable to find sources of meaning, hope, love, peace, comfort, strength, and
connection in life or when conflict occurs between their beliefs and what is
happening in their life. The opposite of this of course could be called spiritual
health....
So......
• Spiritual health is deeply personal and resides in an individual’s deepest fears and
aspirations (which lies at the core of a patient’s ability to participate in one’s care).
• Spiritual health is not necessarily about patients having hope, as hope here is not
the same as having a “positive attitude.” Vaclav Havel stated: “Hope is definitely
not the same thing as optimism. It is not the conviction that something will turn out
well, but the certainty that something makes sense, regardless of how it turns out.”

Manifestations of Spiritual Distress,
Emotional Conditions
• Spiritual Health Therapists (SHT) involvement is recommended for a person in
whom the stress of physical or mental illness, trauma, loss, or situational hardship
(e.g. incarceration) has resulted in a diminished capacity to cope. This may be due
to, or result in, impaired access to their internal resources such as hope, acceptance,
trust and the will to live. Common manifestations of this condition are existential
angst, guilt (false or real), anxiety, depression and the presence of other forms of
emotional suffering/spiritual malaise.
Cognitive Conditions
• SHT involvement is recommended when a person expresses difficulty in making
sense or meaning while utilizing their religious or philosophical framework and, as
a result, experiences a thought-related disorder such as cognitive dissonance, idée
fixe, perseveration or rigid thinking.

Relational Conditions
• SHT involvement is recommended when people experience ruptures in
communication or estrangement between themselves and significant others or
experience enforced periods of isolation. SHTs may be particularly and uniquely
helpful when the presenting issue is related to existential/spiritual issues (e.g. an
inability to discuss death and dying) or involves strong feelings of offence, guilt
and/or shame.
Psychological/Psychiatric Conditions
• SHT involvement is recommended for a person in whom there is a diminished
capacity to work with nuanced distinctions between reality and delusion, truth and
belief, and faith and facts. A person having such a crisis of belief may manifest
with religious delusions or cognitive conditions which exacerbate symptomatology,
increase their experience of suffering, and/or impede treatment.

Substance Abuse/Addiction
• SHT involvement is recommended for a person whose use of substances or
behaviours has created conditions which interfere with their own and/or others’
quality of life. SHTs may be particularly helpful when people are starting to look
at emotional triggers and other reasons which predicate their actions (motivational
Interviewing); when people are seeking to (re)establish spiritual connections and
practices which support their aspirations for change; and when people are dealing
with issues of guilt, shame, and hope related to times of relapse during the recovery
process.

Situational Conditions
• SHT involvement is recommended for a person who experiences spiritual, moral or
existential distress due to a crisis related to a trauma directly or indirectly
experienced. Such traumas could include witnessing the death of a loved one,
having a miscarriage, being incarcerated, or any similar event which is experienced
by the person as a specific assault on their sense of security based on their view of
how life is or ought to be.
Compliance/Cooperation
• SHT involvement is recommended for a person who is non-adherent with or
refusing treatment, especially if the person is appealing to cultural beliefs,
entrenched personal values or religious practices as the basis or justification for
their behaviour.

WHAT IS SPIRITUAL HEALTH?
• The psycho-social model presented by De Jager Meezenbroek called the Spiritual
Attitude and Involvement List (SAIL) supports the idea that spirituality is a shared
universal human experience for all.
• Meezenbroek points out that the most essential elements of spiritual well-being or
spiritual health are connectedness and occurs in three areas:
1. connectedness with oneself (Self Awareness); 2. with others and with nature
(Interpersonal Awareness); and 3. with the transcendent (Spiritual Awareness).
• Developing direct and authentic expression in each area (Three Awarenesses)
creates “spiritual health.”

• The psycho-social model presented by De Jager Meezenbroek called the Spiritual
Attitude and Involvement List (SAIL) identified activities related to spiritual
health:
14 Activities/and or Attributes/Characteristics that are defined as Spirituality or
signs of Spiritual Health-
• 1. Meaningfulness; 2. Authenticity; 3. Inner Peace; 4. Trust and Surrender; 5.
Coming to Terms with Suffering; 6. Inner Power; 7. Awareness of the Present; 8.
Appreciation of Life; 9. Wonder and Affect; 10. Connectedness; 11. Servitude;
12. Higher Power; 13. Spiritual Activities (prayer, meditation, ritual, worship
etc.); 14. Transcendent Experience

• Remember: Meezenbroek’s elements of spiritual well-being and connectedness
occur in three areas: connectedness with oneself (Self Awareness); with others and
with nature (Interpersonal Awareness); and with the transcendent (Spiritual
Awareness).
• Any area (awareness) in a client’s experience that is blocking, repressing,
suppressing or obscuring the 14 activities attributed to spirituality and/or spiritual
health is of course a “problem” that can be addressed.
• If the three areas of spiritual well being/connectedness (awareness) are obscured,
blocked, repressed or cut off--as well as any obstacles to a person’s desire or ability
to engage in any of the 14 activities then there is spiritual despair, spiritual crisis
and/or a spiritual “problem.”
• The “problem” of course is only ultimately “solvable” by the client him/herself.

WHAT IS THERAPY?
• Therapy (often abbreviated tx or Tx) is the attempted remediation of a health
problem, usually following a diagnosis. In the medical field, it is synonymous with
treatment (also abbreviated tx). Among psychologists and other mental health
professionals including psychiatrists, psychiatric nurse practitioners, and clinical
social workers, the term may refer specifically to psychotherapy or talking
therapies. The English word therapy comes via Latin therapīa from Greek:
θεραπεία and literally means "curing" or "healing".
• In healthcare the term therapy is related as well to the treatment of a specialized
profession for example: Respitory therapy, occupational therapy etc.

WHAT IS THERAPY?
• A spiritual health therapist is a “specialist” trained and skilled in assessment,
intervention as well as working with differing aspects of the SAIL activities, related
to differing expressions of spirituality in all its various forms---and understand its
relation to health outcomes.
• This means, that to be a “religious leader” is not a sole ”qualification” for a SHT.
The focus for a religious leader is the community and tradition of which he/she
represents and it cannot be assumed that this “qualifies” a person to be able to
understand “spiritual health” or be able to provide a “therapy” to the varieties and
complexities of all patients in the healthcare environment. However, Religious
leaders can be a part of the therapeutic process of spiritual health therapy if and
when requested /consented by the patient as a part of their movement toward
spiritual health (eg. Sacraments, prayer, ritual, confession etc.).

WHAT IS THERAPY?
• To understand the role of “therapy” in spiritual health, a professional needs to
understand the development of the “problem” that needs “treatment” in order to
assist a client in a way that positively impacts the health outcome.
• To understand the obstructions to “spiritual health” that a client may be
experiencing, the SHT has to use therapeutic interventions. There are three basic
categories of intervention and within each there are varieties of approaches:
Support, Clarification and Confrontation.
• Then there is the application of “treatment” which comes from an intent to
“cure/heal” but the therapist knows the outcome or effectiveness of a “treatment” is
in the hands of the client. Treatments in spiritual health have a broad range but
usually involve exploring one or more of the three awareness areas which can mean
exploring the SAIL activities (refer to above slide) with a client (or arrange for the
client to have access to one or more of the SAIL activities).

WHAT IS SPIRITUAL HEALTH THERAPY?
Therapeutic Interventions and Functions
Relational Approach
• SHTs operate with a person/family-centered approach to assessment and care that
sensitively encounters the other and engages them in their healing process. In
addition to providing a context within which core beliefs, values and concerns can
be shared, the SHTs respectful acknowledgement of the other typically has an
intrinsic therapeutic value by affirming their basic worth and dignity as a human
being.

Spiritual Assessment
• SHTs conduct assessments that evaluate the emotional and spiritual needs of
persons who voluntarily seek care. Such assessments include identifying the care-
seeker’s sources of spiritual strength, hope, coping methods, needs, risks and
wellness goals by using communication strategies that include empathic listening
and reflection, i.e. that demonstrate authentic compassion and empathy. The
assessment requires both a non-judgmental validation of the client’s emotional and
spiritual experience and an appreciation of the client’s world view informed by
historical, theological, philosophical, socio-cultural and psychological
understandings of human development and transition.

Collaborative Care Planning
• SHTs seek to assist the client/family to identify and articulate personalized goals
and objectives that not only are appropriate to the situation but complement and are
integrated with the inter-professional care plan. The SHTs ensures planned
interventions are based on an informed therapeutic approach, realistically match
available resources, and are delivered in a timely fashion.

Spiritually Focused Support
• SHTs assist persons to access resources such as those found in the wisdom of the
care-seeker’s own spiritual tradition in order to foster hope and inner strength.
SHTs facilitate the person’s exploration of the role and function of their
spiritual/religious identity; assist the person to (re)define a sense of meaning or
purpose in life; and foster experiences of relational connection and community.
SHTs provide or facilitate prayers, rituals, instruction, ceremonies, sacred texts,
directed meditation, etc. in service of the other’s authentic, creative and responsible
expressions of spirituality.

Spiritually Focused Therapy
SHTs may operate with a scope of practice which allows them to use a variety of
therapeutic interventions which may have their origins in other social sciences or
helping professions. Such techniques are offered when there is a reasonable belief
that they are consistent with, and supportive of, the client’s own belief system
present at various levels of self awareness. SHTs help clients/families explore the
deeper meaning or interpretation they ascribe to their experience and may facilitate
emotional expression related to the presenting issues. SHTs utilize such
techniques and approaches if they are within their (certified) scope of practice or
while under the direct supervision of a fully qualified practitioner/educator
(CPE/PCE).

• Spiritual Health Therapy is a professional practice that occurs in a variety of
clinical settings, but usually those settings (for example in a hospital or mental
health facility) are not setup in a traditional “talk therapy” environment (one on
one settings; scheduled appointments etc) so unlike certified Pastoral Counselors,
SHT’s do their work at the bedside and in crisis situations.
• This may mean that treatment can involve only one contact with a client---though
depending on the situation there are times when a SHT will see clients over a
longer period of time (prison, hospice, long term care, mental health etc.), so there
is a need to develop long term strategy alongside the usually short term approaches
adapted in this type of client care.

• Spiritual Health Therapy utilizes a companion approach that involves the
“assessment” of a client, “interventions” to help boil down the problem and
“comfort” interventions that include the 14 activities of the SAIL list (prayer,
guided meditation, ritual, support of authentic expression etc.)
• Because of the short term nature and at times crisis aspect of the patient encounters
SHTs use “I” statements in their interventions to make sure the patient “has a way
out” and/or can direct the process interventions according to their willingness and
abilities with each encounter.
• The professional and clinical responsibilities of a SHT include but are not limited
to: initial assessments, crisis interventions, follow ups, clinical charting of spiritual
assessments and follow up interventions, providing meaningful and inclusive
rituals/services for the clinical setting, advocacy for spiritual health in healthcare,
creating processes for connecting patients to local religious leaders (if and when
needed), being involved in committees, care planning sessions, rounds and so on...

Spiritual Health Therapists adhere to Hodges’ Four Considerations:
• Client Autonomy: always respect a client’s autonomy/authority/identity; client
consent is important and we as well do not push an agenda (patient always has a
way out)—client determines the pathway (how deep we go, when it is time to stop
and other boundary considerations)
• Cultural Competency: respect client’s worldview, beliefs, values etc.; be mindful
of religious counter-transference (putting your values onto a client’s experience and
guiding); cultural sensitivity
• Spiritual Norms and Provision: do not stereotype or assume a client’s identified
religion is their spiritual awareness/practice.
• Spiritual Salience: Help clients draw from their own belief system; facilitate
theological reflection that helps clients enhance their understanding etc.

EXPECTATIONS AND OUTCOMES OF SPIRITUAL
HEALTHTHERAPY
• Initial Spiritual Care Assessments- help the patients and staff identify potential
“spiritual problems,” or “distress” and a plan for active follow up by a SHT can be
an integrated part of the patient’s care plan. These assessments identify possible
cultural practices, religious needs, and provide the patient and family an
opportunity to address “spiritual” issues as a part of the healthcare journey
• Follow up visits- these are ongoing visits and SHTs provide clients with
opportunities for theological reflection, meaning-making, spiritual practice, depth
process work etc.
• On-call/Emergency Visits- SHTs provide crisis interventions, inclusive rites
and/or ritual, family system attending, mediation, advocacy, witness with families
etc.
• Chart Notes- SHTs use the FDARE format and communicate initial assessments,
on-call referrals, physician/nurse/SW referrals, follow ups, etc.

EXPECTATIONS AND OUTCOMES OF SPIRITUAL
HEALTHTHERAPY
• Though SHTs don’t necessarily come in with a “plan” the expectation of these
encounters is that if/when a patient is willing they are given the opportunity to
discuss, reflect and process their “spiritual” problems. The outcomes or
expectations is that a client will be better able to articulate feelings, thoughts, ideas,
theology, outlook, view of life, cultural or ethnic expression, religious needs,
personal values, struggles, limitations, strengths etc. Any development of any of
these areas impacts positively the patient’s health outcomes.
• Otherwise SHTs would evaluate progress similar to transpersonal psychology—in
the midst of therapeutic encounters any and all positive developments of self
awareness, interpersonal relating, spiritual health (related to stages of faith, or other
development models of spiritual progress) are indications of therapeutic
progression as each area is related to the whole—knowing of course that this
progression is client centered, client motivated and limited to client activation.

WHO CAN PRACTICE SPIRITUAL HEALTHTHERAPY?
• Spiritual Health Therapists are certified through the Canadian Association for
Spiritual Care CASC (who also accredits CPE/PCE programs, and certifies
Teaching Supervisors and Pastoral Counselors).
• The preparation, training and requirements to be a certified SHT includes: seminary
or divinity school training or its equivalency; ordination and endorsement from a
religious order/community; courses in ethics and psychotherapy; 4-5 units of
accredited CPE training; clinical hours outside of CPE; and CRPO registration.

WHO CAN PRACTICE SPIRITUAL HEALTHTHERAPY?
• William Osler Health System employs a CASC certified Teaching Supervisor who
runs an accredited program of CPE throughout the year. Spiritual Health Therapy
Interns do their clinical work at BCH and EGH as a part of their training program.
• Spiritual Health Therapy Referral Hours: Monday Through Friday 0800-1600,
Daytime ON-CALL PAGER: 416-715-4837 or call LOCATING
• After hours, overnight, weekends and holidays there is RELIGIOUS CARE
COVERAGE by religious volunteer leaders in the community (These individuals
are NOT trained or qualified SHTs---they provide religious counsel and service
related to their designated religious group ONLY). Please call LOCATING---they
have a list for each religion with contacts for each (if you would like a copy of this
list please contact the Spiritual Health Therapy and Education department).

OUR VISION
PATIENT-INSPIRED HEALTH CARE WITHOUT BOUNDARIES

The Practice of Spiritual Health Therapy--Definig our work and profession

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