John Valentine is a volunteer in the spiritual care team at Royal Trinity Hospice in London, where he provides non-religious spiritual care to patients. Here he explains the theory behind it.
It is now widely accepted that spirituality and religion are not the same: that spirituality exists outside religious structures as well as within them. Patients who do not identify with a religion may refer to themselves as ‘spiritual but not religious’. But spiritual care in health care has traditionally been provided by faith professionals employed in a chaplaincy role. This religious, or pastoral, care is where spiritual care began and often where it remains.
The range of belief and non-belief found in modern society has increased dramatically in recent decades. We can no longer assume that all our patients have a common background in one dominant belief system, and we can no longer articulate spiritual care exclusively in the language of that system. It is no longer acceptable to draw spiritual care workers – paid or voluntary – exclusively from among people of faith.
Conflating ‘spiritual’ and ‘religious’ is not just a problem for spiritual care departments: it is common among patients too. We have all come across patients who decline a spiritual care visit because they are not religious – although their reluctance may be reinforced if the spiritual care worker is dressed in a dog collar or carrying a New Testament. Spiritual care should be available to all patients whether they identify as religious, spiritual, both or neither, and it should be offered without preconceptions and without judgement.
There may be cross-over between the terminology of religious and non-religious spirituality, and many core spiritual questions are common to those with faith and those without. Concerns about identity and meaning are universal, but non-religious spirituality is rooted in everyday experience and expressed in vernacular, everyday terms, rather than in the experience and language of faith. But either way, someone who perceives his or her life as being without meaning or purpose may suffer from spiritual distress, perhaps especially near the end of life when there is not much time to address the problem.
Perhaps two broad paths to meaning or purpose in life can be identified. The first is meaning through work or action or in other words involvement in the external world of achievement. The second is meaning through incidents, encounters or relationships; the internal world of experience. These two paths may be equally effective in giving meaning to a life, and many people’s lives contain a mixture of the two.
Some writers have discussed spirituality in terms of the human need for love, belonging and acceptance, and involvement in their family or community. These ideas can fit into either the external or internal paths above: what is more important is how we might encounter and then address them as spiritual care workers in the hospice.
It is not only spiritual care workers who offer spiritual care on the wards: medical, nursing and other professional staff practice it, but usually while they are also delivering another type of care. Families and friends can also have an important role to play. But spiritual care is different to care provided by health professionals in that participants are not in a traditional doctor/patient relationship and care is not ‘handed down’ from care giver to recipient. It is, or should be, a much more equal partnership in which patient input is central.
Listening and questioning/probing skills are key as they are for all forms of care, but the spiritual care worker listens for symptoms that may not be easily or straightforwardly articulated. Spiritual care is not a check-list activity with easily defined outcomes, and no assumptions can be made about the patient’s attitudes, opinions, beliefs or needs. The care-giver cannot impose his or her own attitudes or beliefs onto the relationship or assume they are shared by the patient: the care-giver is in many ways anonymous, focussed entirely on the patient.
The beginning of a spiritual care conversation is important. Opening questions need to make clear that the patient is in control of whether the meeting takes place at all, and what is discussed. They need to show that the care-giver will make no assumptions and no judgements. Questions need to show that the conversation will be honest and acknowledge the realities of the patient’s situation. Denial should not be offered: if the patient says that she has only a month to live, it is tempting to reply that oh no, it might be much longer than that. Perhaps a more useful reply would be to ask what needs to be done during that time, a response that is honest and that also might open up a conversation about the practical and spiritual issues that are in her mind.
A lot of time is spent listening to particular concerns or to life stories, and identifying the values, strengths, hopes and fears that they reveal. Patients often find value in being listened to carefully and sympathetically, and gentle probing can help to articulate their concerns. There may be no direct answers to their questions but sometimes the process of clearly identifying them can provide its own answers.
People in palliative care may want to talk about their fears of dying and their regrets at their lack of time. They may want to review their lives and take stock of them, perhaps talking about what they have done in the external world of work and action as well as the relationships they have enjoyed in the world of experience. They may want to settle their affairs and leave as few loose ends as possible, and exercise control over these areas for as long as they can. In the act of listening the care-giver may be able to offer reassurance, or help the patient to arrive at his or her own self-reassurance, that the life that is coming to an end has meaning, validity and value.
As time goes on and the patient’s disease progresses it may no longer be possible to communicate verbally. The care-giver can hope that work done at an earlier stage is still useful, but it can be difficult to know for sure. All that can be done now is to sit with the patient quietly and keep him or her company on the journey.
For more information visit Royal Trinity Hospice
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