Ann M. Callahan PhD, LCSWLecturer, University of Tennessee, Knoxville

College of Social WorkPsychotherapist, MedOptions

Behavioral Health Services

SWPHN General AssemblyWe’re All In: Advancing Inclusive Practice in

Hospice and Palliative Social WorkTuesday, February 21, 2017

1. Identify potential spiritual needs andresources of hospice clients.

2. Understand how spiritually sensitive hospicesocial work can facilitate spiritual care.

3. Identify means of evaluating the delivery ofspiritual care.

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1. Spiritual Needs 2. Spiritual Suffering 3. Spiritual Resources 4. Spiritual Sensitivity5. Relational Spirituality 6. Spiritual Competence7. Spiritual Care

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SPIRITUALITY

There are LOTS of Reasons!¨ Client Expectations ¨ Spiritual Needs ¨ Developmentally Appropriate¨ Component of Holistic Care¨ Mandated by Accrediting Organizations¨ Supported by Professional Organizations¨ Therapeutic Effects

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¨ Many clients have spiritual needs.¡ 80 to 90 percent (Peteet & Balboni, 2013;

Gijsberts, Echteld, van der Steen, Muller, Otten, Ribbe, & Deliens, 2011)

¨ Time is limited for intervention.¡ In 2014: 36 percent < 7 days (NHPCO, 2014,

2015a) ¡ In 2012: 17 percent (with Medicare ) = 3 days

(Bynum, Meara, Chang, & Rhoads, 2016)

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Unmet spiritual needs can compromise care.

¨ The overall need “to integrate goals, values, and experiences in search of meaning and sense of purpose” (Millison, 1988, pp. 37-38). ¡ Universal human needs as well as individual needs

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Specific to Hospice and Palliative Care

¨ Mrs. Allen’s lung cancer progressed very slowly. Though her respiratory symptoms and pain were well controlled, she suffered considerably from being unable to care for her own bodily functions, manage her own household, and remain active in her church. Initially, Mrs. Allen was able to cope with these losses and remain in good spirits by believing that her daughters needed this time to “prepare” for her death. For a while, she found meaning in the belief that God was helping her grow spiritually in and through this state of dependence.

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¨ As the months wore on, however, and these reasons for being alive were fulfilled, Mrs. Allen despaired. She prayed for God to take her. With the help of the hospice team, she found renewed strength and peace by affirming her long-standing belief that “God has a plan and purpose for everything, even if He doesn’t tell us what it is.” To remain faithful was the answer to her quest for meaning.

(Knight & von Gunten, 2004b)11

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What kind of spiritual need(s) did Mrs. Allen have?

✔

✔

¨ Mr. and Mrs. Mason had been married 50 years when Mrs. Mason was diagnosed with end stage glioblastoma. As the disease progressed, she no longer spoke, made no meaningful eye contact or gestures, did not respond to even simple commands, and showed no sign of recognizing the voice or presence of her husband. Mr. Mason would periodically despair and ask members of the hospice team if they could do something to end this. “She’s gone, she’s not here anymore. What’s the point?”

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¨ On other days, he would persist, however, in telling her about his day, caressing her arms, and advocating for respectful treatment of her by the nurses and aids who came to the home. “She’s not a piece of meat, you know. She’s a human being. She’s still my wife.” With the help of the hospice team, Mr. Mason believe that his presence and love for her was making a difference, even if it couldn’t change the course of the disease.

(Knight & von Gunten, 2004b)14

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What kind of spiritual need(s) did the Masons have?

✔

✔

✔

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Unmet spiritual needs can lead to suffering.

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Spiritual distress Existential painSpiritual pain Existential distressSpiritual struggles Existential sufferingSpiritual problems Religious concerns

Spiritual concerns Religious pain

Spiritual issues Religious distress

Despair Religious struggles

(Exline, Prince-Paul, Root, & Peereboom, 2013; Mako, Galek, & Poppito, 2006; Heyse-Moore, 1996; UA, n.d.; Pargament, 2007; Chochinov & Cann, 2005)

¨ Spiritual suffering is the response to being unable “to experience and integrate meaning and purpose in life through a persons connectedness with self, others, art, music, literature, nature, or a power greater than oneself" (Puchalski, Lunsford, Harris, & Miller, 2006, p. 405; Puchalski, 2008a; Lukoff, n.d.).

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Spiritual suffering can be hard to discern.

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¨ Mr. Horton is a 70-year-old male who is recovering from complications of pneumonia. His primary care provider told him yesterday that has lung cancer, his prognosis is poor. This morning Mr. Horton presents this morning as agitated and tells the social worker he wants to be discharged. He says he needs to go home and take care of his wife. Mr. Horton understands that his wife, who is disabled, is under the care of their oldest daughter. However, he continues to pressure for immediate discharge saying “My wife needs me. Who will take care of her when I am gone?”

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Yes.Is Mr. Horton experiencing spiritual suffering?

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Spiritual needs can inform spiritual resources.

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¨ Spiritually sensitive hospice social work validates a client’s inherent dignity and worth. It is this spiritually sensitive relationship that creates an opportunity for a client to experience enhanced life meaning which is called relational spirituality.

¨ A client’s experience of relational spirituality is believed to confirm that a therapeutic relationship is spiritually sensitive.

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Relational Model for Spiritually Sensitive Hospice Social Work

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Compassionate Facilitating relationships

Empathic Focusing on the ordinary

Trustworthiness Good rapport

Affirming Active Listening

Kindness Self-Awareness

Being a companion Genuine interest

(Callahan, 2010; Callahan, 2015, Callahan, 2017)

Modes of delivery: therapeutic relationship, psycho-education, and supportive counseling

¨ For the spiritual need to be treated like a person, the advanced spiritual care provider may:¡ Respect and focus on client's humanity, dignity,

individuality and autonomy.¡ Talk to the client rather than about them in their presence,

even if they are not capable of complete understanding. ¡ Ask clients how they are doing or feeling before focusing on

specific medical problems. ¡ Explore what it is that helps that client feel like a human

being rather than just a “case” or “client.” ¡ Offer choices and help clients identify areas where they can

have some say to compensate for the tremendous.

28(Knight & von Gunten, 2004b)

¨ For the spiritual need to share in community with others, the advanced spiritual care provider may:¡ Community may involve connection with family, friends,

workplace, school, civic groups and faith community.¡ Roles will change as person’s health declines.

ú May need to consider what changing role means, mourn losses, redefine and affirm new role.

¡ It is important to encourage and facilitate ongoing involvement to maintain human connections.

¡ If practical, help clients maintain a connection with their loved pets.

29(Knight & von Gunten, 2004b)

¨ For the spiritual need to feel safe, the advanced spiritual care provider may:¡ Listen and normalize fears

ú Provide an opportunity for persons to talk about the source of their anxiety or fear.

ú “Being heard” in and of itself can sometimes lessen the spiritual distress.

¡ Help identify sources of comfort and order ú These sources are someone or something that is solid,

trustworthy, or that provides a sense of order.ú They may include other people, spiritual and religious faith,

and religious rituals including ordinary routine (e.g., bathing, preparing for bed).

30(Knight & von Gunten, 2004b)

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Spiritual assessment Assisting in life review

Facilitate S/R expression Inspiring hope

Flexible boundaries Reframing

Problem-solving Use of humor

Assist spiritual self-care Bereavement counsel

(Callahan, 2010; Callahan, 2015, Callahan, 2017)

Modes of delivery: therapeutic relationship, psycho-education, psychotherapy, and alternative*

*Alternative modes of delivery include art therapy, music therapy, dream work, acupuncture, therapeutic touch, biofeedback, relaxation response, guided imagery, and aromatherapy

¨ For the spiritual need to retain hope, the advanced spiritual care provider may:¡ Normalize the wish for death ¡ Confirm that a person is indeed growing weaker or

that they have multiple symptoms that indicate that death is near

¡ State that you know this will not go on forever ¡ Let clients and families feel heard ¡ As with the loss of hope, good spiritual care by the

palliative care team allows for these feelings to be heard

32(Knight & von Gunten, 2004b)

¨ For the spiritual need to process anger, the advanced spiritual care provider may:¡ Often, unrelieved suffering leads persons to blame

themselves or God. ú “I must have done something to deserve this kind of

life.” ú Normalizing these feelings and reviewing with the

person their life history may bring some release from blame, even as it may leave the person with no good explanation for their suffering

¡ If self-blame or anger at God persists, the chaplain or counselor should be notified.

33(Knight & von Gunten, 2004b)

¨ For the spiritual need to resolve grievances, the advanced spiritual care provider may:¡ All members of the interdisciplinary team may be called

upon to help persons gain a sense of peace with the life they have lived, when that is the goal (explicit or implicit) of the dying person and their family.

¡ However, when strong negative or judgmental feelings about a person’s past arise, members of the team with professional expertise in this area should be brought in if possible.

¡ Help client, loved ones and friends cope with anticipatory grief as well as follow-up with bereavement care.

34(Knight & von Gunten, 2004b)

¨ Fragile health of clients¨ Unsupportive work environment¨ Time restraints¨ Unprepared staff¨ Limited research

35(Callahan, 2017)

Threats necessitate spiritual competence.

¨ Do I know how to assess whether this client's “pain” is physical or spiritual in origin?

¨ Am I comfortable talking with this family about their religious beliefs and practices?

¨ Will I have the time and skills to provide comfort if my questions evoke great sadness or distress?

¨ Who could best meet the needs of this client and family at this time?

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(Knight & von Gunten, 2004a)

¨ Hodge & Bushfield (2006) and Hodge (2011) characterized spiritual competence as:

(1) awareness of personal worldview and related assumptions,(2) empathic understanding of the client’s spiritual worldview, and(3) evidence-based interventions based on client preference, clinical expertise, relevant research, and cultural competency.

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¨ Spiritual competence falls on a continuum.

¨ Developing spiritual competence is a process.¡ Set of attitudes, knowledge, and skills that can be

developed over time but requires intentionality.

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Destructive Competent

(Hodge & Bushfield, 2006)

¨ Coordination with other IDT members may be the best expression of spiritual competence.

¨ Experts on spiritual issues include board certified chaplains, faith representatives in the community, or other professionals.¡ Referrals may require client education.¡ Social workers may be THE expert on the IDT.

(Koenig, 2007; Puchalski, Ferrel, Virani, Otis-Green, Baird, Bull, Chochinov, Handzo, Nelson-Becker, PrincePaul, Pugliese, & Sulmasy, 2009; Sperry &

Miller, 2010)39

¨ Certified Chaplains¡ Education Level

ú Master’s level preparation (Theology)ú Clinical Pastoral Education (CPE)

¡ Broader role than that of a clergy person and serves persons from all religious traditions

¡ Prepared to attend to specific religious needs, particularly if associated with own affiliation

(Knight & von Gunten, 2004a; Koenig, 2007;Callahan, 2017)

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¨ Engage in lifelong learning to build spiritual competence by seeking education and skilled supervision.

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How can you help your students becomespiritually competent?

“If the interaction is oriented more toward listening than just to find out solutions, disclosure about suffering may be allowed, and the persons may perceive that they are accepted as a whole, together with their disease. This lets an individual feel that that he/she is a human being and is part of a larger world: a positive cure is reached” (Allamani, 2007, p. 234).

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¨ Clients have spiritual needs that can evoke spiritual suffering and need for spiritual care.

¨ Spiritual needs clarify spiritual resources that are needed to inform additional intervention.

¨ Hospice social workers can address spiritual needs by being spiritually sensitive.

¨ Spiritual competence involves understanding others, self-awareness, and respect for diversity.

¨ Social workers must seek spiritual competence and coordinate their provision of spiritual care.

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1. Spiritual Needs – The need to integrate goals, values, and experiences in search of meaning and sense of purpose.

2. Spiritual Suffering – A response to being unable to experience and integrate meaning and purpose in life.

3. Spiritual Resources – Provide a means through which a client’s spiritual needs are met

4. Spiritual Sensitivity – The awareness of and ability to convey respect for a client’s dignity and worth.

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5. Relational Spirituality – The experience of a relationship that enhances life meaning.

6. Spiritual Competence – A means to evaluate if social work practice is spiritually sensitive.

7. Spiritual Care – A type of care that is delivered in order to address a client’s spiritual needs

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This presentation is based on research completed for the book

Spirituality and Hospice Social Work by Callahan (2017)

available throughColumbia University Press:

http://cup.columbia.edu/book/spirituality-and-hospice-social-

work/9780231171731

You can save 30% when using the “CALSPI” promo code!

47

Please contact me for more information:

Ann M. Callahan PhD, LCSWLecturer, University of Tennessee, Knoxville

College of Social WorkPsychotherapist, MedOptions

Behavioral Health Servicesdranncallahan@gmail.com

Citation for this presentation: Callahan, A. M. (2017, November). An introduction to spiritually sensitive hospice social work. Workshop presented for the Social Work Hospice and Palliative Care Network General Assembly in Scottsdale, AZ.

“Spirituality frequently becomes more salient as clients approach

death. Spiritual needs, for instance, often become more acute.

Yet relatively little guidance exists on this critical topic. This

important new text addresses this gap in the literature and

equips social work practitioners and other hospice workers to

navigate the often difficult process of providing spiritual care in

hospice settings. Indeed, anyone involved in end-of-life care will

likely benefit from this significant contribution.”

—David R. Hodge, Arizona State University

Many hospice social workers must address spiritual issues with

their clients, but do not feel competent to do so effectively. This

targeted volume draws upon multidisciplinary theory and research

to advance a relational model of spiritually sensitive hospice care.

The book will help readers elevate their spiritual competence and

foster a relationship with their clients that will enrich the experi-

ence for all involved.

Spirituality and Hospice Social Work helps practitioners under-

stand various forms of spiritual assessment for use with their

clients. The book teaches practitioners to recognize a client’s

spiritual needs and resources, as well as signs of spiritual suffer-

ing. It also discusses religious and spiritual practices that clients

may use to enhance their spiritual coping. Spirituality and Hospice

Social Work stresses the need for interdisciplinary collaboration

with other members of the hospice team, along with the value of

maintaining professional ethical standards when addressing spiri-

tual issues. Throughout, the importance of spiritual sensitivity and

its effect upon client well-being is emphasized.

C O L U M B I A U N I V E R S I T Y P R E S S

$35.00 / £26.00 · paper · 978-0-231-17173-1 $105.00 / £78.00 · cloth · 978-0-231-17172-4 $34.99 / £26.00 · ebook · 978-0-231-54318-7 febRUARy 2017 224 pages · End-of-Life Care: A Series

Spirituality and Hospice Social Work

Ann M. Callahan

ANN CALLAhAN is professor at the University of Tennessee,

Knoxville College of Social Work. She has a license in clinical

social work with more than twenty years of social work related

clinical, administrative, and teaching experience. for the past

ten years, she has been researching the spiritual dimensions of

the therapeutic relationship in an effort to inform quality hospice

social work.

NOW AVAILABLE Save 30% Using "CALSPI" Promo Code

c u p . c o l u m b i a . e d u · c u p b l o g . o r g

“Spirituality frequently becomes more salient as clients approach

death. Spiritual needs, for instance, often become more acute.

Yet relatively little guidance exists on this critical topic. This

important new text addresses this gap in the literature and

equips social work practitioners and other hospice workers to

navigate the often difficult process of providing spiritual care in

hospice settings. Indeed, anyone involved in end-of-life care will

likely benefit from this significant contribution.”

—David R. Hodge, Arizona State University

Many hospice social workers must address spiritual issues with

their clients, but do not feel competent to do so effectively. This

targeted volume draws upon multidisciplinary theory and research

to advance a relational model of spiritually sensitive hospice care.

The book will help readers elevate their spiritual competence and

foster a relationship with their clients that will enrich the experi-

ence for all involved.

Spirituality and Hospice Social Work helps practitioners under-

stand various forms of spiritual assessment for use with their

clients. The book teaches practitioners to recognize a client’s

spiritual needs and resources, as well as signs of spiritual suffer-

ing. It also discusses religious and spiritual practices that clients

may use to enhance their spiritual coping. Spirituality and Hospice

Social Work stresses the need for interdisciplinary collaboration

with other members of the hospice team, along with the value of

maintaining professional ethical standards when addressing spiri-

tual issues. Throughout, the importance of spiritual sensitivity and

its effect upon client well-being is emphasized.

C O L U M B I A U N I V E R S I T Y P R E S S

$35.00 / £26.00 · paper · 978-0-231-17173-1 $105.00 / £78.00 · cloth · 978-0-231-17172-4 $34.99 / £26.00 · ebook · 978-0-231-54318-7 febRUARy 2017 224 pages · End-of-Life Care: A Series

Spirituality and Hospice Social Work

Ann M. Callahan

ANN CALLAhAN is professor at the University of Tennessee,

Knoxville College of Social Work. She has a license in clinical

social work with more than twenty years of social work related

clinical, administrative, and teaching experience. for the past

ten years, she has been researching the spiritual dimensions of

the therapeutic relationship in an effort to inform quality hospice

social work.

NOW AVAILABLE Save 30% Using "CALSPI" Promo Code

c u p . c o l u m b i a . e d u · c u p b l o g . o r g